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Herpes simplex - oral - Management
How should I manage someone with gingivostomatitis?

  • Reassure the individual or parent that the disease is self limiting.
  • Treat symptomatically:
    • Offer paracetamol or ibuprofen to relieve pain and fever.
    • Encourage adequate fluid intake to avoid dehydration.
    • Avoid acidic or salty foods and consume cool, soft foods.
    • Consider offering topical benzydamine for additional pain relief.
    • Offer chlorhexidine mouthwash to help control secondary infections and to control plaque accumulation if brushing of teeth is painful.
    • The use of a lip barrier preparation (e.g. Vaseline®, Lypsyl®) may be useful to prevent lip adhesion.
  • Provide advice to minimize transmission:
    • Avoid touching the lesions, other than when applying lip barrier preparation.
    • Wash hands with soap and water immediately after touching lesions.
    • Avoid kissing until the lesions have completely healed.
    • Do not share items that come into contact with the lesion area (e.g. lipstick or lip gloss, or barrier lip cream).
    • Avoid oral sex until all lesions are completely healed.
  • Children with gingivostomatitis who are generally well do not need to be excluded from nurseries and schools.
  • Oral antivirals are not routinely indicated for the treatment of gingivostomatitis in immunocompetent individuals but may be indicated in severe episodes. However, the optimum timing and dose of oral antiviral treatment are uncertain. Consider seeking specialist advice.
  • Seek specialist advice if:
    • Symptoms are not improving after 5 days.
    • The affected person is pregnant, a neonate, or is immunocompromised.
  • Admit the person if they are unable to tolerate oral fluids and are at risk of becoming dehydrated. Intravenous fluids may be required.
Basis for recommendation
  • These recommendations are pragmatic advice, given that herpetic gingivostomatitis is a self-limiting disease (lasting from 7–14 days, and up to 3 weeks for severe lesions to heal) [Birek, 2000; Amir, 2001; Esmann, 2001; Sladden and Johnston, 2005; Arduino and Porter, 2006; Kolokotronis and Doumas, 2006; BNF 54, 2007].
  • Prevention of dehydration:
    • Drinking plenty of fluids should be encouraged, particularly in young children as they tend to avoid eating or drinking because of the pain.
    • The most common cause of morbidity following gingivostomatitis is dehydration, and in severe cases this may require hospital admission [Amir et al, 1997; Amir, 2001; Esmann, 2001; Kolokotronis and Doumas, 2006].
  • At risk groups:
    • CKS recommends seeking specialist advice on the management of oral herpes simplex infection in those who are pregnant or immunocompromised, or in neonates, because of the increased risk of severe disease and complications in these groups [Leflore et al, 2000; Scully and Felix, 2006; BNF 54, 2007; Kimberlin, 2007].
    • Herpetic gingivostomatitis generally runs its course within one to two weeks with mild lesions usually healing within 5–7 days [Birek, 2000; Kolokotronis and Doumas, 2006]. Expert feedback suggests that specialist advice should be sought if no improvement in symptoms is seen after 5 days.
  • The Health Protection Agency (HPA) does not recommend children with gingivostomatitis to be excluded from schools and nurseries [HPA, 2003].
  • Antiviral drugs:
    • Oral antiviral therapy might be of value, especially in severe infection, neonates, or immunocompromised people [Scully and Felix, 2006; BNF 54, 2007]. However, there is uncertainty regarding the optimal timing and dosage.
      • CKS found only three randomized controlled trials investigating the use of antiviral drugs in those with gingivostomatitis. All studies involved children.
      • The results suggested that aciclovir suspension may be effective in reducing the duration of symptoms of herpetic gingivostomatitis in young children, but the optimal timing and dose of antiviral therapy are uncertain [Amir, 2001; Esmann, 2001; Arduino and Porter, 2006].
      • It is expected that the maximum clinical benefit from antiviral therapy is gained when treatment is started early because most viral replication occurs within the first 48 hours. Early initiation of antiviral therapy terminates virus replication and hence limits the subsequent epithelial damage responsible for the development of visible lesions [Esmann, 2001].
    • Specialist advice should be sought for systemic treatment of herpes simplex infection in pregnancy [BNF 54, 2007].
  • Use of lip barrier cream:
    • Based on a case report, the use of lip barrier preparations is recommended as a simple measure to prevent adherence of the lips (labial adhesions). This is a rare and serious complication of gingivostomatitis which might require surgical intervention in severe cases [Thomas, 2007].
  • Doxycycline mouthwash:
    • Although recommended by the British National Formulary for the treatment of herpes infection in the mouth [BNF 54, 2007], CKS could not find any evidence to support this use.

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