Subject: Dental Care for the Patient with an Oral Herpetic Lesion

The AAOM affirms that risk factor assessment for oral diseases including oral and oropharyngeal cancers, and a non-invasive visual and tactile oral mucosal examination is part of the standard initial and recall visit by oral health care providers and is recommended for all patients. Originator: Dr. Craig S. Miller, DMD, MS

This Clinical Practice Statement was developed as an educational tool based on expert consensus of the American Academy of Oral Medicine (AAOM) leadership. Readers are encouraged to consider the recommendations in the context of their specific clinical situation, and consult, when appropriate, other sources of clinical, scientific, or regulatory information prior to making a treatment decision. 

Originator:       Dr. Craig S. Miller, DMD, MS
Review:           AAOM Education Committee
Approval:         AAOM Executive Committee
Adopted:         November 25, 2014
Updated:         January 2, 2016


The American Academy of Oral Medicine (AAOM) affirms that treatment of dental patients should encompass recognition of infectious diseases that can manifest in the orofacial region, implementation of disease management, and prevention of disease transmission. Furthermore, the AAOM recommends education and training on infectious diseases and procedures that reduce the risk of disease transmission and that provide for disease control within the dental setting.


This statement is based on a review of the current literature related to dental care for the patient with an oral herpetic lesion. A MEDLINE search was conducted
using the terms “herpes,” “herpes simplex,” “disease control,” “transmission,” and “dentistry.” Expert opinions and best current practices were relied upon when direct evidence was not available.


Viral infections in the oropharynx are common. One widespread viral pathogen that infects the epithelium of this region is herpes simplex virus (HSV). Primary HSV infections are frequent in infants, children, and adolescents and less common in adults.1-3 During the primary infection, the virus replicates in the epithelium of the lips, face, and oral mucosa, and then the progeny penetrate the basal epithelium and infect the peripheral nerve endings.1,4 In the first few days of the infection, virions are transmitted to the trigeminal ganglion, where HSV enters a latent-like state for the life of the host.5 Periodically, the virus reactivates and migrates peripherally via nerve axons to the skin or the mucosa, where it reappears subclinically or as a recurrent lesion (e.g., herpes labialis or intraoral recurrent HSV infection). Primary and recurrent HSV lesions are infectious and can serve as a source of transmission.6 Spread of HSV from patients to dental health care workers and from dental health care workers to patients has been reported.7-9 

Dentists are responsible for the proper evaluation and risk assessment of their patients as well infection control in the health care setting. Thus, recognition of viral infections, knowledge of standard precautions, and implementation of prevention strategies are important components of the infection control process. Clinicians should be aware that primary HSV infection generally appears as multiple vesicles or ulcers on the lips, perioral skin, gingiva, tongue, or oral mucosa. During the first week of the primary infection, the virus replicates and spreads. The initial viral infection is accompanied by inflammation and can lead to coalescing and bleeding ulcers that are painful. Difficulty in eating or swallowing is common. Regional lymphadenitis, fever, and malaise are often present.

Recurrent HSV infection generally appears as single vesicles or a small cluster of vesicles that rupture quickly, forming ulcers. The ulcers usually occur on the keratinized epithelium of the hard palate and gingiva.

Herpes labialis generally appears as a cluster of vesicles on the lips or the perioral region. Recurrent herpetic lesions generally erupt episodically at or near
the site of the primary infection and may be induced by a variety of factors, including trauma, stress, fever, and outdoor exposures. HSV recurrences are generally selflimiting; however, recurrent infections can trigger erythema multiforme10 and can spread and be more severe in immunosuppressed patients.11,12 Patients can shed HSV in their saliva during periods when lesions are present and in between recurrences when lesions are not present.

In summary, clinicians should be aware that:

  1. The oral cavity and saliva contain potentially infectious material (i.e., viruses).13,14

  2. HSV has a predilection for the oral cavity.

  3. HSV recurrences are common in and around the oral cavity.

  4. HSV lesions proceed through several stages before healing. The usual stages are prodrome, macule, papule, vesicle, ulcer, scab, healed area with redness, and complete healing.

  5. HSV lesions are infectious during the vesicle and ulcer stage (i.e., until the scab stage).

  6. Measures should be implemented to prevent the spread of infection.

  7. Antivirals can block replication of HSV-1 if prescribed early in the course of infection and at the appropriate dose.

Policy Statement:
  1. The AAOM recognizes that
    1. risk assessment involves visual inspection of the patient before the delivery of dental treatment, and clinicians should recognize the clinical features of viral infections, such as HSV infection.

    2. viral infections in and around the oral cavity can serve as a source of contagion and are a potential occupational hazard to the dental team and other patients.

    3. clinicians should implement strategies that limit the recurrence of oral and perioral HSV infection.

