Viral Infections of Oral Mucosa

1. VIRAL INFECTIONS OF ORAL
MUCOSA
DR. HADI MUNIB
ORAL AND MAXILLOFACIAL SURGERY RESIDENT

2. OUTLINE
 Human Herpes Viruses Family
 Herpes Simplex Infection
 Herpes Zoster Infection
 EBV infection - Infectious Mononucleosis
 CMV Infection
 Coxsackie Virus infection
 Paramyxovirus infection
 References

3. Human Herpes Virus Family

4.  The human herpes viruses possess the property of latency they can
remain dormant and become reactivated later.

5. Herpes Simplex Virus (Type I and II)
 Type 1 is traditionally associated with infections of the skin and oral mucous
membranes
 Type 2 virus with infections of the genitalia.
 However, either type may be associated with oral and/or genital infection.

6.  Primary infection
 Vesicles which later ulcerates
 Droplet spread or contact with the lesions
 Young Children
 Subclinical frequently
Primary Herpetic Gingivo-Stomatitis

7. Clinical Features of Herpetic
Gingivostomatitis
 Vesicles which can affect any part but the hard palate and dorsum of the
tongue are favored sites.
 Circular, sharply defined, shallow, painful ulcers with yellowish or greyish
floors and red margins.
 The gingival margins are frequently swollen and red.
 Regional lymph nodes are enlarged and tender.
 Fever and systemic upset.

9. Diagnosis of Herpetic Gingivostomatitis
 Clinical Picture
 Smear
 Rising Titer of Antibodies 2 – 3 weeks provides Retrospective but absolute
confirmation of diagnosis

10. Treatment of Herpetic Gingivostomatitis
 Usually Self-limiting disease and it resolves within 10 -14 days
 Analgesics and Antipyretics
 Only in severe cases: Acyclovir (200–400 mg/day by mouth for 7 days)

12. Latency

13. Secondary Infection
 30 – 40% of patients who had Primary infection
 Resides in the Trigeminal Ganglion
 If the recurrence affects the lips it is then termed “Herpetic Labialis” or “Cold Sores”
 If the recurrence affects the intraoral structures it is then termed “Recurrent intra-oral
herpetic infection”
 If it happens in the finger it is then termed “Herpetic Whitlow”.

14. Recurrence Triggers
 Sunlight.
 Mechanical trauma.
 Mild febrile conditions such as the common cold.
 Emotional factors.

15. Clinical Presentation of Recurrent HSV infection
 Prodromal  Mild degree of Tiredness and Malaise
 Irritation and Itching in the lips area
 Vesicles arise surrounded by a mildly erythematous area  Highly infectious.
 Healing in 10 – 14 days.
 Treatment
 Prodromal Acyclovir or Pencyclovir cream application at least 5 times a day

17. Herpes Zoster Infection - Chickenpox
 Childhood.
 Incubation period of 14–21 days.
 Direct contact or droplet infection
 Clinical Features:
1. The rash manifests as pink, maculopapular lesions that develop into itchy vesicles on the
back, chest, face, and scalp.
2. Malaise, fever, and lymphadenopathy
3. Oral lesions may appear on the hard palate, uvula and pillars of fauces.

19. Herpes Zoster infection - Shingles
 middle-aged or older
 Immunosuppression
 The characteristic superficial lesion of herpes zoster is a vesicular eruption in an area
of distribution of a sensory nerve.
 The trigeminal nerve is involved in about 15% of the cases.
 The ophthalmic division is the most frequently involved.

20. Shingles – Clinical Features
 Tenderness in the affected area
 The prodromal pain may last for 2 or 3 days
 Vesicles in a rash; sparse or so dense as to be almost confluent.
 Corneal ulceration.
 The vesicles and oral ulceration fade after around 2 to 4 weeks.

21. Shingles - Complications
 Post-Herpetic Neuralgia; Anesthesia, Paresthesia or pain.
 Ramsay Hunt Syndrome; Geniculate Ganglion of the Facial Nerve

22. Ramsay Hunt Syndrome

24. Treatment of Shingles
 Shingles should be treated as soon as possible by systemic antiviral therapy; such as
acyclovir or famcyclovir.
 Topical treatment (tetracycline mouthwash) is used for oral lesions

26. Epstein-Barr Virus
 Oncogenic virus
 Oral Hairy Leukoplakia
 AIDS

27. Infectious Mononucleosis
 Relatively common
 Early Adulthood
 Subclinical
 Differential WBC count to confirm diagnosis
 Paul-Bunell Test - Monospot

28. Infectious Mononucleosis
 Malaise, Fever and Lymphadenopathy
 In the early stages: a sore throat and oral ulceration.
 Petechiae may be visible at the junction of the hard and
soft palate.
 Treatment: Symptomatic

31. Cytomegalovirus (CMV) infection
 Up to 80% of adults show serological evidence of CMV infection without clinical effects.
 The oral ulcers are large, shallow, raised, single, and affect either the masticatory or
non-masticatory mucosa with minimally rolled borders.
 Owl-eye intranuclear inclusions, usually recognizable by light microscopy but their nature can
be confirmed by:
1. Immunocytochemistry
2. In-Situ Hybridization
3. Electron Microscopy

33. Coxsackie Virus infection
 Group A and group B viruses.
 Group A viruses are responsible for: ‘hand,
foot, and mouth disease’ and herpangina.
 Treatment for both these infections is
symptomatic.

34. Hand-Foot-Mouth Disease
 Ulceration on the mouth and vesicular eruption in the extremities
 Coxsackie A Virus
 Incubation Period: 3 – 10 days
 Foot-and-mouth disease of cattle is a different rhinovirus infection; rarely
affects humans but can cause a mild illness with vesiculating stomatitis.

35. Hand-Foot-Mouth Disease - Clinical
 The rash consists of vesicles, sometimes deep-seated, mainly seen around the base of
fingers or toes.
 Serological confirmation is rarely necessary as the history and clinical features are
usually adequate.
 The disease typically resolves within a week.
 Myocarditis or encephalitis are rare complications.

37. Herpangina
 Mild infection, seen predominantly in children.
 The patient complains of a moderate degree of malaise, sore throat, a minor degree of muscle
weakness and pain.
 Small vesicular lesions appear on the soft palate.
 Self-limiting, they fade after 3–5 days

38. Paramyxovirus Infection
 Mumps virus
 Morbillivirus

39. Mumps
 Bilateral swelling of the parotid glands, less common involvement of the
submandibular gland.
 Red and inflamed and occasional dry mouth sensation, Trismus and extremely
painful and tender to touch.
 Complications of mumps include pancreatitis, encephalitis, orchitis, oophoritis, and
deafness.
 Management is symptomatic with general supportive measures

41. Measles
 Systemic, febrile illness with an initial nasal discharge, (catarrhal stage).
 Koplik's spots: bluish-white, pinpoint spots, with dark-red aveolae, appearing on the buccal
mucosae and they disappear after 3–4 days.
 A maculopapular skin rash then appears but resolves after a few days.
 Complications: encephalitis and pneumonia.
 Management is symptomatic with general supportive measures.
 Antibiotics may be required for complications.

43. Rubella vs. Rubeola
 Rubeola, also called 10-day measles, red measles, or measles.
 Rubella, also known as German measles or three-day measles.
 Difference?

44. Vaccine

45. References
• Cawson’s Chapter 12: Diseases of the oral mucosa: introduction and mucosal
infections
• Tyldesly’s Chapter 4: Infections of the Gingivae and oral mucosa
• Oral Pathology 5th edition: Infections of the Oral Mucosa

46. References

47. THANK YOU