Herpetic Gingivostomatitis


Article Author:
Minira Aslanova


Article Editor:
Patrick Zito


Editors In Chief:
Jon Parham
Abigail Frank
Jon Sivoravong


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/11/2019 2:30:32 PM

Introduction

Herpetic gingivostomatitis is a condition that most often results from initial gingiva (gums) and oral mucosa infection with herpes simplex virus type 1 (HSV-1). While herpetic gingivostomatitis is the most common cause of gingivostomatitis in children before the age of 5, it can also occur in adults.[1] The condition is characterized by a prodrome of fever followed by an eruption of painful, ulcerative lesions of the gingiva and mucosa, and often, yellow, perioral, vesicular lesions. HSV-1 is usually spread from direct contact or via droplets of oral secretions or lesions from an asymptomatic or symptomatic individual. Once a patient is infected with the herpes simplex virus, the infection can recur in the form of herpes labialis with intermittent re-activation occurring throughout life.[2]

Etiology

Two, double-stranded DNA viruses of the Herpesviridae family, HSV-1 and HSV-2, are known to cause primary and recurrent herpetic gingivostomatitis. HSV-1 is mostly responsible for oral, ocular, and facial infections, while HSV-2 results primarily in herpetic lesions of the genital and cutaneous lower body. While most cases of herpetic gingivostomatitis are associated with HSV-1 infection, cases have been reported, mostly in older patients, of HSV-2 isolation. Oral infection with HSV-2 is probably transmitted through orogenital contact and has also been observed in HIV-positive patients and those on immunosuppressive therapy.[3]

Epidemiology

Primary herpetic gingivostomatitis typically occurs in children younger than the age of 5, but can also occur in adolescents and adults. It is estimated that almost 90% of the world’s population is seropositive for HSV-1 by age 35, and half of the individuals carrying the virus will experience reactivation in the form of herpes labialis. Herpetic gingivostomatitis is equally distributed amongst gender and race groups and is not found to have a particular seasonal or geographic distribution.[4],[5]

Pathophysiology

The pathogenesis of herpetic gingivostomatitis involves replication of the herpes simplex virus, cell lysis, and eventual destruction of mucosal tissue. Exposure to HSV-1 at abraded surfaces allows the virus to enter and rapidly replicate in epidermal and dermal cells. This results in the clinical manifestation of perioral blisters, erosions of the lips and mucosa, and eventual hemorrhagic crusting. Sufficient viral inoculation and replication allow the virus to enter sensory and autonomic ganglia, where it travels intra-axonally to the ganglionic nerve bodies. HSV-1 most commonly infects the trigeminal ganglia, where the virus remains latent until reactivation most commonly in the form of herpes labialis.[2]

Histopathology

Histological appearance of a mucosal herpetic infection includes degeneration of stratified squamous epithelium cells, acantholysis, and formation of an inflammatory infiltrate around the capillaries of the dermis. The characteristic intranuclear inclusion bodies known as Cowdry type A are found on light microscopy showing arrays of viral capsids and electron dense glycoproteins.[6] Cowdry type A bodies are eosinophilic inclusion bodies that are also found in varicella-zoster, making the histologic lesions of herpetic gingivostomatitis and varicella indistinguishable. Direct immunohistochemistry using fluorescent antibodies can be used to further distinguish between the herpes virus and the varicella virus.[7]

History and Physical

The initial sign of herpetic gingivostomatitis is inflammation of the oral and perioral mucosa, followed by rapidly spreading ulcerative and vesicular lesions on the gingiva, palate, buccal, and labial mucosa. The ulcerative lesions eventually rupture and become flat, yellow lesions with a red, pseudomembrane ranging from 2 to 5 mm in size. The ulcers are described as painful, quick to bleed, and typically heal without scarring in 2 to 3 weeks. Associated symptoms of herpetic gingivostomatitis include a prodrome of fever, anorexia, irritability, and lymphadenitis primarily in the cervical and submandibular region.[8]

