What is the best treatment for herpetic gingivostomatitis (infection of the gums and mouth caused by the herpes simplex virus)?

From the Guidelines

The best treatment for herpetic gingivostomatitis is oral aciclovir, which reduces the time to healing, especially when initiated early in the course of the disease. According to a study published in the Journal of Clinical Virology 1, oral aciclovir is of some benefit in reducing the time to healing for the initial outbreak of herpetic gingivostomatitis.

Key Considerations

• The treatment should be initiated within 72 hours of symptom onset for maximum effectiveness.
• Supportive care, including adequate hydration, soft or liquid diet, and pain management with acetaminophen or ibuprofen, is equally important.
• Topical anesthetics like viscous lidocaine 2% can provide temporary relief before meals.
• Maintaining good oral hygiene is essential, using a soft toothbrush and gentle saltwater rinses several times daily.

Antiviral Therapy

• Oral antiviral therapy, such as aciclovir, famciclovir, or valaciclovir, decreases outbreak duration and the associated pain by 1 day, as indicated by a meta-analysis of five placebo-controlled and two dose-comparison studies 1.
• Short-course, high-dose antiviral therapy offers greater patient and physician convenience, is cost-beneficial, and may improve patient adherence.
• Topical antiviral medication does not impact the host immune response and consequent inflammatory cascade, but the co-administration of a topical corticosteroid may limit the inflammation, as shown by an experimental topical combination of aciclovir and hydrocortisone 1.

Special Considerations

• For severe cases, particularly in immunocompromised patients, hospitalization may be necessary for intravenous acyclovir and fluid management.
• Patients should avoid spicy, acidic, or rough-textured foods that may irritate the oral lesions.
• The antiviral medications work by inhibiting viral DNA synthesis, preventing the herpes simplex virus from replicating, while supportive measures help manage symptoms and prevent complications like dehydration until the infection resolves, typically within 7-14 days.

From the FDA Drug Label

Herpes Simplex Infections in Immunocompromised Patients Acyclovir for Injection is indicated for the treatment of initial and recurrent mucosal and cutaneous herpes simplex (HSV-1 and HSV-2) in immunocompromised patients The best treatment for herpetic gingivostomatitis is Acyclovir (IV), as it is indicated for the treatment of initial and recurrent mucosal and cutaneous herpes simplex (HSV-1 and HSV-2) in immunocompromised patients 2 2.

• Key Points:
  • Acyclovir is effective in reducing virus excretion, pain, and promoting healing of lesions
  • The recommended dose is 5 to 15 mg/kg every 8 hours
  • Acyclovir is also indicated for the treatment of severe initial clinical episodes of herpes genitalis, herpes simplex encephalitis, neonatal herpes infections, and varicella-zoster infections in immunocompromised patients.

From the Research

Treatment Options for Herpetic Gingivostomatitis

• The most commonly recommended treatment for herpetic gingivostomatitis is acyclovir, an antiviral medication 3, 4, 5.
• The proposed therapeutic dose of acyclovir is 15 mg/kg, 5 times daily for 5-7 days, and treatment should begin within the first three days of disease onset 3, 4.
• Acyclovir has been shown to significantly shorten the duration of all clinical manifestations and infectivity of affected children compared to placebo 3, 4, 5.
• A systematic review found that only one study provided weak evidence that acyclovir is an effective treatment, improving healing of oral lesions and reducing duration of symptoms 6.
• Another study suggested that treatment with acyclovir should only be started within the first 72 hours of symptom onset if substantial pain or dehydration are documented 7.

Efficacy of Acyclovir

• Acyclovir has been shown to reduce the number of individuals with oral lesions, new extraoral lesions, difficulty in eating, and drinking difficulties in children under 6 years of age with primary herpetic gingivostomatitis 5.
• Acyclovir may also reduce hospital admission for children under 6 years of age with primary herpetic gingivostomatitis 5.
• However, the evidence for the effectiveness of acyclovir is limited, and more research is needed to confirm its efficacy 6, 5.

Other Treatment Options

• Other treatment options, such as symptomatic drugs and empiric regimens, have been proposed, but their effectiveness is unclear 6.
• Supportive care, such as fluids and analgesics, may also be necessary to manage symptoms and prevent dehydration 6, 7.