Herpetic stomatitis: causes, symptoms, treatment and prevention

Introduction

Herpetic stomatitis-also known as herpetic gingivostomatitis-is an acute inflammation of the oral mucosa caused by Herpes simplex virus type 1 (HSV-1). It is the typical manifestation of first HSV-1 infection, most frequently affecting preschool children, but it can also occur in adolescents and, more rarely, in adults. This condition is highly contagious: the virus is transmitted through saliva and direct contact with lesions, such as through kissing or sharing contaminated cutlery, glasses or toothbrushes.

After initial infection, the virus remains dormant in the body (in the trigeminal nerve ganglia) for life and can reactivate later, causing recurrent episodes of herpes (typically as cold sores on the lips). Interestingly, in most cases (about 80 percent), first contact with HSV-1 causes no obvious symptoms, while only the remaining 20 percent or so develop primary herpetic stomatitis with pronounced lesions and discomfort. In other words, many people contract the virus without realizing it, while in some the virus causes this troublesome stomatitis at an early stage.

In this article, we will delve into the causes, symptoms, methods of diagnosis, treatment options, and prevention strategies for herpetic stomatitis. The goal is to provide clear and accurate information useful for recognizing this condition and managing it as best as possible, in language that is accessible to all.

Causes

Herpetic stomatitis is caused by a primary infection with the herpes simplex virus type 1 (HSV-1). This virus is the same virus responsible for cold sores, and once it enters the body it can remain dormant in the nerve ganglia, reactivating periodically. Herpetic stomatitis usually occurs when first infected with HSV-1: the virus penetrates through the mucosa of the mouth and triggers widespread inflammation.

How to get it and factors of contagion

Infection typically occurs through direct contact with saliva or lesions of an infected person. For example, children can contract the virus from parents or family members through kissing, or by sharing utensils, toothbrushes, glasses or towels with someone who has active herpes. Because herpetic vesicles contain a high viral load, transmission is more likely when these lesions are present and full of fluid; the risk remains until the vesicles are fully healed. Herpetic stomatitis is therefore considered highly contagious.

Certain factors may increase susceptibility to the virus or the severity of primary infection, including young age (developing immune system) and any immunodepressing conditions. Typically, first exposure to HSV-1 occurs at an early age; in fact, most adults already carry the virus. However, if a person reaches adulthood without ever having contracted HSV-1, he or she may still develop primary herpetic stomatitis if infected late in life.

Once the acute phase has passed, the virus remains dormant and hidden in the trigeminal ganglion (a facial nerve center). Years later, the virus can reactivate-for example, in situations of stress, fever, intense sun exposure, or declining immune defenses-causing episodes of cold sores or, more rarely, new lesions within the mouth ( secondary herpetic stomatitis). Importantly, relapses (reactivations) tend to be less severe than the first infection: they are often limited to a few lesions (such as classic “fevers” on the lip) and are preceded by milder or absent symptoms.

Symptoms

Herpetic stomatitis usually begins suddenly and can cause both general and local symptoms that are very pronounced, especially during the first infection (primary herpetic stomatitis). Typical symptoms include:

• High fever: often one of the first signs. The temperature may reach 39-40°C and may precede the appearance of lesions in the mouth by 1-2 days. The child may appear dejected and have chills associated with fever.
• General malaise and irritability: the patient (especially if a young child) may be irritable, tired, with possible headache and nausea. Enlarged and painful lymph nodes in the neck may occur due to the infection.
• Gum swelling and pain: the gums appear reddened, swollen and easily bleeding (herpetic gingivitis). This inflammation of the gums makes chewing and cleaning teeth very painful.
• Blisters and ulcers in the mouth: numerous vesicles filled with clear fluid appear all over the oral mucosa – inner cheeks, gums, hard palate, tongue and inner lips. These bubbles may be clustered or larger and isolated. Within a few hours or 1-2 days, the vesicles rupture, leaving very painful superficial ulcers surrounded by an inflamed red halo. The ulcers may also fuse together, forming larger areas of erosion. Lesions often also affect the lip rim and the skin around the mouth, causing crusting and fissuring.
• Intense pain and difficulty eating: ulcerations cause sharp pain and burning, making it difficult to chew and swallow (odinophagia). Younger children may refuse food and drink because of the pain, risking dehydration. Talking may also be painful.
• Halitosis: Inflammation and ulcers can cause transient bad breath (halitosis) due to the presence of ulcerated tissues and poor oral hygiene due to pain.
• Abundant salivation: sialorrhea (excessive salivation) and difficulty holding saliva in the mouth may be noted in toddlers, again due to pain during swallowing.
• Duration of symptoms: the acute phase of primary herpetic stomatitis typically lasts 7-14 days. Fever tends to resolve within the first 5-7 days, while lesions in the mouth heal within about 10-21 days, often without scarring. In some mild cases in immunocompetent patients, complete healing may occur as early as 7-10 days, while in more severe forms or in immunocompromised patients, healing may take longer.