Evaluation

The diagnosis of herpetic gingivostomatitis is usually clinical, based on the appearance of perioral and oral ulcers. However, if additional testing is required, herpetic gingivostomatitis can be confirmed diagnostically using a direct immunofluorescent examination of ulcer scrapings or blister fluid. Another test that can be used but is not entirely diagnostically reliable is the Tzanck smear. The Tzanck smear will confirm the presence of a virus in active lesions but fails to distinguish between HSV-1, HSV-2, and varicella-zoster virus.[9]

Treatment / Management

The most important component in the management of herpetic gingivostomatitis is hydration. Adequate hydration is often achieved with pain control; thus, analgesics such as oral acetaminophen and oral rinses are encouraged to make the patient more comfortable and promote fluid intake. It is important to note that patients who are unable to drink to maintain proper hydration should be hospitalized. Other indications for hospitalization include immunocompromised children, patients who develop eczema herpeticum, and HSV spread that results in encephalitis or pneumonitis.[10]

Immunocompetent patients with significant pain or refusal to drink can be administered oral acyclovir if they present within 96 hours of disease onset.[11] Studies show that administration of oral acyclovir within 96 hours of disease onset can result in reduced viral shedding, early resolution of lesions, and improvement in eating difficulties.[7] Immunocompromised patients with herpetic gingivostomatitis can benefit from intravenous (IV) acyclovir to shorten the duration of symptoms and lesions. In patients with acyclovir-resistant herpetic gingivostomatitis, foscarnet 80 to 120 mg per kg per day is the recommended drug.[12]

Barrier lip creams such as petroleum jelly have been suggested to prevent adhesions in patients with active herpetic gingivostomatitis.

Differential Diagnosis

Without perioral and oral lesions, the diagnosis of herpetic gingivostomatitis can often be overlooked. In the pediatric population, the child’s decreased appetite can be attributed to changes in diet or teething.[9] Despite the largely based clinical diagnosis of herpetic gingivostomatitis, it is important first to rule out other diseases that present similarly, keeping in mind the age group and past medical history of the patient. Some of the differential diagnoses to keep in mind when considering herpetic gingivostomatitis include:

  • Aphthous ulcers: Characterized by gray membranes and peripheral erythema, aphthae are small oral ulcers that, unlike the lesions of herpetic gingivostomatitis, are rarely found fixed on the mouth[13]
  • Herpangina: The Coxsackie-A virus causes herpangina. Typical presentation includes small blisters (unlike the large ulcers found in herpetic gingivostomatitis) with gray-fibrous membrane and peripheral erythema limited to the soft palate and high fever.
  • Infectious mononucleosis: Unlike herpetic gingivostomatitis, infectious mononucleosis presents with fever and lymphadenopathy. On physical exam, infectious mononucleosis is characterized by oral petechiae with occasional gingivostomatitis and ulceration.
  • Behcet syndrome: An inflammatory disorder characterized by recurrent aphthous ulcers and several systemic complications including genital lesions, arthritis, uveitis, and gastrointestinal manifestations mimicking irritable bowel syndrome.
  • Varicella: Characterized by vesicular lesions on the scalp and trunk, and small ulcers found in the posterior oral cavity.[7]

Complications

Complications of herpetic gingivostomatitis may include:[14]

  1. Dehydration
  2. Herpes labialis
  3. HSV encephalitis
  4. Herpetic whitlow
  5. Herpetic keratitis
  6. Eczema herpetic[15]

Enhancing Healthcare Team Outcomes

Herpes gingivostomatitis is best managed by a multidisciplinary team that includes the primary care provider, nurse practitioner, emergency department physician and infectious disease expert. Because of the pain, many patients are not able to eat or drink. In sich cases, admission is recommended for IV hydration. If an antiviral is started, it should be given within 24 hours of symptoms to be effective. Delayed dosing is not only expensive but futile.

Most patients do recover without any treatment but unfortunately, recurrences are common.


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Herpetic Gingivostomatitis - Questions

Take a quiz of the questions on this article.

