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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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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➤ 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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➤ 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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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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° 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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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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