In recurrences (secondary herpetic stomatitis), symptomatology is generally milder. Often recurrences do not present with fever or major systemic complaints; the patient perhaps experiences only mild local burning or tingling before the eruption, and the lesions tend to be less numerous and localized (e.g., only a few canker sores/vesicles). Recurrences last less long and are sometimes confused with common canker sores if they appear inside the mouth, or with cold sores if they appear outside on the lips. It is important to distinguish herpetic stomatitis from aphthous stomatitis: the latter causes aphthae that are not contagious and are not related to the herpes virus.

Diagnosis

Diagnosis of herpetic stomatitis is mostly clinical, based on observation of symptoms and characteristic oral cavity lesions. The physician (pediatrician, dentist, or general practitioner) generally recognizes the condition by the typical presentation: a child with high fever, inflamed gums, and multiple painful ulcerations in the mouth is strongly suggestive of primary herpetic stomatitis. A history of contact with someone with cold sores may also point toward the diagnosis.

In doubtful or atypical cases, tests can be performed to confirm or rule out other pathologies. Among these, rarely used are:

• Swab or virological examination: collection of fluid from vesicles to identify HSV-1 by PCR or viral culture.
• Blood tests: detection of anti-HSV antibodies in the blood has limited utility in the acute phase, but may indicate recent or past infection.
• Biopsy of the lesion: very rarely needed, it is mainly used if it is suspected that the ulcers may be due to other diseases (e.g., lesions from autoimmune disease or other infection). Biopsy involves taking a small fragment of mucosa for analysis under a microscope.

In the vast majority of cases, however, these tests are not necessary. The clinical presentation is so typical that the physician can diagnose herpetic stomatitis with a simple examination. However, it is important to consult a health care professional for proper diagnosis, as other conditions (such as severe aphthous stomatitis, “hand-foot-mouth” disease in babies, Coxsackie virus infections, or allergic reactions) can sometimes cause similar oral ulcerations and should be distinguished for appropriate treatment.

Treatment

For herpetic stomatitis, there is no targeted treatment that permanently eliminates the virus from the body (to date, we have no drugs that can eradicate HSV-1). Fortunately, in the healthy individual the primary infection is self-limiting, that is, it tends to resolve spontaneously within about two weeks. Treatment therefore mainly aims to relieve symptoms, promote wound healing, and prevent complications such as dehydration or bacterial overinfection.

The most commonly used measures and therapies are:

• Rest and hydration: it is essential to make sure the patient drinks enough. Offer plenty of cool fluids (water, milk, warm chamomile tea, etc.) to prevent dehydration, especially in children who struggle to drink due to pain. If they have difficulty feeding themselves, soft, cool foods such as smoothies, yogurt, ice cream or lukewarm purees can be offered, but avoid acidic, spicy or salty foods that can irritate ulcers.
• Antipyretics and painkillers: to reduce fever and pain, the doctor may recommend antipyretic drugs (e.g., acetaminophen) and nonsteroidal analgesics/anti-inflammatory drugs (NSAIDs, e.g., ibuprofen) appropriate for the patient’s age. These medications help control both temperature and oral pain, improving overall condition and allowing the child to rest and feed better. It is important to adhere to pediatric doses and indications if it is a child.

• Local application of ozone: Medical ozone represents an innovative and natural technology in the treatment of oral lesions. Due to its antiviral, antibacterial and healing properties, localized application of ozone can help reduce viral load, accelerate ulcer healing and relieve pain. At Marano Dental Experience, we have recently equipped ourselves with this state-of-the-art technology, which we use successfully in cases of herpetic stomatitis and other oral conditions.

• Local anesthetics or protectants: to provide temporary relief of pain in the mouth, the doctor or dentist may recommend the use of oral anesthetic gels (e.g., low-concentration lidocaine-based) to be applied to lesions before meals, or analgesic mouthwashes. Alternatively, there are soothing and emollient gels specifically for stomatitis, often based on natural substances (such as aloe vera) that form a protective film over ulcers, promoting healing. These products help reduce local burning and protect the lesions while eating.
• Systemic an tivirals (acyclovir): the use of antiviral drugs is indicated in more severe cases of herpetic stomatitis, particularly if the patient is immunocompromised or is evaluated within the first few days of onset. The most commonly used drug is oralacyclovir (syrup or tablets) typically taken for 5 to 7 days. Acyclovir works by inhibiting HSV-1 replication and, if started early (ideally within 72-96 hours of symptom onset), can reduce the duration and severity of the episode. Valacyclovir or famciclovir, which are oral antiviral analogs, are also used in some cases. It should be emphasized that antiviral therapy does not eliminate the virus from the body permanently, but limits active infection. In very young children or if unable to drink due to pain, intravenous acyclovir can be evaluated in a hospital setting. Note: Topical antivirals (creams) used for cold sores are not effective in herpetic stomatitis because the lesions are inside the mouth and multiple.
• Gentle oral hygiene: despite the pain, it is important to maintain some oral hygiene to prevent bacterial overinfection of ulcers. Brushing teeth gently (perhaps with a soft toothbrush) and, if tolerated, rinsing with an antiseptic mouthwash (e.g., low concentration chlorhexidine ) or simply with water and baking soda is recommended. This helps keep the area clean and promotes healing. Of course, one should avoid mouthwashes that burn (containing alcohol) and discontinue any practice that the patient cannot tolerate.
• Local or systemic corticosteroids: these are not usually used in herpetic stomatitis, unlike sometimes in aphthous stomatitis. In some exceptional cases, if the inflammation is very extensive and the pain cannot be controlled with the above measures, a medical specialist might consider short courses of systemic corticosteroids (e.g., cortisone), but these are rare situations and should be weighed carefully.
• Medical care: if your child cannot drink anything or appears dehydrated, you should take him to the doctor or emergency room. He may need temporary intravenous rehydration. Similarly, if signs of complications appear (e.g., very dejected appearance, fever lasting more than 7 days, eye injury, etc.), the doctor should be consulted.