  2. The AAOM recognizes that
    1. standard precautions should be implemented that protect the health care provider and patient from the spread of infection per published guidelines.15-17 This includes
      1) wearing of personal protective equipment during the treatment of patients
      2) avoiding the manipulation of tissues infected with HSV
      3) implementing airborne precautions, that is, minimizing the use of aerosolizing agents and devices (e.g., handpiece, ultrasonic scaler, and air polisher) around HSV lesions15-17
      4) avoiding the use of petrolatum products on active HSV lesions that contain fluids or are emanating fluids (i.e., prior to the scab stage)

  3. The AAOM recognizes that
    1. delaying care until an HSV lesion is scabbed over or completely healed is prudent for minimizing recurrences and spread of the infection, and that the presence of an infectious HSV lesion orally or periorally can be a reason for deferral of care.

  4. The AAOM recognizes that:
    1. antiviral agents can be provided to help prevent recurrent herpes lesions, shorten lesion duration, and reduce pain.18,19

    2. the administration of antiviral agents is likely most beneficial when taken within 72 hours of lesion eruption.20

    3. use of topical anesthetics, anti-inflammatory agents, and analgesics can help reduce the pain of recurrent herpes lesions.

  1. Miller CS, Redding SW. Diagnosis and management of orofacial herpes simplex virus infections. Dent Clin North Am. 1992;36: 879-895.

  2. Amir J, Nussinovitch M, Kleper R, Cohen HA, Varsano I. Primary herpes simplex virus type 1 gingivostomatitis in pediatric personnel. Infection. 1997;25:310-312.

  3. Elangovan S, Karimbux NY, Srinivasan S, Venugopalan SR, Eswaran SVK. Hospital-based emergency department visits with herpetic gingivostomatitis in the United States. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113:505-511.

  4. Fatahzadeh M, Schwartz RA. Human herpes simplex virus infections: epidemiology, pathogenesis, symptomatology, diagnosis,
    and management. J Am Acad Dermatol. 2007;57:737- 763.

  5. Hill JM, Ball MJ, Neumann DM, et al. The high prevalence of herpes simplex virus type 1 DNA in human trigeminal ganglia is not a function of age or gender. J Virol. 2008;82: 8230-8234.

  6. Lewis MA. Herpes simplex virus: an occupational hazard in dentistry. Int Dent J. 2004;54:103-111.

  7. Browning WD, McCarthy JP. A case series: herpes simplex virus as an occupational hazard. J Esthet Restor Dent. 2012;24: 61-66.

  8. Manzella JP, McConville JH, Valenti W, et al. An outbreak of herpes simplex virus type I gingivostomatitis in a dental hygiene practice. JAMA. 1984;252:2019-2022.

  9. Goodman RA, Solomon SL. Transmission of infectious diseases in outpatient health care settings. JAMA. 1991;265:2377-2381.

  10. Samim F, Auluck A, Zed C, Williams PM. Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. Dent Clin North Am. 2013;57:583-596.

  11. Silverman S Jr. AIDS update. Oral manifestations and management. Dent Clin North Am. 1991;35:259-267.

  12. Johnson NW. The mouth in HIV/AIDS: markers of disease status and management challenges for the dental profession. Aust Dent J. 2010;55:85-102.

  13. Miller CS, Danaher RJ. Asymptomatic shedding of herpes simplex virus (HSV) in the oral cavity. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;105:43-50.

  14. Tateishi K, Toh Y, Minagawa H, Tashiro H. Detection of herpes simplex virus (HSV) in the saliva from 1,000 oral surgery outpatients by the polymerase chain reaction (PCR) and virus isolation. J Oral Pathol Med. 1994;23:80-84.

  15. Kohn WG, Harte JA, Malvitz DM, Collins AS, Cleveland JL, Eklund KJ. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settingsd2003. J Am Dent Assoc. 2004;135:33-47.

  16. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Health care infection control practices advisory committee. 2007 guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007;35:S65-S164.

  17. Harrel SK, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc. 2004;135:429 437.

  18. Gilbert S, Corey L, Cunningham A, et al. An update on shortcourse intermittent and prevention therapies for herpes labialis. Herpes. 2007;14:13A-18A.

  19. Rahimi H, Mara T, Costella J, Speechley M, Bohay R. Effectiveness of antiviral agents for the prevention of recurrent herpes labialis: a systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113:618- 627.

  20. Sawtell NM, Thompson RL, Stanberry LR, Bernstein DI. Early intervention with high-dose acyclovir treatment during primary herpes simplex virus infection reduces latency and subsequent reactivation in the nervous system in vivo. J Infect Dis. 2001;184: 964-971.

This Clinical Practice Statement was developed as an educational tool based on expert consensus of the American Academy of Oral Medicine (AAOM) leadership. Readers are encouraged to consider the recommendations in the context of their specific clinical situation, and consult, when appropriate, other sources of clinical, scientific, or regulatory information prior to making a treatment decision.