Journal of Investigative and Clinical Dentistry (2013), 4, 1–9

REVIEW ARTICLE
Periodontics

Viruses: are they really culprits for periodontal disease?

A critical review
Ranjith Ambili, Chandran Preeja, Vilasan Archana, Krishnavilasam Jayakumary Nisha, Abraham Seba
& Mohammed Khasim Reejamol
Department of Periodontics, PMS College of Dental Science and Research, Kerala, India

Keywords
etiology, herpes virus, periodontal disease,
periodontitis, virus.
Correspondence
Dr R. Ambili, Department of Periodontics,
PMS College of Dental Science and Research,
Golden Hills, Vattappara, Venkode P O,
Thiruvananthapuram-695028, Kerala, India.
Tel: +919447463676
Fax: +91-472-258-7874
Email: ambiliranjith@yahoo.com
Received 8 September 2012; accepted 3
December 2012.
doi: 10.1111/jicd.12029
Abstract
Periodontal diseases are multifactorial, and many etiological agents are suggested
to play a role in their etiopathogenesis. Various risk factors are also suggested to
influence the progression of periodontal disease. Until recently, specific bacteria
were considered the major pathogens for the disease. However, the occurrence
of periodontal disease in some patient groups is still poorly understood, and the
role of other initiating agents is being investigated. Evidence strongly suggests
the presence of many strains of viruses in the periodontal environment, and
possible mechanisms have also been suggested. Periodontal disease as a risk
factor for other systemic diseases can also be better explained based on this viral
etiology. In this review, we critically analyze the role of viruses in different
periodontal diseases, and provide a categorical description of the underlying
mechanisms. Clinical implications and future directions are also discussed.
Evidence of a causal role of herpes viruses in periodontitis might revolutionize
existing strategies to diagnose, prevent, and treat the disease.

was also suggested as a major determinant in the onset

Introduction
Periodontitis is a common chronic oral disease that can
occur in otherwise healthy individuals. There is a plethora
of information in the field of periodontology of the
events before and during this disease process. Different
types of bacteria were implicated in its pathogenesis.
Microbiological culture and culture-independent molecu-
lar studies have identified more than 1200 bacterial spe-
cies1 and 19 000 phylotypes2 in the oral cavity. At least
400 bacterial species inhabit subgingival sites,3 but despite
the long list of different bacteria in periodontitis, fewer
than 20 species are considered to be major periodontal
pathogens.4,5
Periodontitis is site specific, although periodontopathic
bacteria are abundant in saliva. The progressive course of
periodontitis typically includes prolonged periods of dis-
ease remission, interrupted by occasional episodes of clin-
ical relapse, the underlying biological basis of which is
not clearly understood. To explain this phenomenon,
environmental, genetic, demographic, and host defense
factors were introduced. The virulence of infecting agents
and severity of periodontitis, as in any other human dis-
ease. With this background, the importance of viruses in
periodontal etiopathogenesis has emerged as a major
research area in recent years.
Since the mid 1990s, herpes viruses have emerged as
putative pathogens in various periodontal diseases.6 At
present, the evidence is so strong that it is reasonable to
believe that viruses do play a real role in periodontal etio-
pathogenesis. Total viral copy count detected in advanced
periodontitis sites might even approach the total bacterial
count in some cases.7 Evidence of a causal role of herpes
viruses in periodontitis might revolutionize existing strat-
egies to diagnose, prevent, and treat the disease. The aim
of the present review is to provide a critical evaluation of
the role of viruses in periodontal etiopathogenesis and
their future clinical implications.
Viruses implicated in periodontal disease
Although more than 30 000 pathogenic viruses are identi-
fied, fewer than 40 viral families and genera have been

ª 2013 Wiley Publishing Asia Pty Ltd 1

Viruses and periodontal disease R. Ambili et al.

