Management of Common Oral Sores

Mea A. Weinberg, DMD, MSD, RPh; Stuart L. Segelnick, DDS, MS


US Pharmacist. 2013;38(6):43-48. 

In This Article

Herpetic Lesions

Herpes simplex virus type 1 (HSV-1) is a nongenital infection usually transmitted during childhood through nongenital contact. HSV-1 can occur as either a primary or recurrent infection. HSV-1 lesions usually occur on the oral mucosa, lips, and hard palate. Other nonoral HSV-1 infections include herpetic keratitis, herpetic whitlow, herpes gladiatorum, and herpetic sycosis of the beard.[18]

Primary herpes infection occurs with the first exposure to HSV-1. This infection is referred to as primary herpetic gingivostomatitis (PHGS) and usually occurs in infants and children (between 2 and 3 years of age) by nonsexual contact, but can occur in adults through sexual contact. After primary exposure, herpes simplex virus may persist in a latent state in the trigeminal ganglion until it is reactivated in adulthood.[19]

All herpes infections, whether type 1 or genital type 2, are transmissible from person to person. An important part of the transmission is intimate contact between an infected shedding person (the host) and a susceptible person. Common stimuli that disturb the host's immune system include trauma to the oral area, fever, menstruation, exposure to sunlight, or prolonged use of corticosteroids. By adulthood, up to 90% of people will have antibodies to HSV-1.[20]

Pathophysiology (PHGS)

The initial or primary transmission of HSV-1 is via contact with an infected person's saliva through kissing or sharing food utensils or hand towels. The virus travels from the skin during contact and invades and replicates in neurons and skin cells. It is highly contagious and typically affects children but is also seen in adults.[21] The virus remains dormant in the trigeminal sensory ganglia until a stimulus reactivates it. This results in the development of recurrent herpetic infections, which appear on the mucosa of the lips, on the face, and on the oropharyngeal and ocular mucosa.[22]

Clinical Features (PHGS)

In children and young adults, PHGS is characterized by a high fever, malaise, fatigue, nausea and vomiting, and oral ulcers.[18] Adults may have less typical clinical features, making a diagnosis more difficult.

Painful intraoral vesicles appear on the oral mucosa (e.g., lips, gingiva, hard palate, tongue), which rapidly rupture, forming small ulcers with red halos. Usually the child refuses to eat or drink because of the severe pain. Lesions first appear 12 to 36 hours after the initial symptoms. Lesions are self-limiting and will usually resolve within 10 to 14 days.[23] There is also a generalized severe gingivitis, and submandibular and cervical lymphadenopathy may be present.

Diagnosis and Management

The clinical appearance of HSV-1 is usually diagnostic, but viral DNA testing can be done to confirm the diagnosis, if necessary.[18] Since the infection is self-limiting but severely painful, treatment is palliative, including fluids and analgesics or antipyretics such as acetaminophen. Aspirin is contraindicated in children under 19 years of age with a viral illness due to the risk of Reye syndrome.[24] Acyclovir (Zovirax) oral suspension (15 mg/kg 5 times a day for 7 days) is highly recommended.[25] Early treatment with acyclovir or famciclovir may significantly shorten the duration of clinical manifestations and infectivity of affected children.