Take Quiz
A 3-year-old patient is brought in with high fever, crying, salivation, and refusal to eat and drink for 4 days. The child has been previously healthy and attends daycare. The exam is remarkable for clusters of small vesicles on the tongue, gums, and lips. The posterior pharynx is spared, and there is no cervical lymphadenopathy. There are no other physical findings. What is the most likely diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 27-year-old male recently diagnosed with HIV presents with new onset oral pain. On physical exam, careful inspection of the gingival tissue reveals small clusters of vesicles that burst easily and multiple ulcers surrounded by red halos. The patient denies associated symptoms of fever, malaise, and swollen lymph nodes. What is the next best step in the management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which one of these statements on herpetic gingivostomatitis is false?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is the most common complication of herpetic gingivostomatitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of these symptoms is the earliest to be observed in primary herpetic gingivostomatitis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Herpetic Gingivostomatitis - References

References

George AK,Anil S, Acute herpetic gingivostomatitis associated with herpes simplex virus 2: report of a case. Journal of international oral health : JIOH. 2014 Jun     [PubMed]
Faden H, Management of primary herpetic gingivostomatitis in young children. Pediatric emergency care. 2006 Apr     [PubMed]
Goldman RD, Acyclovir for herpetic gingivostomatitis in children. Canadian family physician Medecin de famille canadien. 2016 May     [PubMed]
Amir J,Harel L,Smetana Z,Varsano I, Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ (Clinical research ed.). 1997 Jun 21     [PubMed]
Amir J,Harel L,Smetana Z,Varsano I, The natural history of primary herpes simplex type 1 gingivostomatitis in children. Pediatric dermatology. 1999 Jul-Aug     [PubMed]
Leinweber B,Kerl H,Cerroni L, Histopathologic features of cutaneous herpes virus infections (herpes simplex, herpes varicella/zoster): a broad spectrum of presentations with common pseudolymphomatous aspects. The American journal of surgical pathology. 2006 Jan     [PubMed]
Arduino PG,Porter SR, Herpes Simplex Virus Type 1 infection: overview on relevant clinico-pathological features. Journal of oral pathology     [PubMed]
Yarom N,Buchner A,Dayan D, Herpes simplex virus infection: part I--Biology, clinical presentation and latency. Refu'at ha-peh veha-shinayim (1993). 2005 Jan     [PubMed]
Mortazavi H,Safi Y,Baharvand M,Rahmani S, Diagnostic Features of Common Oral Ulcerative Lesions: An Updated Decision Tree. International journal of dentistry. 2016     [PubMed]
Sciubba JJ, Herpes simplex and aphthous ulcerations: presentation, diagnosis and management--an update. General dentistry. 2003 Nov-Dec     [PubMed]
Tamay Z,Ozcekert D,Onel M,Agacfidan A,Guler N, A child presenting with primary gingivostomatitis and eczema herpeticum. Minerva pediatrica. 2016 Feb     [PubMed]
Taieb A,Body S,Astar I,du Pasquier P,Maleville J, Clinical epidemiology of symptomatic primary herpetic infection in children. A study of 50 cases. Acta paediatrica Scandinavica. 1987 Jan     [PubMed]
Cataldo F,Violante M,Maltese I,Traverso G,Paternostro D, [Herpetic gingivostomatitis in children: the clinico-epidemiological aspects and findings with acyclovir treatment. A report of the cases of 162 patients]. La Pediatria medica e chirurgica : Medical and surgical pediatrics. 1993 Mar-Apr     [PubMed]
Mohan RP,Verma S,Singh U,Agarwal N, Acute primary herpetic gingivostomatitis. BMJ case reports. 2013 Jul 8     [PubMed]
Tovaru S,Parlatescu I,Tovaru M,Cionca L, Primary herpetic gingivostomatitis in children and adults. Quintessence international (Berlin, Germany : 1985). 2009 Feb     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Family Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Family Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Family Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Family Medicine. When it is time for the Family Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Family Medicine.