Oral Herpes Simplex Viral (HSV) infections are commonly referred to as “Cold Sores”. The following is an article I had co-written for Canadian continuing education programs for Medical Doctors and Pharmacists.
Viral infections of the oral mucosa are frequently encountered in general practice. The clinical diagnosis of these lesions can sometimes be confusing due to similar clinical presentations as other oral conditions, such as ulcers, blisters, trauma or connective tissue disorders.
There are three types of oral herpetic infections: Acute Primary Herpetic Gingivostomatitis, Herpes Simlex Labialis and Recurrent Intra-Oral Herpes. The clinical presentation, diagnosis and appropriate management of these herpetic infections of the oral mucosa are discussed here.
Acute Primary Herpetic Gingivostomatitis
Approximately 1% of initial oral infections with Herpes Simplex Virus manifests as a very visible and acutely symptomatic primary infection. While this infection usually occurs in children, they also occur in adults . Mild forms look like multiple small punctuate shallow ulcers involving both the keratinizing (dorsal surface of the tongue, hard palate and gums) and non-keratinizing (buccal mucosa, ventral and lateral tongue and vestibule) oral mucosal surfaces. Severe forms may present as large diffuse whitish ulcers that have scalloped borders and erythematous halos. The patient often experiences fever and lymphadenopathy that lasts from 2 to 10 days. The painful ulcers and myalgia make masticating and swallowing difficult. In healthy individuals, these symptoms usually only last 2 to 4 days. However, in an immune-compromised patient an extended period of primary herpetic gingivostomatitis may develop. In these patients, the surface lesions are often larger and deeper than the lesions in healthier patients.
Herpes Simplex Labialis & Recurrent Intra-Oral Herpes
The two clinical types of recurrent oral herpes simplex infections, recurrent herpes labialis and recurrent intraoral herpes, are based on the location of the lesions. Recurrent herpes labialis affects the lips, whereas recurrent intraoral herpes involves the slope of the hard palate or maxillary gingiva. These recurrent lesions are commonly seen after the fragile lips have been manipulated during dental treatment. Lesions on the lips form fluid-filled vesicles that rupture, ulcerate and resolve as crusted brownish lesions. Intraoral lesions differ as they are punctuate with red or white bases. Herpes labialis is the most common form of recurrent herpes simplex infections, and occurs in 15-20% of those who have had a primary infection. As it often occurs following an upper respiratory tract infection, it is frequently referred to as a “cold sore”. The herpes simplex virus remains latent in the trigeminal ganglion but can be reactivated by prolonged exposure to sunlight, trauma and manipulation of the lips, fever, immune-suppression, menstruation, stress and anxiety. Patients often report a prodromal phase of tingling in the area in the days before an oral lesion appears. While patients are often uncomfortable from these infections, they usually do not experience concurrent fevers or lymphadenopathy. However, immune-suppressed patients usually experience larger and deeper lesions and have fevers and lymphadenopathy resembling a primary form of the disease.
When an outbreak starts, it usually goes through these phases:
1. Prodrome—This is often called the “tingle” stage, which is the first warning sign that an outbreak is coming on.
2. Blister—At this stage, swelling develops, with the blister filling with fluid that contains millions of virus particles.
3. Ulcer—At this point, the blister usually ruptures, leaving a painful, reddish ulceration. During this stage the cold sore is most contagious.
4. Scab/Crusting—When the ulcer dries, it leaves a scab or crust. Many find this stage painful because smiling, talking and eating can break the scab open. Severe itching and/or burning is also a problem.
5. Healing—At this stage, the scab starts to come off, leaving some dry flaking and residual swelling.
Patients may be uncomfortable talking to their health care professionals about their herpetic viral infections. Alternatively, they may attempt to self-medicate with various products including lip balms and “natural” remedies.
However, they may be more confused than ever, given the new category entrants that promise faster healing but lack sufficient supporting clinical research. Unfortunately, the overabundance of misinformation on the internet related to HSV treatments adds further confusion as the patient has no ability to separate fact from fiction.
Since dental practitioners encounter patients with HSV infections on a routine basis, they should use this opportunity to educate their patients.
Treatment of HSV Infections
Patients should be advised that HSV-1 is self-limiting and lesions will heal without treatment. Since oral herpetic infections can be physically and emotionally distressing to patients, treatment goals should include prevention, palliative measures to help minimize symptoms, and medications that may yield a faster healing process and shorter symptom duration.
Preventive measures must include lowering the risk of trauma to the oral mucosa such as the frequent use sunscreen-containing lip balms. If the manipulation of the lips during dental appointments leads to a manifestation of the infection, the dentist may want to consider prescribing an antiviral medication as a prophylactic.
There are several treatments available to help minimize symptoms. In the prodromal phase antiviral creams, such as Zovirax, can be used. For patients presenting with a lesion, pain control with analgesics and topical anaesthetics and prevention of lesion dryness and cracking with a petroleum-based moisturizer is beneficial. Recurrent herpes labialis and recurrent intraoral HSV infections can be treated with various classes of medications:
1. Over-The-Counter (OTC) Palliative Care Agents — This category of medications relieve symptoms only with no impact on the healing cycle. Examples include topical anesthetics and coating agents (diphenhydramine elixir 12.5mg mixed with kaopectate OTC or Maalox OTC mixed to a 50:50 ratio. Directions are rinse 1tsp for 2min BID and before each meal, and spit out)
2. OTC Cell-Entry Virus Blockers — This class of medications inhibits penetration of viral DNA into healthy oral mucosal cells. They are the only OTC class to have shown a clinically significant positive impact on shortening the healing cycle.
3. Prescription Antivirals — These medications inhibit DNA-polymerase in mucosal cells where viral penetration has already occurred. They shorten the healing period.
4. Healing Patches — These use hydrocolloid technology to form a protective barrier that contains the virus. Not only do they relieve symptoms and have a positive impact on the healing cycle, they also cover herpetic lesions, causing less social embarrassment.
5. Propolis-based NPH products — These indirectly act as an anti-viral agent by interfering with one of the steps of viral replication. They also help prevent the spread of infection through antibacterial and antifungal effects.
Understanding the differences in OTC products is important. Without the proper information, your patients may suffer in silence or use the wrong product, inadvertently prolonging their outbreak. Health practitioners should explain to their patients that OTC treatments such as lip balms may include moisturizers to prevent cracking and analgesics to relieve comfort, but they have not been proven to shorten the healing period.
The sooner treatment begins, the more effective a treatment will be. Unlike prescription products, a clinically proven OTC medication could allow patients to treat their cold sore immediately at the first tingle.