Who Can Be Affected by Herpes Infections?
Herpetic gingivostomatitis is a common disease occurring in children below five years of age and adults infected by the HSV-1 (herpes simplex virus). This condition is mainly characterized by the prodromal symptoms of initial fever followed by the oral manifestation characterized by painful ulcerative eruptions on the gingiva and oral mucosa. These lesions may appear yellow in color around the perioral region. Herpetic gingivostomatitis commonly affects children between 6 months to 5 years, but it can also occur in adults when predisposition factors trigger or activate the viral state again. HSV-1 virus would be either transmitted by direct contact with the infected individual through oral contact or by droplet infections from an infected individual.
A preliminary or latent infection lodged in the host immune system will make the host susceptible to activation as the virus stays latent. This is especially true for herpes labialis, categorized by cold sore manifestation with intermittent re-activation occurring throughout the infected individual's life under specific trigger factors or conditions.
What Are the Causes of Herpetic Gingivostomatitis?
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The causative agent is always Herpes simplex virus type 1 (HSV-1), which belongs to the alphaherpesvirus group family.
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These viruses are specifically enveloped with a double-stranded and linear DNA genome.
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HSV-1 is responsible for developing oral, ocular, and orofacial infections because it exhibits a tendency of tropism for oral epithelium. While most cases of herpetic gingivostomatitis in children and adults have been reported with HSV-1 infection, other cases are not uncommon, wherein HSV-2 can be isolated from oral lesions.
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Oral infection with HSV-2 can be transmitted mainly by route of oro-genital contact. HSV-2 transmission can also be observed in HIV-positive patients or those patients who are undergoing immunosuppressive therapies.
What Are the Clinical Features of Herpetic Gingivostomatitis?
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The initial sign of herpetic gingivostomatitis is the hyperemic reaction within the oral and perioral mucosa followed by rapid spreading vesicular lesions on the gingiva, palate, buccal or labial mucosa of the oral cavity.
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On clinical examination by the dental surgeon, these lesions appear to be ulcerative and eventually tend to rupture by themselves. On physical examination, these lesions are rather flat and yellowish, approximately 0.07 to 0.19 inches in diameter.
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The ulcers can bleed very quickly and are self-limiting, meaning they typically heal independently without any scarring in usually two to three weeks.
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Recurrent herpes lesions usually infect approximately one-third of patients with symptoms such as burning and itching sensations in the oral cavity and the formation of vesicular lesions in localized areas of the mouth. It is often accompanied with fever of relatively higher grade. In addition the affected person experiences severe dryness inside the mouth.
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These lesions tend to develop more on the keratinized skin, like the vermillion border (outer line) of the lips, on the perioral skin surfaces, or even on the hard palate.
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These lesions are commonly seen in individuals with predisposing risk factors such as physical and emotional stress, environmental triggers like sunlight exposure, sudden trauma, or those suffering from systemic diseases.
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Because of the inherent immunosuppressive nature of such conditions, individuals experience lesions in the same area during episodes of recurrence, along with systemic manifestations like malaise and localized lymphadenopathy.
What Is the Differential Diagnosis for Herpetic Gingivostomatitis?
The dentist should diagnose persistent lesions post two to three weeks on follow-up, and a confirmatory diagnosis should be established by looking at the other probable differential diagnosis enlisted below;
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Herpes zoster lesions.
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Acute necrotizing gingivostomatitis.
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Reactive arthritis lesions.
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Cytomegalovirus ulcerations (ulcerations evoked by cytomegalovirus infection).
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Traumatic ulcers of the oral cavity.
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Chemical injuries of the oral cavity or burns.
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Factitial injuries (self inflicting wounds).
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The primary form of chickenpox.
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Oral manifestations of Behçet’s disease.
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Herpetiform aphthae.
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Erythema multiforme lesions.
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Vesiculobullous diseases.
How Is the Diagnosis and Oral Management of Herpetic Gingivostomatitis Done?
Diagnosis:
The characteristic clinical appearance of the oral vesicular or ulcerative lesion in the mouth is a sufficient criterion for considering the diagnosis of herpetic gingivostomatitis.
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Direct Immunofluorescence: Herpetic gingivostomatitis is also confirmed by the direct immunofluorescent examination of scrapings obtained from the ulcers or blister fluids.
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Tzanck Smear Test: Another test that is not entirely reliable for diagnosis is the Tzanck smear test. By the Tzanck smear, the cytologic changes induced by the herpes virus can be seen clearly; however, they fail to distinguish between HSV-1, HSV-2, or the varicella-zoster virus.
Oral Management:
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Though this condition is self-limiting, the patient needs to follow up with the dental surgeon to gain temporary relief from pain or oral discomfiture during this phase.
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Also, the dentist may suggest barrier lip creams like petroleum jelly to prevent simple adhesions in patients with active forms of herpetic gingivostomatitis.
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Effective oral pain control measures with analgesics like Acetaminophen or ulcer-relieving oral rinses or Lidocaine containing anesthetic and analgesic gels would be recommended by the dentist.
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More water consumption or hydration throughout the day is encouraged for these patients as it can ease patient discomfort and promote fluid intake in the system, enhancing individual immunity.
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Usage of Acyclovir cream or oral suspensions through rinse form and swallow technique can also be recommended by surgeons in severe oral manifestations or recurring cases of HSV. It is not routinely advised for all the herpetic gingivostomatitis cases.
Conclusion
To conclude, herpetic gingivostomatitis through self-limiting is a severely discomforting and clinically severe oral condition that needs timely management by the dentist and also to prevent the spread of infection. It is quite painful, which makes it a distressing condition, symptomatic patients should be advised pharmacological management using painkillers. However, in certain patients, the condition remains without obvious manifestations. Proper hydration and symptomatic treatment interventions are the key strategies to tackle herpetic gingivostomatitis.