identified as being of medical importance in humans. antibodies are useful for assessing the susceptibility to
Individual periodontal lesions have been reported to har- primary infection and viral reactivation.
bor millions of genomic copies of herpes viruses,8 papil- Electron microscopy has been used to detect various
loma viruses, HIV, human T-lymphotropic virus-1,9 virions in periodontal tissues.22 Recently-developed
hepatitis B virus,10 hepatitis C virus,11 and torque teno molecular technologies for detecting viral DNA or RNA
virus.12 Chikungunya virus is another virus reported to in clinical specimens are now routinely been used in
be associated with gingivitis in the Indian population.13 virology laboratories. Viral nucleic acid can be measured
Eight members of the herpes family are known to cause directly by hybridization, or be detected after amplifica-
human diseases. They are herpes simplex virus (HSV)-1, tion by nucleic acid amplification methods. Polymerase
HSV-2, varicella zoster virus (VZV), Ebstein–Barr virus chain reaction (PCR) offers a rapid and relatively inex-
(EBV), human cytomegalovirus (HCMV), human herpes pensive method of identifying viral nucleic acids in clini-
virus (HHV)-6, HHV-7, and HHV-8. EBV and HCMV cal specimens, including tissue and blood. The presence
are the most commonly researched viruses in periodon- of herpes virus in the periodontium has also been studied
tology. HHV-6 and HHV-8 were detected only in biopsies using various methods, such as labeled DNA probes,23
from periodontitis lesions, and HHV-8 originated from flow cytometry,24 and immunofluorescence staining.25
patients with confirmed HIV infection.14 Although herpes The newer technological advancements in viral diagnoses
virus carriage varies by age, country, region within coun- are described in (Table 1).26
try, and population subgroups,15 studies from various
countries all report a high prevalence of herpes virus
Viruses in different forms of periodontal disease
DNA in periodontitis lesions.16–18
The detection of viruses depends on many factors, such as
the type of periodontal lesion studied, disease activity at the
Genetic polymorphism in periodontal viruses
sampling site, influence of periodontal treatment, immune
Genetic polymorphism in viruses has been detected in status of the patient, viral identification method employed,
different groups of periodontal patients, and herpes virus and ethnic/geographic factors. False positive and negative
subtypes may differ in pathogenicity.19 EBV nuclear anti- results can occur due to a variation in any of these factors.
gens 2 (EBNA2) genotype 1 occurs more frequently in In spite of all these, there is ample evidence for the presence
periodontitis lesions than the EBNA2 genotype 2. The of different strains of viruses in periodontal disease.
cytomegalovirus (CMV) gB-II genotype is seen frequently
in periodontitis, and co-infection with EBV-1 and the
CMV gB-II genotype was associated with deep pocket and Table 1. Recent techniques for viral diagnosis
attachment loss. A high prevalence of the HCMV-2 and
Serial no. Technique Advantage Disadvantage
EBV-1 genotypes has also been reported in peri-implanti-
tis sites.20 1 Nested PCR Can detect small Cumbersome,
quantities of prone to
bacterial or contamination,
Virus isolation and detection methods in periodontal viral DNA viability or
disease quantity of
organism
The identification of viruses has traditionally been based cannot be
on cell culture to detect characteristic cytopathic effects, assessed
and the morphological determination of intracytoplasmic 2 Real time Reproducibility, Less sensitive
and intranuclear inclusion bodies. Immunohistochemical PCR or reverse specificity, than nested
techniques and immunoassays are used to identify viral transcriptase PCR can quantify, PCR
speed, less
antigens in clinical specimens, or for the measurement of
contamination
total or class-specific antibodies against specific viral anti- 3 Multiplex PCR Multiple organisms Difficulty to
gens. Oral fluid collection might constitute a convenient can be detected perform
and non-invasive method for virus detection. Saliva is simultaneously non-specific
identified as an equally-effective sample as subgingival amplifications
plaque in identifying viruses. However, it has been 4 Metagenomic Can detect Less sensitive
reported that EBV DNA presence and burden in saliva do pyrosequencing complete set and less
& microarray of viruses in expensive
not correlate with periodontal disease severity.21 In some
the sample
viral infections, immunoglobulin (Ig) M antibodies are
useful for determining primary infection, and IgG PCR, polymerase chain reaction.