In summary, the treatment of herpetic stomatitis is symptomatic in most cases. With rest, fluids and the listed precautions, the oral mucosa will gradually heal. Systemicacyclovir, when indicated, can hasten resolution and shorten the course of the disease. It is important not to use antibiotics (unless the doctor finds bacterial overinfection), because the cause is viral: antibiotics would be unnecessary and are not recommended. When in doubt about treatment, it is always good to follow the advice of the pediatrician or dentist.

Prevention

Preventing herpetic stomatitis completely can be difficult, as HSV-1 is very common in the population. However, some measures can reduce the risk of infection and recurrence:

• Avoid contact with active lesions: the main rule is not to come into direct contact with herpes blisters. If a person (adult or child) has active cold sores or ongoing herpetic stomatitis, avoid kissing them and sharing objects that have been in contact with their saliva (cutlery, glasses, napkins, toothbrush, towels, etc.). This is especially important to protect infants and young children, who are more vulnerable to primary infection.
• Careful personal hygiene: people with herpetic stomatitis should wash their hands often, especially after touching their mouth or vesicles. This will prevent spreading the virus to others (through handshakes, contaminated surfaces) and also from self-inoculating it to other parts of the body (e.g., then touching the eyes with contaminated hands risks ocular herpes).
• Avoid risky behaviors during infection: those with herpetic stomatitis in the active phase should avoid oral sex in addition to kissing, so as not to transmit the virus to other mucous membranes (e.g., to a partner’s genitals). In addition, it is good for sick children to stay home as long as they have fever and blisters, so as not to infect other children at daycare or school.
• Relapse triggers: for those who have already contracted HSV-1, certain precautions help reduce reactivations of the virus. For example, protect the lips with lip balm or sunscreen if there is heavy sun exposure (intense sun can facilitate cold sores in those who are predisposed), maintain a healthy lifestyle to support the immune system (avoiding stress and excessive fatigue), and treat other febrile illnesses promptly. Good oral hygiene also reduces the risk of trauma or infection in the mouth facilitating herpes reactivation.
• No vaccine (for now): there is currently no approved and available vaccine to prevent HSV-1 infection in healthy individuals. Research is active in this area, but prevention is currently based solely on prudent behaviors.
• Education and awareness: informing family members and people in contact with infants and children about herpes is important. For example, an adult with cold sores should refrain from kissing an infant on the face or little hands, and in general everyone should be aware that even a simple “fever” on the lip is contagious. This awareness helps to limit the spread of the virus.

In summary, the prevention of herpetic stomatitis relies primarily on common sense and hygiene. Avoiding direct contact with those with ongoing herpetic manifestations and maintaining proper hygiene habits can significantly reduce the risk of contracting or transmitting the virus.

Conclusion

Herpetic stomatitis is a painful and debilitating condition, especially for young children, but fortunately it is transient. With proper supportive care and a little patience, the lesions heal completely within a few weeks without leaving permanent consequences. It is important to recognize the symptoms early and consult the doctor or dentist for proper diagnosis, so that the patient’s discomfort can be alleviated and complications such as dehydration can be avoided.

Although highly contagious in the acute phase, with simple precautions it is possible to contain the spread of HSV-1. After the first episode, the virus remains latent: we cannot eliminate it from the body, but in any relapses, symptoms will usually be milder and more manageable. If there is any doubt or symptoms take a long time to resolve, it is always advisable to consult a health care professional.

Ultimately, good information is the best weapon: knowing the causes, symptoms, treatments, and preventive measures of herpetic stomatitis allows you to deal with it in the best way possible, protecting the oral health of children and adults and reducing anxiety and worry in the face of this infection. With the right care and support from your dentist or pediatrician, herpetic stomatitis can be successfully overcome.

 

References

1. Bambino Gesù Children’s Hospital. “Stomatitis of the child – Herpes (herpetic stomatitis).” Last updated April 16, 2024. Available online: https://www.ospedalebambinogesu.it/stomatiti-del-bambino-80407/
2. Aslanova M., Ali R., Zito P. “Herpetic Gingivostomatitis.” StatPearls (NCBI Bookshelf), last updated June 12, 2023.
3. MSD Manual (Merck) – “Herpes simplex virus infections” section. MSD Manual, professional version. Available online: https://www.msdmanuals.com/it/professionale/malattie-infettive/herpes-virus/infezioni-da-virus-dell-herpes-simplex