ORAL HERPES AND COLD SORES IN CHILDREN. Information on herpes simplex,herpes labialis,herpetic gingivostomatitis,fever blister,recurrent herpes labialis,and Abreva

Pediatric Dental Health

January 25, 2004

ORAL HERPES AND COLD SORES IN CHILDREN
One of the most common causes of painful blisters around the mouth is oral herpes. Herpes simplex virus (HSV) is responsible for most of the viral infections of the mouth. Herpes is also one of the most difficult viruses to control.

Oral herpes is easily transmitted, and is the most common form of the herpes simplex virus. Oral herpes affects people of all ages, races, and social groups. The highest incidence of initial infection occurs in children between six months and three years of age. By adolescence, 62% of Americans have been infected with herpes simplex virus-1 (HSV-1). Serum antibodies to HSV-1 can be found in up to 90% of Americans.

DESCRIPTION OF ORAL HERPES SIMPLEX:

Oral herpes in an infection caused by the herpes simplex virus. This virus can cause painful sores on the lips, tongue, roof of the mouth, and face. Herpes simplex virus-1 causes 80% of oral herpes infections, and herpes simplex virus–2 causes the rest. The herpes family of viruses contain a DNA core (double-stranded linear virus) which is surrounded by a capsid and lipid envelope.
The first infection a child will experience is termed primary herpetic gingivostomatitis. During this initial infection, infants and toddlers can develop very painful blisters on their tongue, and on the roof of the mouth. The gums will have a fiery red color, and the toddler may have a fever.
Between 20% to 40% of initial oral HSV-1 infections recur within one year. Recurrences are milder than the primary infection, and are commonly known as cold sores or fever blisters. Fever blisters on the lips and face is called herpes simplex labialis. This condition lasts about 7-10 days in healthy, immunocompetent children.
Oral herpes infections should not be confused with canker sores (aphthous ulcers). Aphthous ulcers are not caused by viruses, and appear as small white or grayish ulcers on the movable (unattached) gingival tissue.

THE DISEASE PROCESS OF ORAL HERPES:
Immediately after a child has been infected with the oral herpes virus, the infection proceeds to three distinct stages: primary herpes infection, dormancy, and recurrent herpes infection.
PRIMARY INFECTION:
This is the first infection a child will experience with the HSV-1 virus. The virus enters through abraded skin or normal intraoral tissue (mucous membrane). An oral infection called primary herpetic gingivostomatitis can develop at this time. In most cases, the virus never causes symptoms during this primary infection, however.
LATENCY (DOMRANCY):
After the primary infection, the viral particles move from the skin through branches of nerve cells that end at the trigeminal nerve ganglia, facial nerve ganglia, or dorsal root spinal ganglia. While residing in the ganglia, the herpes virus reproduces, and then becomes inactive (dormant). It is also possible for the virus to become dormant in the lips.
RECURRENT ORAL HERPES (HERPES SIMPLEX LABIALIS):
Approximately 30 to 40 percent of children who have been exposed to HSV will develop recurrent infections. These recurrent infections are a reactivation of the herpes simplex virus. The first symptoms may include a tingling or itching sensation on the lips or face. Recurrent herpes blisters usually appear around the lips within 12-36 hours after the first symptoms (the prodrome) appear. The blisters (vesicles) rupture quickly, and coalesce into larger lesions that have a crusted surface. In healthy children, these recurrent lesions on the lips and face will heal without scarring within seven to fourteen days.

Recurrent erythema multiforme has been linked to a previous HSV infection, and is called herpes-associated erythema multiforme.

The body normally produces an immune response to HSV, but the immune system cannot eradicate the virus completely. For patients with a depressed immune system, a herpes virus infection can have life-threatening consequences. Occasionally during the primary infection in infants, the virus can spread to the brain and cause aseptic meningitis, or disseminated neonatal HSV infection.