2 ª 2013 Wiley Publishing Asia Pty Ltd

R. Ambili et al.
Gingivitis
Gingivitis studies reveal a median genome detection rate
of 20% for EBV and 33% for CMV. Herpes virus-infected
periodontally-healthy and gingivitis sites typically harbor
the viruses in a non-transcriptional state27 and in copy-
counts of only 1000–20 000.8 Pregnancy might increase
the risk of subgingival EBV presence by 3.647 times.28
Periodontitis
A wide variation in the occurrence of HSV (13–100%),
EBV (3–89%), and CMV (0.3–83%) has been reported in
periodontitis lesions due to multiple factors involved.
There are conflicting reports regarding the number of
viruses detected in chronic and aggressive periodontitis
sites. Most studies report a higher level of viruses in
aggressive lesions;29 some describe a similar occurrence,30
or even a lower occurrence in aggressive cases.31
Aggressive periodontitis
Cytomegalovirus and Porphyromonas gingivalis were
detected in sites with localized aggressive periodontitis in
Afro-Caribbean adolescents.32 Periodontal CMV also
exhibited a close association with the presence of Dialis-
ter pneumosintes.33 The cytomegalovirus transcription of
the major cuspid protein was detected in deep periodon-
tal pockets of patients with localized aggressive periodon-
titis of 10–14 years of age.34Herpes virus-like virions
were identified in an electron microscopic study of
aggressive periodontitis lesions, signifying an active viral
infection.22
Advanced sites of generalized aggressive periodontitis
demonstrated HSV-1, EBV, and CMV in 73–78% young
military recruits in Turkey. The viruses were absent in the
subgingival sites of healthy periodontia.35 Periodontal
dual infection with EBV-1 and CMV was detected in a
patient with generalized aggressive periodontitis in a Hopi
American Indian population.36 EBV, CMV, and EBV–
CMV cohabitation was significantly associated with peri-
odontitis active areas in early onset periodontitis in a
Greek population.37
Chronic periodontitis
The main herpes viruses identified in chronic periodonti-
tis are EBV-1, HSV-1, and CMV.38 The latent form of
CMV is seen in the majority of chronic periodontitis
sites, which might account for the slow progression of the
disease.19 Herpes virus can multiply in the gingival tissue
and tends to reach a higher copy count than in the
subgingival area. Antibodies were detected against EBV in
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Viruses and periodontal disease
32%, and against CMV in 71% of gingival crevice fluid
samples from 34 study sites.39
Cytomegalovirus and human herpes virus 7 can be pres-
ent in periodontitis-affected sites, but are uncommon in
healthy sites. CMV can be related to an inflammatory
infiltrate with a predominance of CD3 (+) T cells, whereas
human herpes virus 7 can be associated with an infiltrate
with predominance of T-\CD4 (+) cells. All these data
indicate that herpes viruses could play a role in human
chronic periodontitis by the modulation of the T-cell
response.40
Periodontal abscess
Ebstein–Barr virus was detected in 72%, CMV in 67%, and
co-infection with the above two viruses in 56% of
abscesses studied, while the herpes viruses were not identi-
fied in healthy periodontium or after treatment of the peri-
odontal abscess.41 Hypermobility was present in 90% of
abscessed teeth showing a herpes viral dual infection. CMV
has been implicated in periodontal and extraoral abscesses
of HIV-infected individuals. It is suggested that reactiva-
tion of a periodontal herpes virus latent infection impairs
the periodontal host defense and permits bacterial patho-
gens to enter the gingiva, causing periodontal abscess.
HIV-associated periodontitis
HIV-induced immunosuppression facilitates herpes virus
reactivation,42 but active herpes viruses might also acti-
vate latent HIV.43 The reactivation of latent periodontal
herpes viruses by HIV might start a cascade of tissue-
destructive events, leading to periodontal breakdown.
CMV, the most common herpes virus in HIV-associated
periodontitis, was identified in 81% of lesions. Herpes
virus-like virions were detected electron microscopically
in 56% of gingival tissue from HIV-seropositive patients
with necrotizing ulcerative periodontitis.44 EBV-1 was
identified more frequently in subgingival sites,45 and
EBV-2 was detected in 57% of biopsies46 from HIV-asso-
ciated periodontitis lesions. HSV, EBV, CMV, and
HHV-8 genomes have been detected in the saliva of
