What is the treatment for herpetic gingivostomatitis?

Treatment of Herpetic Gingivostomatitis

For herpetic gingivostomatitis, oral aciclovir is the recommended treatment as it significantly reduces healing time and symptom duration, with a dosage of 20 mg/kg body weight (maximum 400 mg/dose) orally three times daily for 5-10 days for mild cases, or IV therapy for moderate to severe cases. 1

Treatment Algorithm Based on Severity

Mild Symptomatic Gingivostomatitis

• Aciclovir, 20 mg/kg body weight (maximum 400 mg/dose) per dose orally three times daily for 5-10 days 1
• Treatment should begin within the first three days of disease onset for optimal effectiveness 2, 3

Moderate to Severe Symptomatic Gingivostomatitis

• Aciclovir, 5-10 mg/kg body weight per dose IV three times daily 1
• After lesions begin to regress, transition to oral aciclovir 1
• Continue therapy until lesions completely heal 1

For Adults and Adolescents

• Valacyclovir is approved at a dosage of 1 g orally twice daily 1
• Famciclovir is approved at a dosage of 500 mg orally twice daily 1
• These medications lack pediatric preparations, but could be used by older children able to receive adult dosing 1

Evidence for Effectiveness

• Randomized controlled trials have demonstrated that early aciclovir treatment significantly shortens:

  • Duration of oral lesions (4 days vs 10 days with placebo) 4
  • Fever (1 day vs 3 days with placebo) 4
  • Eating difficulties (4 days vs 7 days with placebo) 4
  • Drinking difficulties (3 days vs 6 days with placebo) 4
  • Viral shedding (1 day vs 5 days with placebo) 4

• Without treatment, herpetic gingivostomatitis symptoms typically last:

  • Oral lesions: approximately 12 days 5
  • Fever: approximately 4.4 days 5
  • Eating/drinking difficulties: 7-9 days 5

Important Clinical Considerations

• Early initiation of therapy is crucial - treatment should begin within the first 72 hours of symptom onset for maximum benefit 2, 3, 4
• For aciclovir-resistant HSV infection, foscarnet (40 mg/kg body weight per dose IV three times daily or 60 mg/kg body weight per dose IV twice daily) is recommended 1
• Supportive care is important, including:
  • Adequate hydration (dehydration is a common complication requiring hospitalization) 5, 6
  • Pain management with topical anesthetics or analgesics 1
  • Antipyretics for fever 1

Common Pitfalls and Caveats

• Topical antivirals are less effective than systemic therapy and are not recommended as first-line treatment 1
• Topical antivirals are not effective for prophylaxis as they cannot reach the site of viral reactivation 1
• The FDA has not approved any antiviral agent specifically for primary gingivostomatitis, though aciclovir has demonstrated clear benefits 1
• Delaying treatment beyond 72 hours significantly reduces therapeutic effectiveness 2, 3, 4
• Monitor for dehydration, which is the most common complication requiring hospitalization 5, 6