Oral herpes

Oral herpes is an infection of the mouth and lips caused by a specific type of the herpes simplex virus also termed HSV-1, type 1 herpes simplex virus, or oral herpes. The virus causes painful sores on the lips, gums, tongue, roof of the mouth, inside the cheeks, and sometimes on the face and neck. It also can cause symptoms such as fever and muscle aches. People commonly refer to the infection as herpes labialis or "cold sores." Another condition, "canker sore," is sometimes thought to be caused by HSV, but this is not true. Canker sores occur only inside the mouth, on the tongue, and on the soft palate (roof of mouth), not on skin surfaces. Although they reoccur, they are not contagious, usually are self-limiting, and have almost no complications. Canker sores are caused by substances that irritate the oral mucosa.
There are two types of HSV, termed HSV-1 and HSV-2. These two viruses have distinctly different DNA, and both cause oral and genital lesions. However, HSV-1 causes about 80% of all oral lesions and only about 20% of genital lesions while HSV-2 causes the reverse (80% genital and 20% oral). Studies also suggest that in adolescents, up to 40% of genital herpes is caused by HSV-1 because of reported increased oral/genital contact (transmission by oral sex).
Oral herpes (HSV-1) infection or exposure without noticeable infection is common. About 65% of the U.S. population has detectable antibodies to HSV-1 by age 40. This article will focus on HSV-1, or oral herpes, not on HSV-2, also commonly known as genital herpes. HSV-2 is considered to be a sexually transmitted disease (STD). In addition, HSV-2 virus should not be confused with human papillomavirus (HPV), the cause of genital warts and some cervical and other cancer types.

•    HSV-1 affects only humans. Mouth sores most commonly occur in children 1-2 years of age, but they can affect people at any age and any time of the year also termed herpes gingivostomatitis
•    People contract HSV-1 by touching infected saliva, mucous membranes, or skin. Because the virus is highly contagious, a majority of the population is infected by at least one herpes subtype of HSV-1 before adulthood.
•    After HSV-1 infects a person, it has a rather unique ability to proceed through three stages.
  
      o    Stage 1 - Primary infection: The virus enters the skin or mucous membrane, usually through small cracks or breaks, and then reproduces. During this stage, oral sores and other symptoms, such as fever, may develop.The virus may not cause any sores and symptoms. People may not know that they have an infection. This is called asymptomatic infection.
    Asymptomatic infection occurs twice as often as the disease with symptoms.
      o    Stage 2 - Latency: From the infected site, the virus moves to a mass of nerve tissue in the spine called the dorsal root ganglion. There the virus reproduces again, usually without any symptoms, and becomes inactive, until reactivated by certain body conditions .
      o    Stage 3 - Recurrence: When people encounter certain stresses, emotional or physical, the virus may reactivate and cause new sores and symptoms. The following factors may contribute to recurrence: stress, ultraviolet light (including sunshine), fever, fatigue, hormonal changes (for example, menstruation), immune depression, and trauma to a site or a nerve region where previous HSV infection occurred.

Oral Herpes (HSV-1) Causes
Herpes simplex virus (HSV) is a DNA virus that causes sores in and around the mouth. Two herpes subtypes may cause these sores.
•    Herpes simplex virus (type 1, herpes-1or HSV-1), which causes about 80% of cases of oral herpes infections
•    Other herpes simplex viruses (type 2, herpes-2 or HSV-2), which causes the other approximately 20%
These viruses enter the body through small cuts, abrasions, or breaks in the skin or mucous membranes. The majority enter after an uninfected person has direct contact with someone carrying the virus (either with or without noticeable lesions). Simply touching an infected person is often the way children get exposed. Adolescents and adults frequently get exposed by skin contact also but may get their first exposure by kissing or sexual contact, especially for HSV-2.
Oral lesions and genital lesions can reoccur. This happens because the HSV viruses are still alive but exist in nerve cells in a quiet, inactive dormant state. Occasionally, conditions in the body  allow the HSV to actively multiply, resulting in a new crop of lesions.
The HSV viruses multiply in the human cells by overtaking and utilizing most of the human cells functions. One of the HSV steps in multiplication is to take control of the human cell's nucleus and alter its structure. The altered nucleus enlarged and lobulated or multinucleated is what is used to help diagnose HSV infections by microscopic examination. The reason sores appear is because as they mature the many HSV particles rupture the human cell's membrane as they break out of the cell.

 Symptoms and Signs
•    Incubation period: For HSV-1, the amount of time between contact with the virus and the appearance of symptoms, the incubation period, is two to 12 days. Most people average about four days.
•    Duration of illness: Signs and symptoms will last two to three weeks. Fever, tiredness, muscle aches, and irritability may occur.
o    Pain, burning, tingling, or itching occurs at the infection site before the sores appear. Many patients have reported these symptoms prior to the appearance of sores, bumps, or blisters. Then clusters of blisters erupt. These blisters break down rapidly and, when seen, appear as tiny, shallow, gray ulcers on a red base. A few days later, they become crusted or scabbed and appear drier and more yellow.
o    Oral sores: The most intense pain caused by these sores occurs at the onset and can make eating and drinking difficult.
  The sores can occur on the lips, gums, throat, the front of the tongue, the inside of the cheeks, and the roof of the mouth.
    They can also extend down the chin and neck.
   The gums can become mildly swollen, red-colored, and may bleed. 
    Neck lymph nodes often swell and become painful.
    People in their teens and 20s can develop a painful throat with shallow ulcers and a grayish      coating on the tonsils

Medical Treatment
Treatment includes medication for fever and taking plenty of fluids.
•    A topical anesthetic such as viscous lidocaine (Dilocaine, Nervocaine, Xylocaine, Zilactin-L) may be prescribed to relieve pain associated with oral blisters and lesions.
•    Oral or IV medication does exist for HSV but is not recommended for people with a normal immune system. It is used only for people with weakened immune systems, infants younger than 6 weeks of age, or people with severe disease.
•    Some people may require hospital admission.
o    Those with severe local infection
o    People whose infection has spread to other organ systems
o    People with weakened immune systems
o    Dehydrated individuals who need IV hydration
o    Infants younger than 6 weeks of age
Mild uncomplicated eruptions of herpes simplex require no treatment. Severe infection may require treatment with an antiviral agent. Oral antiviral drugs include
•    acyclovir (Zovirax),
•    valacyclovir (Valtrex),
•    famciclovir (Famvir),
•    topical acyclovir or penciclovir (Denavir), (creams) may shorten attacks of recurrent HSV-1 if it is applied early, usually before lesions develop.
These drugs may stop viral replication in the skin but do not eliminate HSV from the body or prevent later outbreaks HSV reactivation. These drugs are used more frequently with HSV-2 infections. Most investigators suggest consulting an infectious disease expert when HSV infected people need hospitalization. Research findings suggest laser treatments may speed healing and lengthen the time before any recurrent sores.