HIV-infected individuals.47 EBV-1 and co-infection (EBV-
1–HCMV) showed significant association with HIV-asso-
ciated periodontitis.48 HPV was detected in the gingival
crevicular fluid of HIV-positive patients under highly-
active antiretroviral treatment (HAART), independently
of the periodontal conditions.49
Necrotizing ulcerative gingivitis⁄periodontitis
Necrotizing gingivitis lesions of malnourished children
yielded 23% HSV, 27% EBV, and 59%CMV, while
3
Viruses and periodontal disease
periodontal sites of malnourished but periodontally-nor-
mal children revealed virtually no herpes viruses.50 It has
been suggested that necrotizing ulcerative gingivitis in
African children might be caused by the acquisition of
herpes viruses in early childhood as a result of impaired
immune defenses, malnutrition, and an abundance of
virulent periodontal bacteria.
Syndromes
Cytomegalovirus was detected in periodontitis lesions in
Guillain–Barre syndrome,51 Kostmann syndrome,52 Papil-
lon–Lefevre syndrome,53 Fanconi’s anemia,54 and Down
syndrome.55 Natural killer cells play a crucial role in the
antiherpes viral host defense. The suppressed killer cell
activity in these syndromes might have been induced by
CMV as an immunoevasive strategy.
Peri-implantitis
A statistically-significant correlation was found between
the presence of HCMV-2 and EBV-1 genotypes and the
clinical parameters of peri-implantitis.20 Studies confirm
the high prevalence of HCMV and EBV in subgingival
plaque, and suggest that these viruses have a possible
active pathogenic role in peri-implantitis.56
Other oral lesions
Cytomegalovirus infection was identified in periapical
lesions, and in periapical monocytes/macrophages and
T lymphocytes, as determined by multicolor flow cytome-
try.57 A virological sample of peripheral giant cell granu-
loma of a 47-year-old female yielded CMV and EBV.58
Viruses might play a role in refractory periodontitis
cases. The failure of free connective tissue grafts has been
reported, due to recurrent HSV-1 infection.59 The interac-
tion of tobacco products reactivating periodontal herpes
viruses in an animal model is attributed as one of the mech-
anisms by which it acts as a risk factor for periodontitis.60
Despite the abundance of evidence supporting the pres-
ence of viruses in periodontal health and disease, contra-
dictory reports are also published. Salivary copy counts of
EBV did not reveal any significant difference in a study
conducted among a sample of patients with gingivitis,
chronic periodontitis, and aggressive periodontitis com-
pared to periodontally-healthy individuals.61 DNA of
HCMV, HSV, and VZV were not detected in any of the
plaque samples taken from aggressive periodontitis
patients. EBV DNA was detected in four localized aggres-
sive periodontitis (25%), two generalized aggressive peri-
odontitis (3%) patients and four healthy individuals
(10%).62 In another published study, it was reported that
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R. Ambili et al.
EBV was infrequent and that CMV was rarely present in
individual subgingival sites affected by chronic periodonti-
tis.63 HPV-16 was not detected in any of the 104 gingival
samples evaluated (healthy periodontium, gingivitis and
chronic periodontitis) in a study conducted in Brazilian
population.64 These variations could be due to factors, such
as variations in race, sampling site selected and technique.
Viruses in periodontal etiopathogenesis: how is it
possible?
Herpes virus pathogenicity is complex, and is executed
through direct virus infection and replication, or via a
virally-induced alteration of the host immune defense.
The early phases of periodontitis in immunologically-naive
hosts might predominantly involve cytopathogenic events,
whereas most clinical manifestations in immunocompe-
tent individuals are secondary to cellular or humoral
immune responses. Many of the risk factors for gingival
and periodontal diseases, such as stress, smoking, HIV
infection, and hormonal changes, can activate the latent
viruses, enhancing the pathogenicity. The alteration
between latent and active periods of viruses might explain
episodic burst-like activity in periodontitis. The main
mechanisms in viral periodontitis include a direct effect
on different cells in the periodontium, alteration in host
response to periodontal infections, and enhancement of
bacterial pathogenicity, but in many ways, these three
