Viral Infections in Children
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Direct answer
Primary herpetic gingivostomatitis is the viral illness a paediatric dentist owns: HSV-1 infection of a young child, peaking between six months and five years, presenting with fever, drooling and refusal to eat, and gingiva that is red and swollen, studded with vesicles that rupture into yellow-grey ulcers across the anterior mouth. Management is hydration first, analgesia with weight-appropriate paracetamol, and oral acyclovir at commonly cited paediatric doses (15 mg per kilogram five times daily for about seven days) when started within roughly 72 hours of onset. Around it sit the look-alikes and neighbours: herpangina and hand-foot-mouth disease from coxsackieviruses, dominated by posterior pharyngeal and peripheral lesions respectively; measles announcing itself through Koplik spots; mononucleosis with its palatal petechiae in adolescents; and HPV lesions from verrucae to focal epithelial hyperplasia.
What you must remember
- Primary herpetic gingivostomatitis: HSV-1, typically between six months and five years; fever, cervical lymphadenopathy, fiery swollen gingiva, vesicles breaking to fibrin-covered ulcers; illness runs 7-14 days and dehydration is the real danger.
- Acyclovir arithmetic: commonly cited as 15 mg/kg five times daily for seven days, most effective within about 72 hours — always paired with "supportive care and hydration".
- Supportive protocol: fluids tracked by urine output, soft bland diet, paracetamol 10-15 mg/kg, topical benzydamine rinses; viscous lidocaine is avoided in young children.
- Herpangina: coxsackievirus A, summer-autumn seasonality, vesicles and ulcers confined to the soft palate, tonsillar pillars and posterior pharynx — the posterior distribution is the differentiator.
- Hand-foot-mouth disease: coxsackievirus A16 and relatives, oral ulcers plus vesicles on palms, soles and buttocks; monsoon-season outbreaks in Indian schools.
- Koplik spots: pathognomonic prodromal measles — grey-white "grains of salt" on an erythematous buccal mucosa opposite the molars, appearing before the rash.
- Infectious mononucleosis (EBV): adolescent fever, lymphadenopathy and fatigue, with palatal petechiae at the hard-soft palate junction; a rash classically follows amoxicillin.
- Practice points: elective treatment is deferred during active HSV and varicella; gloving protects staff from herpetic whitlow; recurrent herpes labialis follows triggers like UV light and illness.
Two febrile toddlers with ulcers
A twenty-month-old arrives after three days of fever, drooling and refusing everything including water. Examination shows swollen, bleeding interdental papillae and a crop of yellow-grey ulcers on the dorsal tongue and anterior buccal mucosa, none posterior enough for herpangina. This is primary herpetic gingivostomatitis at the edge of the acyclovir window — the prescription carries the hydration instruction: small frequent sips, cold fluids, paracetamol dosed by weight, review in 48 hours, and explicit return criteria of reduced urine, drowsiness or persistent refusal. The mother is taught the two facts that prevent the next month's chaos: the ulcers are contagious to other children and to her own fingers, and teething is not the diagnosis.
The second toddler, four years old, arrives in August with fever and ulcers — but the lesions sit on the soft palate and pillars, the gums are normal, and the mother has noticed "blisters on his palms". Hand-foot-mouth disease is a clinical diagnosis, managed supportively without acyclovir, plus a note to the playschool about exclusion. The pair teaches the discriminator the exam will test: anterior mouth with gingivitis is herpetic; posterior pharynx with clean gums and peripheral vesicles is enteroviral. A third child with grey dots on the buccal mucosa opposite the first molars, feverish before any rash, extends the lesson — Koplik spots mean measles, and the dentist's notification starts the public health clock.## How exams frame the topic
Theory papers ask for primary herpetic gingivostomatitis as a short note: causative agent, age band, clinical picture, differential and management — with the acyclovir timing (within 72 hours) as the mark-carrying detail. MCQs revolve around position: herpangina's posterior palate versus herpetic gingivitis anteriorly, Koplik spot location opposite the molars, HFMD's peripheral vesicles, and the palatal petechiae of mononucleosis. The management MCQ tests the negative list — viscous lidocaine withheld in toddlers, antibiotics useless unless superinfection. Indian exam conventions sit this topic at the junction of pedodontics, oral pathology and oral medicine, so identical questions recur across papers — and the monsoon-season framing of coxsackievirus outbreaks is the locally flavoured sentence that earns the viva smile.
Frequently asked questions
What causes primary herpetic gingivostomatitis and at what age?
HSV-1, typically six months to five years of age, with fever, swollen gingiva and vesicles rupturing into anterior oral ulcers.
When should acyclovir be given in primary herpetic infection?
Early — ideally within about 72 hours of onset — at commonly cited doses of 15 mg/kg five times daily for around seven days, alongside hydration and analgesia.
How is herpangina distinguished from herpetic gingivostomatitis?
Herpangina lesions sit posteriorly on the soft palate and pillars with normal gingiva; herpetic disease inflames the gingiva and predominates anteriorly.
What are Koplik spots and their significance?
Grey-white spots on erythematous buccal mucosa opposite the molars — pathognomonic prodromal measles signs, appearing before the rash.
Should routine dental treatment proceed in a child with active herpes infection?
No — elective care is deferred for contagion and comfort while lesions are active.