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FACT SHEET: Herpangina (also known as “enteroviral vesicular pharyngitis”; usually caused by various non-polio enteroviruses1; closely related to hand, foot, and mouth disease)

Date of Publication: January 27, 2017

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • Yes, if the patient/client is infectious and/or has significant morbidity.

Is medical consult advised?  

  • Yes, if the diagnosis is uncertain (including differentiation from primary herpes simplex gingivostomatitis and aphthous stomatitis) and/or the patient/client is not already under medical care.

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • Yes, if the patient/client is infectious and/or has significant morbidity.

Is medical consult advised? 

  • See above.

Is medical clearance required? 

  • No.

Is antibiotic prophylaxis required?  

  • No.

Is postponing treatment advised?

  • Yes, during the period of communicability (see below) or at least until after the first week of illness. While herpangina is generally a mild disease in adults, infection during pregnancy has been associated with an increased risk of low birth weight, pre-term delivery, and small-for-gestational-age infants.

Oral management implications

  • Mode of transmission is through direct oropharyngeal contact with virus-laden saliva, respiratory secretions, or feces, and occasionally with contaminated objects (such as surfaces and toys). Aerosol droplet spread may occur via coughing and sneezing. As well, asymptomatic persons2, especially siblings or other close contacts of patients/clients with herpangina, may be a source of infection.
  • This highly contagious disease occurs worldwide sporadically and in epidemics. It usually develops in children aged 3 to 10 years, occasionally occurring in newborns, adolescents, and adults. Outbreaks are common in childcare settings. In Canada and other temperate countries, peak incidence is during the summer and early autumn, whereas in the tropics occurrence is year-round. 
  • Herpangina is most infectious during the first week of illness, which usually follows a 3- to 14-day incubation period (i.e., time from viral infection to illness). The period of communicability, however, may extend to 2 weeks after the onset of illness due to viral shedding in throat secretions and to 11 weeks due to viral shedding in stools.
  • Once recovery occurs from herpangina, life-long immunity is conferred against the specific causative virus. However, although uncommon, it is possible to have another attack of herpangina due to a different virus.  
  • No vaccine or specific antiviral medicine is available to protect against the enteroviruses that cause herpangina.
  • Over-the-counter medications (such as acetaminophen or ibuprofen, avoiding aspirin in children) can be used to relieve pain and fever. Bland mouth rinses such as sodium bicarbonate in warm water may alleviate oropharyngeal discomfort, as may numbing oral rinses (e.g., benzydamine) or sprays in age-eligible patients/clients3. A soft diet and avoidance of hot beverages, citrus fruits, and spicy/irritating foods are helpful. Saline mouth rinses after eating are recommended. Adequate hydration is essential.
  • All healthcare providers and patients/clients should follow standard infection control practices to prevent enteroviruses from spreading in the workplace. Viral transmission can be reduced by isolating infected children and by promoting hand washing with soap and water and other hygienic measures. Contaminated surfaces and soiled articles should be appropriately cleaned or discarded.

Oral manifestations

  • The oral lesions of herpangina are similar to those of hand, foot, and mouth disease but are usually limited to the posterior oral cavity, including the soft palate, anterior pharyngeal folds, uvula, and tonsils. In some children, the lesions may occur in other parts of the mouth, including the posterior tongue and buccal mucosa.  
  • After the prodrome, multiple, tiny vesicles erupt and shortly thereafter rupture, resulting in tiny ulcerations. These often painful ulcers exhibit shallow, necrotic centres and red borders. A diffuse redness of the soft palate is often also seen.
  • The oral lesions are typically 1 to 2 mm (and smaller than 5 mm) in diameter, number 2 to 12, and take 5 to 10 days to heal.
  • Erythematous pharyngitis (sore throat) and odynophagia (painful swallowing) often occur, as well as enlargement of the submandibular and anterior cervical lymph nodes.
  • Acute lymphonodular pharyngitis is a variant4 of herpangina. In this condition, nodular lesions occur in the same location and distribution as the lesions of herpangina but do not undergo vesiculation or ulceration.
  • Dry mouth can result from dehydration.

Related signs and symptoms

  • Herpangina is usually a brief illness characterized by multiple painful ulcers predominately in the posterior oral cavity. There are no characteristic skin lesions, unlike hand, foot, and mouth disease. However, a subset of patients/clients may develop a rash on the body that may be macular, maculopapular, vesicular, papulovesicular, papulopustular, morbilliform, or petechial.
  • Moderate fever, malaise, sore throat, cervical lymphadenopathy, and dysphagia are common features following the incubation period. Headache, backache, loss of appetite, drooling (in infants), abdominal pain, vomiting, and/or diarrhea may also occur.
  • Dehydration can occur as a result of poor feeding and difficulty in hydrating due to painful oropharyngeal ulcers. Decreased skin turgor, sunken eyes, decreased urine output, dark urine, lack of tears, and fatigue are signs/symptoms of dehydration. 
  • Signs and symptoms are usually mild to moderate and generally resolve in 1 to 2 weeks without treatment. 
  • While herpangina is generally considered benign and self-limited, rare severe complications (associated with certain causative viruses) may occur. These include encephalitis, meningitis, myelitis, myocarditis, cardiopulmonary failure, and potentially death (primarily in infants aged 6 to 11 months).

References and sources of more detailed information

Date: January 3, 2017
Revised: March 2, 2022


1 These non-polio enteroviruses include coxsackie A and B viruses (most commonly coxsackievirus A16) and enterovirus 71, in addition to less frequently causative echoviruses. Herpangina can also infrequently be caused by adenoviruses and paraechoviruses.
2 50% of infected persons remain asymptomatic.
3 Benzydamine oral rinse is not recommended for young children. While topical numbing therapies containing lidocaine or diphenhydramine in age-eligible patients/clients may be considered, their use is controversial. This is because of the risk of toxicity associated with these medications and lack of adequate clinical trials.
4 This variant is caused by coxsackievirus A10.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.