mechanisms are interconnected.
Cytopathic effects
Herpes viruses can exert direct cytopathic effects on fibro-
blasts, keratinocytes, endothelial cells, and inflammatory
cells, including polymorphonuclear leukocytes, lympho-
cytes, monocytes, macrophages, and possibly bone cells in
periodontitis lesions.6 As a result of a herpes virus peri-
odontal infection, aggressive periodontitis lesions contain
fewer overall viable cells, more T-suppressor lymphocytes,
and more B lymphocytes (EBV effect) than chronic peri-
odontitis lesions or healthy periodontal sites.65 Viruses can
invade the defense cells of periodontium, thereby influenc-
ing host response to infections. HCMV infects periodontal
monocytes⁄macrophages and T lymphocytes, and EBV
infects periodontal B lymphocytes.24 By infecting and
altering the function of fibroblasts and other periodontal
cells, herpes viruses might reduce healing after surgery and
the regenerative potential of periodontal ligaments.
Host response
Herpes virus infection triggers the release of pro-
inflammatory cytokines that have the potential to impair
R. Ambili et al.
antibacterial immune mechanisms, causing an upgrowth
of periodontopathic bacteria.66 The herpes virus-associated
pro-inflammatory cytokines and chemokines also stimu-
late bone-resorbing osteoclasts, upregulate matrix metal-
loproteinase, and downregulate tissue inhibitors of
metalloproteinase, thereby impeding tissue turnover and
repair, and increasing the risk of periodontal tissue break-
down.67 An active periodontal herpes virus infection
might be partially responsible for the increased level of
gingival interleukin-1b and tumor necrosis factor-a.68
Periodontitis tends to be of greater severity in carriers
of the human leukocyte antigen (HLA)–DR4 alloantigen,
while CMV-specific CD8+ T cells can cross-recognize
HLA–DR4 molecules and potentially induce autoimmune
reactions.69 EBV can generate antineutrophil antibodies
and neutropenia, leading to increased bacterial pathoge-
nicity and overgrowth.
Synergism with bacteria
Periodontal herpes virus infection is typically associated
with an increased occurrence of periodontopathic bacte-
ria. Quantitative PCR studies of severe periodontitis have
revealed a close relationship between EBV and CMV and
the pathogens P. gingivalis, Tannerella forsythia, Prevotella
intermedia, Prevotella nigrescens, and Treponema denticola.
Periodontal HCMV showed a particularly close associa-
tion with the occurrence of Dialister pneumosintes and
P. gingivalis.
A pathogenic synergy promoting the growth of each
other through different mechanisms exists between peri-
odontopathic bacteria and viruses. Bacterial enzymes or
other inflammation-inducing factors have the potential to
activate periodontal herpes viruses. P. gingivalis sup-
presses interferon-c, and this antiviral host response
might partly explain the increase in CMV pathogenicity.32
Recent evidence shows that P. gingivalis induces the EBV
lytic switch transactivator Z Epstein–Barr replication acti-
vator by histone modification.70
Viruses predispose the host to secondary infections by
inducing abnormalities in the adherence, chemotaxis,
phagocytic, oxidative, secretory, and bactericidal activities
of polymorphonuclear leucocytes. Th1 cytokines associ-
ated with active herpes virus infections reduce Th2 cell
responses and the antibody-mediated control of patho-
genic bacteria. Viral proteins expressed on eukaryotic cell
membranes and the basement membrane of virus-dam-
aged epithelial cells can act as bacterial receptors and gen-
erate new bacterial-binding sites. CMV can enhance the
adherence of Aggregatibacter actinomycetemcomitans to
primary periodontal pocket epithelial cells and to HeLa
cells.71 EBV active infection can also generate antineutro-
philic antibodies and neutropenia, and polyclonally
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Viruses and periodontal disease
stimulate the proliferation and differentiation of B
lymphocytes.
Viral pathogenesis of aggressive periodontitis
Repeated evidence suggests that active CMV might be the
primary cause for the disease in aggressive periodontitis,
and can be a secondary invader after the pathological
changes in the periodontium, or it can be a combination
of the two.
Primary CMV infection at the time of root formation
of permanent incisors and first molars can be the reason
for defective periodontium in aggressive cases.34 Viral