SIGNS AND SYMPTOMS OF AN ORAL HERPES INFECTION:
PRIMARY HERPTIC GINGIVOSTOMATITIS:
The symptoms of this intial infection are painful for infants and toddlers. Blisters form on the tongue and palate. The child’s gums (gingiva) appear fiery red and are painful to the touch. Infected children easily become dehydrated and weak, due to the pain associated with eating and drinking. Toddlers with primary herpes experience fever, malaise, loss of appetite, and severe intraoral pain. Increased salivation and foul breath may also be present.
RECURRENT HERPES LABIALIS:
Tingling or itching (prodromal signs) occurs at the infection site before the lip blisters actually appear. Then, clusters of blisters (vesicles) erupt. These blisters break down rapidly and appear as tiny gray ulcers on a red base. Within one or two days, they form a crust, and appear more yellow. It can take up to 14 days for the lip lesions to heal.

Sores may also appear inside of the mouth, along with swollen and red gums ( edematous and erythematous gingival tissue). These occasional intraoral sores may occur on the tongue, roof of the mouth, inside of the cheeks, and throat. The lymph nodes of the neck may swell and become painful.

DIAGNOSIS OF ORAL HERPES:
The child’s medical history and physical examination are usually sufficient to diagnose an HSV-1 infection. Any time an infant or toddler presents with: intraoral blisters, fiery red gingiva, fever, and intraoral pain - the diagnosis is likely to be primary herpetic gingivostomatisis.
Children older than 4 who experience painful lip or perioral lesions likely suffer from recurrent herpes labialis. The appearance of the lip lesions are very typical. Fever is usually not present during recurrent RHL.

LABORATORY TESTS USED IN DIAGNOSING ORAL HERPES:
The laboratory tests used to diagnose herpes viruses include:
the direct fluorescent assay, microscopic Tzank smear, viral culture analysis, immunologic tests, and polymerase chain reaction.
In the direct fluorescent assay, a monoclonal antibody labeled with fluorescein isothyocyanate is incubated with virally infected cells which have been placed on a glass slide. The infected cells appear fluorescent green when examined under a fluorescent microscope. The overall sensitivity of the DFA technique to detect HSV is 80% and the specificity is 98%-100%.
In the Tzank test, the base of the oral lesion must be scraped to obtain a sample of infected cells. The scraping are stained and examined microscopically. Finding specific giant cells with nuclei that carry the virus (inclusion bodies) suggests an HSV infection. Unfortunately, the test is accurate in only 50% to 70% of cases.
In the viral culture analysis, vigorous swabbing of the lesion with a special Dacron swab is needed to produce a usable fluid sample. The fluid containing the infected cells must be placed into a special viral transport medium, and must be kept refrigerated during transport to the laboratory. Viral cultures are almost 100% accurate if the lesions are still in the blister stage. A viral culture is the “gold standard” for the diagnosis of HSV-1.
In immunologic tests, a blood sample is taken for antibody studies. These test are most accurate when administered 12 to 16 weeks after exposure to the virus, however.

The three immunlolgic tests are the Western Blot, Herpes Select, and POCkit tests. These serologic tests are not always useful, however, since fewer than 5% of patients with recurrent HSV have a significant rise in their antibody levels.
During the polymerase chain reaction (PCR) assay, segments of the DNA of the herpes virus are isolated – and then replicated millions of times until the virus is detectable. It is a very expensive test.

TRANSMISSION OF ORAL HERPES VIRUS TO CHILDREN:
Most people have been infected by oral herpes before they reach adulthood. The oral herpes virus has been detected in the blood and saliva of children who have an active herpes infection. Children contract oral herpes having by having infected saliva touch their oral soft tissue or skin wounds.

Transmission may occur by:
kissing an infected child or adult, eating with contaminated utensils, mouthing or playing with contaminated toys, using a contaminated toothbrush, and exposure to another child with who has an oral herpes infection. Many children contract oral herpes by sucking on contaminated toys that have been used by infected children. Day care is notorious for spreading the oral herpes virus.

DENTAL TREATMENT AND ORAL HERPES INFECTION:
All stages of a herpes virus infection can be contagious, and the dentist must decide whether it is prudent to treat a child with an active infection. If a dentist decides to treat a child with an oral herpes infection - then gloves, mask, and eye protection are mandatory. The dentist must avoid spreading the virus to other areas of the child’s mouth and face. Fluid-filled vesicles are much more infectious than other stages of the herpes infection.
Dental treatment can cause reactivation of oral herpes within 3 days of major dental treatment, such as root canal treatment or dental surgery. Dental treatment may also cause introaoral recurrent herpes in the oral soft tissue (mucosa) adjacent to the teeth. Injections into the trigeminal or facial ganglions could cause massive outbreaks of the herpes infection.

