The case

A two year old male presents with “really bad breath” and swollen gums. He was fine until 2 to 3 days ago, when his mom noted that he looked uncomfortable when he was chewing. The next morning she noted that his gums were red and swollen and seemed to bleed easily. He also developed a fever to 102.7 F.

The diagnosis

This is herpetic gingivostomatitis. According to Kolokotronis et al. it is the most common primary herpes virus infection in children. 


Primary herpetic gingivostomatitis patients have ulcerative lesions of the gingiva and mucous membranes. The peak age range is 6 months to 5 years and effects both boys and girls. Children can be exposed to symptomatic or asymptomatic individuals through contact with oral secretions and then exhibit symptoms one week later. Children with primary gingivostomatitis may shed HSV for 1-3+ weeks. They may have intermittent, and undetected, asymptomatic shedding throughout life because the virus hides in the trigeminal ganglion.

After the initial 4 day-ish prodrome that includes fever, decreased appetite, malaise and headache. At first many parents may confuse this with teething. Teething does not include red and edematous oral mucosae that eventually evolve into clusters of small vesicles. Though these lesions can often be seen on the gums they also show up on the tongue, palate, pharynx and lips too. Most of these lesions heal within one week, some last up to 3 weeks. Scarring does not occur. A prospective study from Amir et al noted the following regarding symptoms;

  • Mean duration of oral lesions – 12.0+/-3.4 days
  • Extraoral lesions – 12.0 +/-3.9 days
  • Fever – 4.4+/-2.4 days
  • Eating/drinking difficulties – 9.1+/-3.0 and 7.1+/-3.1 days

The most common complication is dehydration, which is a sequelae from refusing to drink. Treatment centers around good pain control. Avoid oral opiates if possible and use appropriate weight-based dosing of acetaminophen and ibuprofen. Children with lip lesions should have a barrier cream like petroleum jelly applied. “Magic mouthwash” or other oral therapies, including topical anesthetics are not routinely recommended and may have toxicity from central absorption. Hopper et al. demonstrated that topical 2% lidocaine offered no benefit over placebo gel in improving oral intake.


Kolokotronis A, Doumas S. Herpes simplex virus infection, with particular reference to the progression and complications of primary herpetic gingivostomatitis. Microbiol Infect. 2006;12(3):202. 

Daniels CA, LeGoff SG. Shedding of infectious virus/antibody complexes from vesicular lesions of patients with recurrent herpes labialis. Lancet. 1975;2(7934):524.

Amir J, Harel L, Smetana Z, Varsano I. The natural history of primary herpes simplex type 1 gingivostomatitis in children. Pediatr Dermatol. 1999;16(4):259. 

Hopper SM, McCarthy M, Tancharoen C, Lee KJ, Davidson A, Babl FE. Topical lidocaine to improve oral intake in children with painful infectious mouth ulcers: a blinded, randomized, placebo-controlled trial. Ann Emerg Med. 2014;63(3):292. Epub 2013 Nov 7.