infection can disrupt normal cell differentiation and can
result in cemental hypoplasia. Profound hormonal
changes at the onset of puberty might reactivate a peri-
odontal CMV infection, resulting in the suppression of
antibacterial immune defenses and the overgrowth of
exogenous-like bacteria in the early phases of localized
aggressive periodontitis. Localized aggressive periodontitis
lesions harboring an active CMV infection tend to be
more heavily infected with A. actinomycetemcomitans than
sites showing a latent CMV infection.34,71 CMV-mediated
damage to the periodontal tissue constituents, antiviral
pro-inflammatory cytokine responses, and bacteria-
induced injury of the epithelium might allow gingival
tissue invasion by A. actinomycetemcomitans and the break-
down of the periodontal attachment and alveolar bone.
Viruses: a better explanation for periodontal medicine?
Periodontitis has been suggested as a major risk factor for
various systemic diseases, such as atherosclerosis, preterm
low birth weight, diabetes mellitus, osteoporosis, and
rheumatoid arthritis. Various mechanisms have been sug-
gested to explain this periodontal systemic link. Direct
viral invasion into systemic circulation or the effect of
viral-induced changes in host response can be responsible
for the systemic impact.
Atherosclerosis might develop as a result of infection
with CMV, HSV, Chlamydia pneumoniae, Helicobacter
pylori, or periodontopathic bacteria.72 CMV seropositivity
has been linked to cardiovascular disease. CMV and HSV,
especially when acting together, have the potential to pro-
mote the inflammatory and procoagulant environment
that underlies the pathogenesis of atherosclerosis. CMV
infection of vascular cells and cells of cardiac musculature
induces cell activation, leading to the expression of adhe-
sion proteins, major histocompatability complex mole-
cules, and cytokine receptors, and to the release of
cytokines and growth factors. HSV and periodontopathic
bacteria in aggregate73 and herpes virus-8 have also been
associated with this vascular disease.
5
Viruses and periodontal disease
In some patients, CMV might be a common etiology
of periodontitis and premature birth. CMV can be trans-
mitted transplacentally to the fetus, and a proportion of
premature births are caused by a congenital CMV infec-
tion.74
A greater frequency of EBV was found in the shallow
pockets of patients with poor glycemic control. EBV-free
patients presented moderate or good glycemic control.
Glycemic control did not influence the frequency of CMV
in all pocket categories.75
Periodontitis has been statistically associated with sev-
eral other diseases/conditions, including rheumatoid
arthritis,76 which in turn has been linked to EBV and
CMV; a variety of renal diseases (associated with CMV
and several other viruses); and with premature death
from neoplasms and from vascular and digestive diseases,
which have a herpes viral etiology.
Human T-lymphotropic virus (HTLV)-1-positive
patients have higher incidence of periodontitis, which is
characteristically associated with a systemic immune-med-
iated inflammatory disease that results in tissue damage.77
It has also been reported that HTLV-1 infection can mod-
ify the pathophysiology of osteoarthritis, which is again
linked to periodontal disease.78
Chikungunya virus is reported to be associated with
gingivitis, as well as arthritis.79 P. gingivalis has frequently
been related to non-oral diseases as a consequence of a
periodontal herpes virus infection, which is capable of
stimulating an overgrowth of periodontal P. gingivalis.
Elevated serum levels of C-reactive protein are also associ-
ated with aggressive periodontitis and with various non-
oral diseases due to herpes virus infection.
Oral diseases, such as carcinoma of tongue, hairy leu-
koplakia, oral leukoplakia, and lichen planus, can be
caused by papilloma virus and EBV. CMV can cause non-
neoplastic peripheral giant cell granuloma. Periodontal
pockets can serve as a reservoir for viruses for these vari-
ous oral diseases.
Clinical relevance and future implications
Even though periodontal research has established various
mechanisms in pathogenesis, including at the molecular
level, our treatment methods still rely on old concepts.
Little progress has been made in treating recurrent or
refractory cases, and current periodontal therapy fails in
2 Keijser BJ, Zaura E, Huse SM et al.
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