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Oral Medicine

Recurrent Herpes Simplex: What Are the Possible Interventions?

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This short consult is presented by Dr. Eric Stoopler, DMD; Dr. Arthur Kuperstein, DDS; and Dr. Thomas Sollecito, DMD

Stoopler_Recurrent Herpes Simplex_Figure 2Stoopler_Recurrent Herpes Simplex_Figure 1

Peer-reviewed content that appeared in the JCDA OASIS “point of care” searchable database at www.jcdaoasis.ca and in the sixth edition of the print JCDA.

Primary and recurrent infection with herpes simplex virus (HSV-1 and HSV-2) can cause oral and/or genital lesions, although the majority of oral infections are caused by HSV-1. Symptomatic vesicles/ulcers of the oral mucosal tissues generally follow the onset of systemic symptoms and are often accompanied by significant erythema of the gingival tissues (i.e., “primary herpetic gingivostomatitis”). Treatment of primary HSV infections is usually palliative, while the majority of infections resolve within 2 weeks of symptom onset.

When a diagnosis of recurrent herpes simplex labialis (RHL) is determined, you have a range of interventions at your fingertips that are based on frequency and severity of lesions:

  • Abortive Therapy: Valacyclovir 2000 mg twice a day for one day or famciclovir 500 mg 2-3 times a day when the patient experiences prodromal symptoms.
  • Active Therapy: Acyclovir 400 mg 3 times a day for 5 to 7 days.
  • Prophylaxis Therapy: Sunscreen alone (SPF 15 or higher) or acyclovir 400 mg 2-3 times a day or valacyclovir 500 to 2000 mg twice a day.
  • Suppressive Therapy: This may be considered for patients with frequent, severe, and disfiguring RHL episodes. Patients should be referred to the appropriate dental or medical specialist for this type of management.
  • RIH: Immunocompromised patients with this condition may require extended courses of systemic antivirals and should be referred to the appropriate dental or medical specialist for this type of management.

Follow-up

  • It is unusual for lesions to not respond to typical antiviral agents. However, some lesions may be resistant to typical medications.
  • If lesion does not resolve with application of usual medications, further investigation is warranted.
  • Elective dental treatment should be deferred for patients with active lesions as aerosolization of the virus may occur during dental procedures, placing both the patient and oral health care provider at risk for possible infection or re-infection.

JCDA-OASIS supports clinical decisions. However, it does not provide medical advice, diagnosis or treatment details. JCDA-OASIS is a rapidly accessible, initial clinical resource—not a complete reference.

Suggestions and feedback should be directed to jcdaoasis@cda-adc.ca

 

6 Comments

  1. John Lovas DDS February 27, 2013

    Given that 1) Herpetic infections in general are so common; 2) recurrent Herpes labialis (RHL) is such a common, mild, primarily cosmetic inconvenience; 3) systemic antiviral therapy reduces the symptomatic period for RHL by ONLY 1 day; 4) Herpes viruses are known to develop resistance to systemic antivirals (probably in proportion to frequency of exposure to these drugs); 5) effective treatment of systemic Herpetic infections can be a life-or-death issue – should we then advocate the use of systemic antivirals for recurrent Herpes labialis?

    Reply
    1. Peter Olejarz March 1, 2013

      Based on personal experience, strong immune system seems to play a role. Since I started vitamin D3 supplementation, my oral herpes decreased from 4 to 6 episodes per year to 1 to 2 over the last 4 years. Since last Januaryr I started using ASEA, a redox signalling molecule product. As of today, I have not had a single episode of oral herpes.

      Peter Olejarz, DDS

  2. Eric Stoopler, DMD, FDS RCSEd February 27, 2013

    Thank you for your post.

    In response to your question “. . . should we then advocate the use of systemic antivirals for recurrent Herpes labialis?”,
    systemic antivirals are routinely used for management of recurrent herpes labialis. As mentioned in this post, they can be used in a variety of ways:

    Abortive Therapy: Valacyclovir 2000 mg twice a day for one day or famciclovir 500 mg 2-3 times a day when the patient experiences prodromal symptoms.

    Active Therapy: Acyclovir 400 mg 3 times a day for 5 to 7 days.

    Prophylaxis Therapy: Sunscreen alone (SPF 15 or higher) or acyclovir 400 mg 2-3 times a day or valacyclovir 500 to 2000 mg twice a day.

    Suppressive Therapy: This may be considered for patients with frequent, severe, and disfiguring RHL episodes. Patients should be referred to the appropriate dental or medical specialist for this type of management.

    Reply
    1. John Lovas DDS February 27, 2013

      Thank you, I’m well aware that systemic antivirals are routinely prescribed for RHL. I simply doubt that this is reasonable based on a risk : benefit analysis.

      When radiation therapy was first introduced, it was grossly overused, then scaled back because of radiation-induced sarcomas; when antibacterials were first introduced, these were grossly overused, then scaled back because of drug-resistant strains, drug reactions etc. Now systemic antivirals are routinely prescribed for an extremely common, trivial condition, to achieve – at best trivial benefits, – at worst drug-resistance with potentially fatal consequences.

  3. Ronn Gibb February 27, 2013

    The herpes simplex virus appears to be highly opportunistic in that it tends to find areas of inflammation and lodge there, creating ideal conditions for lesion formation. A piece of peanut that sits in the vestibule overnight can “cause” a canker sore. People that are prone to lesions must watch their diet, avoiding acidic foods, etc. Many are sensitive to chemicals in toothpaste (eg. sodium lauryl sulphate). These patients can have frequent outbreaks. Two patients of mine (father & daughter) had frequent lesions. The father had multiple lesions every month since he was a teenager. We took him off regular toothpaste and put him on Biotene. Almost immediately he was free of lesions and now says he has one occasionally and he is happy with that infrequency. This is only one of several patients like this.
    I agree with the above comments about restricting our use of anti-virals. Determining the reason that allows the viruses to get going is better treatment/prevention.

    Reply
  4. nasrin karim April 12, 2013

    I was the “demonstration” patient a couple of years ago for the treatment of a cold sore on my lip for lazer training at our clinic. The treatment lasted a few minutes and the lesion cured in a few hrs ,. There has been no recurrance since

    Reply

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