What is the treatment for herpetic gingivostomatitis?

Treatment of Herpetic Gingivostomatitis

Oral acyclovir is the treatment of choice for herpetic gingivostomatitis, administered at 15 mg/kg five times daily for 5-7 days, and should be started within 72 hours of symptom onset for maximum effectiveness. 1

Antiviral Therapy Options

First-line Treatment

• Acyclovir:
  • Children: 15 mg/kg orally, five times daily for 5-7 days 1, 2, 3
  • Adults: 800 mg orally, five times daily for 7-10 days 1

Alternative Antivirals

• Valacyclovir: 1000 mg three times daily for 7 days 1
• Famciclovir: 500 mg three times daily for 7 days 1

Special Populations

• Immunocompromised patients:
  • Higher doses of acyclovir (400 mg five times daily)
  • Longer treatment duration (7-10 days) 1
  • For severe cases: IV acyclovir 5-10 mg/kg every 8 hours until lesions heal 1
• Pregnant patients:
  • Acyclovir 400 mg orally three times daily for 5-7 days OR
  • Acyclovir 200 mg orally five times daily for 5-7 days 1

Clinical Evidence and Efficacy

Early treatment with acyclovir has been shown to significantly:

• Reduce duration of oral lesions (4 vs 10 days with placebo)
• Shorten fever duration (1 vs 3 days)
• Decrease eating difficulties (4 vs 7 days)
• Reduce drinking difficulties (3 vs 6 days)
• Shorten viral shedding period (1 vs 5 days) 4

A Cochrane review found that acyclovir effectively reduces:

• Number of individuals with oral lesions
• Development of new extraoral lesions
• Difficulties in eating and drinking
• Need for hospital admission for rehydration 5

Supportive Care

In addition to antiviral therapy, supportive care is essential:

1. Pain management:

   • Acetaminophen or other analgesics based on pain severity 1
   • Topical pain relief options:
     • Mixture of Maalox and diphenhydramine (swish and swallow/spit)
     • Viscous lidocaine (use with caution in young children) 6

2. Hydration:

   • Encourage fluid intake to prevent dehydration
   • Consider IV fluids if oral intake is severely compromised 7, 1

3. Nutrition:

   • Soft, non-acidic foods
   • Cold foods/beverages may provide comfort

Important Clinical Considerations

Timing of Treatment

• Critical factor: Treatment should begin within the first 72 hours of symptom onset, preferably within 24-48 hours 1, 2, 3
• Earlier treatment correlates with better outcomes 1

Common Pitfalls to Avoid

1. Delayed treatment: Many clinicians fail to prescribe acyclovir early enough, reducing its effectiveness 6
2. Inappropriate use of corticosteroids: Topical corticosteroids should be avoided as they can potentiate HSV infection 1
3. Inadequate pain management: Insufficient pain control can lead to decreased oral intake and dehydration
4. Insufficient monitoring: Follow-up is needed if symptoms worsen or don't improve after 72 hours of treatment 1

Follow-up Recommendations

• Follow-up within 7-10 days if:

  • Symptoms worsen
  • No improvement after 72 hours of treatment
  • New symptoms develop
  • Patient is immunocompromised 1

• Consider treatment failure and possible resistance if lesions don't begin to resolve within 7-10 days 1

Prevention of Recurrence

• Avoid known triggers (UV radiation, fever, psychological stress, local trauma)
• Use sunscreen (SPF 15 or above) to prevent UV-triggered recurrences
• Keep affected areas clean and dry to prevent secondary infection 1