What is the appropriate treatment for a patient with gingivitis complicated by a viral infection and oral ulcers?

Treatment of Gingivitis with Viral Infection and Oral Ulcers

For gingivitis complicated by viral infection (specifically herpes simplex virus) and oral ulcers, initiate oral acyclovir 15 mg/kg five times daily for 5-7 days within the first 3 days of symptom onset, combined with supportive oral care including antiseptic rinses, topical analgesics, and mechanical debridement if bacterial superinfection is present. 1, 2

Antiviral Therapy (Primary Treatment for Viral Component)

Oral acyclovir is the treatment of choice for herpetic gingivostomatitis, as it significantly reduces healing time and duration of all clinical manifestations when started early 1, 2:

• Dosing: 15 mg/kg five times daily for 5-7 days 2
• Timing is critical: Treatment must begin within the first 3 days of disease onset, as peak viral titers occur in the first 24 hours after lesion onset 1, 3
• Short-course, high-dose regimens offer greater convenience and may improve adherence 1

For immunocompromised patients, more aggressive antiviral therapy is required, as episodes are typically longer, more severe, and may involve the entire oral cavity or extend across the face 1, 3

Supportive Oral Care Protocol

Antiseptic Rinses (Reduce Bacterial Colonization)

Use antiseptic oral rinses twice daily to reduce bacterial colonization of ulcerated mucosa 4:

• 0.2% chlorhexidine digluconate mouthwash (10 mL twice daily), diluted by up to 50% if soreness occurs 4
• Alternative: 1.5% hydrogen peroxide mouthwash (10 mL twice daily) 4

Pain Management (Stepwise Approach)

First-line: Benzydamine hydrochloride oral rinse or spray every 3 hours, particularly before eating 4

Second-line (if benzydamine inadequate): Viscous lidocaine 2% (15 mL per application) as topical anesthetic 4

For severe pain: Consider systemic analgesics following WHO pain ladder, including NSAIDs (amlexanox 5% oral paste for moderate pain) or opioids for persistent severe pain 4

Mucosal Protection and Hygiene

• Apply white soft paraffin ointment to lips immediately and every 2 hours throughout acute illness 4
• Mucoprotectant mouthwash (e.g., Gelclair) three times daily to protect ulcerated surfaces 4
• Clean mouth daily with warm saline mouthwashes or oral sponge, sweeping gently in labial and buccal sulci to reduce fibrotic scar risk 4
• Sodium bicarbonate-containing mouthwash (non-alcoholic) 4-6 times daily, increasing to hourly if needed 4

Avoid alcohol-based mouth rinses as they can exacerbate mucosal injury 4

Treatment of Secondary Infections

Fungal Superinfection

If candidal infection is suspected (take oral swabs regularly) 4:

• Nystatin oral suspension 100,000 units four times daily for 1 week 4
• Alternative: Miconazole oral gel 5-10 mL held in mouth after food four times daily for 1 week 4

Bacterial Component (If Necrotizing Features Present)

If necrotizing ulcerative gingivitis (NUG) features are present—characterized by ulceration and necrosis of interdental papillae, bleeding gums, and severe pain 5:

• Mechanical debridement with tartar removal is essential 5
• Systemic antibiotics combined with local antimicrobial delivery 5
• Treatment typically results in ulcer healing within a few days 5

Topical Corticosteroids (For Severe Inflammation)

Consider topical corticosteroids four times daily if inflammation is severe 4:

• Betamethasone sodium phosphate 0.5 mg in 10 mL water as 3-minute rinse-and-spit preparation 4
• For localized severe ulcers: Clobetasol propionate 0.05% mixed with Orabase, applied directly to affected areas 4

Critical Clinical Pitfalls

• Do not delay antiviral therapy: Efficacy drops significantly after 72 hours of symptom onset 2
• Topical antivirals are ineffective for herpetic gingivostomatitis as they cannot reach the site of viral replication 1
• Monitor for neutropenia-associated ulceration in immunocompromised patients, which presents as extensive ulceration without typical ANUG microflora and requires different management 6
• Watch for HSV reactivation if oral mucosa heals slowly despite treatment, as this may indicate secondary HSV infection 4
• Younger patients and those with oral candidiasis are at higher risk for gingival ulceration complications 6

Daily Monitoring Requirements

• Daily oral examination throughout acute illness to assess response and detect complications 4
• Regular oral and lip swabs if bacterial or candidal secondary infection is suspected 4
• Assess nutritional status as severe oral pain may lead to malnutrition, particularly in children where disease typically lasts 12 days 1, 3