PREVENTING RECURRENT ORAL HERPES INFECTION:
By avoiding certain triggers, it is possible to prevent recurrent herpes labialis infections (cold sores). Certain stimuli or triggers can activate a dormant (latent) herpes virus. The reactivation triggers include: UVB radiation from sunlight, oral or lip tissue injury, physical or emotional stress, common cold or influenza, fever, and malnutrition.
Using sunscreen is a very effective preventive measure for individuals whose recurrent herpes infections are triggered by ultraviolet light.
Colds and influenza are physically stressful conditions that affect the immune system. To reduce the risk of a recurrent herpes infection, sick children should get adequate rest, drink plenty of fluids, and maintain a healthy diet.
Individuals with 6 or more recurrences of herpes per year, those whose immune systems are suppressed, and children who suffer from erythema multiforme – require antiviral drugs to suppress the herpes virus.
It is almost impossible to prevent primary herpes in infants and toddlers, however.

TREATMENT FOR ORAL HERPES SIMPLEX:
No drug can actually cure or eliminate the herpes simplex virus. There are some drugs, however, that can improve healing time and reduce symptoms. The drugs developed against herpes are antiviral agents called nucleosides and nucleoside analogues – which block virus reproduction. Penciclovir 1% cream, acyclovir, and valacyclovir are prescription antiviral drugs which have been approved by the Federal Drug Administration for the treatment of recurrent herpes labialis (cold sores).
Penciclovir 1% cream (Denavir) is applied every 2 hours for 4 days. It reduces the duration of pain caused by recurrent herpes labialis.
Oral acyclovir (Zovirax) is prescribed at 20 mg/kg per day for children. Acyclovir may also be prescribed for a severe primary attack of HSV-1 in infants and toddlers. The oral and IV forms of acyclovir speed the healing of oral sores, and suppress viral shedding if taken within 24 hours of the first symptoms (the prodrome). Acyclovir is a competitive inhibitor of viral DNA polymerase. It does not kill the herpes virus, but limits the replication and spread of the virus to other cells.
Valacyclovir (Valtrex) is converted to acyclovir in the liver and intestine. It provides a higher concentration of acyclovir in the bloodstream, and requires less frequent dosing than with acyclovir.
Docosanol cream 10% (Abreva) is an OTC agent for oral herpes. It works by altering the healthy cell membranes to prevent viral entry.
Oral or IV antiviral medications are used only for children who : are younger than 6 months, have a weakened immune system, or have a severe infection.

TIPS FOR PARENTS:
For a primary oral herpes infection in an infant or toddler, ask your dentist or physician to prescribe a mouth rinse containing Benadryl and Kaopectate. This mixture can then be applied to the painful oral tissue using a couple of cotton swabs.
For recurrent herpes infection, consider using an OTC product such as docosanol cream (Abreva) – which will decrease pain and healing time.
For any herpes infection, discourage your child from touching oral sores. Wash your child’s hands frequently to prevent infecting the eyes or other parts of the body.
Do not let an infected child kiss siblings or other loved-ones.
Blisters and cold sores should be kept dry. Use tissue or apply some cornstarch.
Eating utensils should be thoroughly washed either by a dishwasher, or by hand – using hot, soapy water. Infected children must not share spoons, forks, or small toys.
Provide children’s Tylenol for fever and muscle aches.
Provide plenty of fluids to prevent dehydration.
If your child’s immune system is weakened, you should call your physician as soon as the cold sores appear. If your child is younger than 6 months, notify your physician when oral sores appear. In addition to affecting the mouth, the herpes virus can travel to the brain and cause encephalitis.

JOURNAL ARTICLE:
An article in U.S. Pharmacist discusses the problem of oral herpes. It covers: the etiology or herpes simplex labialis, describes the symptoms associated with cold sores, discusses methods to prevent the recurrence of cold sores, identifies the categories of drugs which can be used to provide symptomatic relief, and explains the mechanism of drugs used for treatment of oral herpes.

Makowiak ED. Prevention and treatment of cold sores. December 2003.

Copyright ©2004 Daniel Ravel DDS, FAAPD

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