Dental Management of Hand-Foot-Mouth Disease: Updated Clinical Guide for Dentists

Hand-foot-mouth disease (HFMD) is a common viral illness affecting children, often caused by Coxsackievirus A16 and Enterovirus 71. Its oral manifestations may lead to painful ulcers, feeding difficulties, and misdiagnosis with other conditions such as herpetic gingivostomatitis.

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Dentists play a crucial role in early recognition, supportive management, and patient education. This article provides updated clinical guidelines for oral healthcare professionals in the diagnosis and management of HFMD.

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✅ Introduction
HFMD primarily affects children under five, with outbreaks reported worldwide. Although self-limiting, its oral lesions may interfere with nutrition and hydration, increasing parental concern and healthcare consultations. Dental practitioners must differentiate HFMD from other viral infections and implement evidence-based management strategies to reduce discomfort and prevent complications.

✅ Clinical Oral Manifestations of HFMD

° Multiple painful vesicles and ulcers on the tongue, buccal mucosa, and palate.
° Lesions appear 2–3 days after fever and may resemble aphthous ulcers.
° Increased salivation and feeding refusal due to oral pain.
° Coexisting cutaneous lesions on palms, soles, and buttocks.

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✅ Dental Management Guidelines

1. Accurate Diagnosis
° Differentiate HFMD from herpetic gingivostomatitis, varicella, or aphthous stomatitis.
° Consider recent exposure to outbreaks in daycare or school settings.
2. Supportive Care
° Recommend soft, cold foods (yogurt, smoothies, ice cream).
° Ensure adequate hydration with water or electrolyte solutions.
3. Pain and Fever Management
° Analgesics such as acetaminophen or ibuprofen may be prescribed under medical supervision.

° Avoid topical anesthetics with benzocaine in children under 2 years (FDA warning).
4. Oral Hygiene Measures
° Gentle brushing with a soft-bristled toothbrush.
° Non-alcoholic mouth rinses for older children.
5. Infection Control
° Advise parents on isolation to prevent spread.
° Disinfect toys, utensils, and surfaces frequently.

📊 Tabla comparativa: Clinical Approaches in Dental Management of HFMD

Aspecto	Ventajas	Limitaciones
Supportive dietary recommendations	Relieve pain and improve hydration	May not provide full nutritional requirements
Pharmacological management	Controls pain and fever, improves patient comfort	Requires medical supervision, risk of misuse
Oral hygiene guidance	Prevents secondary infections and promotes healing	Difficult to maintain due to pain and irritability
Infection control education	Reduces community spread, improves public health	Dependent on parental adherence

Discussion
The dental management of HFMD focuses on symptomatic relief, prevention of dehydration, and infection control. While the disease is self-limiting, the oral discomfort it causes may lead to feeding difficulties and parental anxiety. Dentists must be well-informed to avoid unnecessary prescriptions such as antibiotics, which are ineffective against viral infections. Interdisciplinary collaboration with pediatricians enhances patient safety and ensures consistent guidance for families.

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Conclusion
HFMD is a frequent pediatric condition with significant oral manifestations. Dentists must recognize its clinical features, differentiate it from other viral illnesses, and provide supportive, evidence-based care. Educating parents about hydration, nutrition, oral hygiene, and infection control is essential in reducing disease burden.

📚 References

✔ Centers for Disease Control and Prevention (CDC). (2023). Hand, foot, and mouth disease (HFMD). Retrieved from https://www.cdc.gov/hand-foot-mouth/index.html

✔ Mayo Clinic. (2023). Hand-foot-and-mouth disease. Retrieved from https://www.mayoclinic.org/diseases-conditions/hand-foot-and-mouth-disease

✔ World Health Organization (WHO). (2022). Hand, foot and mouth disease. Retrieved from https://www.who.int/westernpacific/health-topics/hand-foot-and-mouth-disease

✔ Ooi, M. H., Wong, S. C., Lewthwaite, P., Cardosa, M. J., & Solomon, T. (2010). Clinical features, diagnosis, and management of enterovirus 71. The Lancet Neurology, 9(11), 1097–1105. https://doi.org/10.1016/S1474-4422(10)70209-X

✔ Cabrera-García, L., & Ramírez-Mora, J. (2021). Clinical manifestations of hand-foot-mouth disease in pediatrics. Revista de Pediatría y Salud Infantil, 38(2), 115–122.

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Viral diseases affecting the oral mucosa are frequent in pediatric dentistry and often present diagnostic and therapeutic challenges. The most common conditions include primary herpetic gingivostomatitis (HSV-1), hand-foot-mouth disease (HFMD, caused by Coxsackie and enteroviruses), and herpangina. Other relevant viral infections include varicella-zoster virus (VZV), Epstein–Barr virus (EBV), and cytomegalovirus (CMV).

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This article reviews the main viral oral diseases in children, including their signs, symptoms, diagnostic approaches, clinical features, pharmacological management, and therapeutic options, ending with a discussion and clinical conclusion.

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1. Major Viral Oral Diseases in Children

1.1 Primary Herpetic Gingivostomatitis (HSV-1)

➤ Signs and symptoms: Painful vesicles and ulcers on gingiva, lips, and oral mucosa; fever, malaise, cervical lymphadenopathy, and refusal to eat or drink, increasing the risk of dehydration.
➤ Diagnosis: Mainly clinical. In uncertain cases, PCR, viral culture, or Tzanck smear may be used.
➤ Treatment: Oral acyclovir (40–80 mg/kg/day in 3–4 doses for 7–14 days) is the drug of choice. Valacyclovir or famciclovir are options for recurrences. Topical antivirals are less effective.
➤ Clinical features: Highly contagious; recurrences are common and may benefit from daily prophylaxis in selected cases.

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1.2 Hand-Foot-Mouth Disease (HFMD)

➤ Signs and symptoms: Painful ulcers (2–4 mm) on tongue, gingiva, and palate; accompanied by papules and vesicles on hands and feet; fever and malaise are common.
➤ Diagnosis: Clinical. In atypical presentations, throat or stool samples may confirm viral etiology.
➤ Treatment: No specific antiviral therapy exists. Management includes analgesics (acetaminophen, ibuprofen), hydration, and topical anesthetics for oral pain. Aspirin should be avoided in children.
➤ Clinical features: Self-limiting, resolving within 7–10 days. High transmissibility in children under 5 years of age.

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1.3 Herpangina

➤ Signs and symptoms: High fever, sore throat, and headache, followed by small vesicles on the soft palate, tonsillar pillars, and uvula that evolve into ulcers ≤5 mm.
➤ Diagnosis: Clinical; differentiation from HSV is based on posterior vs. anterior lesion distribution.
➤ Treatment: Supportive; pain relief and hydration. Symptoms usually resolve within 5–7 days.

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2. Other Viral Infections of the Oral Cavity
Other less frequent but clinically relevant infections include varicella-zoster (chickenpox and herpes zoster), infectious mononucleosis (EBV), CMV infections, and oral papillomavirus lesions. These conditions may present with vesicles, erythematous patches, or papillary growths such as squamous papilloma and focal epithelial hyperplasia.

3. Diagnostic Considerations
A careful evaluation of lesion distribution, systemic symptoms, and medical history is crucial. In complex or atypical cases, laboratory tests such as PCR, serology, or biopsy may be required to confirm viral etiology.

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4. Management and Pharmacological Interventions

° Herpangina & HFMD: Supportive care with analgesics and hydration.
° HSV-1: Oral acyclovir remains the gold standard; valacyclovir and famciclovir are effective alternatives in adolescents and recurrent cases.
° Other viral infections: Generally self-limited; antiviral therapy is rarely required, except in immunocompromised patients or severe cases.

Comparative Table: Viral Oral Diseases in Children

Feature	Primary Herpetic Gingivostomatitis (HSV-1)	Hand-Foot-Mouth Disease (HFMD)	Herpangina
Etiology	Herpes simplex virus type 1 (HSV-1)	Coxsackie A16, Enterovirus 71	Coxsackie A, B
Age group	6 months – 5 years	<5 years	<10 years
Oral lesion location	Anterior mucosa, gingiva, lips	Tongue, gingiva, hard palate	Soft palate, tonsillar pillars, uvula
Lesion type	Vesicles → painful ulcers	Vesicles and small ulcers	Small gray vesicles → ulcers
Systemic symptoms	High fever, malaise, lymphadenopathy	Low-grade fever, malaise	High fever, sore throat, headache
Transmission	Saliva, direct contact	Fecal-oral, droplets	Fecal-oral, droplets
Duration	10–14 days	7–10 days	5–7 days
Treatment	Oral acyclovir, hydration, pain control	Symptomatic: analgesics, hydration	Symptomatic: analgesics, hydration
Complications	Dehydration, recurrence, secondary infection	Dehydration, nail changes (rare)	Dehydration, rare complications

5. Discussion
Viral oral infections in children are highly prevalent and must be correctly identified to ensure proper management. Although most are self-limiting, they can significantly affect nutrition, hydration, and quality of life. Pediatric dentists must differentiate among herpetic gingivostomatitis, HFMD, and herpangina to prevent misdiagnosis and overtreatment.
Recent literature emphasizes decision-making algorithms for pediatric oral lesions, highlighting the need for continuous education in pediatric dentistry.

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6. Conclusion
The most common viral diseases of the oral mucosa in children—HSV-1, HFMD, and herpangina—present distinct features that allow clinical differentiation. While HSV requires specific antiviral therapy, HFMD and herpangina rely on symptomatic management. Accurate diagnosis prevents complications such as dehydration and secondary infections. Pediatric dentists must remain updated on viral oral manifestations to provide evidence-based care.

📚 References

✔ American Academy of Family Physicians (AAFP). (2010). Nongenital herpes simplex virus. American Family Physician, 82(9), 1075-1082. Retrieved from https://www.aafp.org/pubs/afp/issues/2010/1101/p1075.html
✔ Guillouet, C., et al. (2022). Oral lesions of viral, bacterial, and fungal diseases in children: Diagnostic decision tools. Frontiers in Pediatrics. https://pmc.ncbi.nlm.nih.gov/articles/PMC9358008/
✔ Mayo Clinic. (2025, July 26). Hand-foot-and-mouth disease: Diagnosis & treatment. Retrieved from https://www.mayoclinic.org/diseases-conditions/hand-foot-and-mouth-disease/diagnosis-treatment/drc-20353041
✔ Santosh, A. B. R., & Muddana, K. (2020). Viral infections of the oral cavity: Clinical presentation, pathogenic mechanism, investigations, and management. Journal of Family Medicine and Primary Care, 9(1), 36–42. https://journals.lww.com/jfmpc/fulltext/2020/09010/viral_infections_of_oral_cavity.8.aspx


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