VIRAL INFECTIONS

OF ORAL CAVITY
PRESENTED BY :
DR LEKSHMI V
SECOND YEAR POST GRADUATE STUDENT
DEPARTMENT OF PEDODONTICS
NAVODAYA DENTAL COLEGE,RAICHUR
 CONTENTS
•INTRODUCTION
•HERPES INFECTION
•HERPES SIMPLEX
•PRIMARY HERPETIC GINGIVOSTOMATITIS
•HERPES LABIALIS
•HERPES WHITLOW
•CHICKEN POX
•SHINGLES
•GLANDULAR FEVER
•CYTOMEGALOVIRUS INFECTION
•KAPOSI’S SARCOMA HERPES VIRUS
•COXSACKIE VIRUS INFECTION
•HUMAN PAPILLOMA VIRUS INFECTION
•HUMAN IMMUNDEFICIENCY VIRUS
INTRODUCTION
• A viral infection is a proliferation of a
harmful virus inside our body.
• They cannot reproduce without the
assistance of a host.
• Viruses infect a host by introducing their
genetic material into the cells and
hijacking the cell's internal machinery to
make more virus particles.
COMMON VIRAL INFECTIONS
OF ORAL CAVITY
VIRUS TYPE PRIMARY REACTIVATION
INFECTION
Herpes simplex Primary Herpetic Herpes labialis
gingivostomatitis
Herpes zoster Herpetic Whitlow; Chicken Herpetic
pox Whitlow;shingles
Epstein-Barr,Cytomegalo Glandular fever No
virus
Coxsackie group Herpangina;Hand ,foot and No
mouth disease
Human Papilloma Squamous cell papilloma Squamous cell
Verucca vulgaris papilloma
Condyloma Accuminatum Verucca vulgaris
Condyloma
Accuminatum

Paramyxovirus Mumps;measles No
HERPES INFECTION
• 80 known herpes viruses – 8 are known cause infection in humans
• It is classified on the basis of biological characteristics
HERPES SIMPLEX VIRUS
 Herpes simplex virus is categorized into 2 types:
 Herpes simplex virus type 1 (HSV-1)
 Herpes simplex virus type 2 (HSV-2).
 They are distinguished by two main criteria :
 HSV 1 : Above the waist,usually during child hood
 Acute gingivostomatitis
 Recurrent herpes labialis (cold sores)
 Keratoconjunctivitis (keratitis)
 Encephalitis
 HSV 2 : Below the waist
 Herpes genitalis (genital herpes)
 Neonatal encephalitis and other forms of neonatal herpes
 Aseptic meningitis
 PRIMARY HERPETIC GINGIVOSTOMATITIS
• Primary herpetic gingivostomatitis (PHGS) develops when a nonimmune individual
is exposed to HSV-1 for the first time.
• CLNICAL FEATURES :
• Most cases affect children 1 to 5 years of age and are often subclinical.
• Lymphadenopathy, fever, sore throat, and vesiculo-ulcerative lesions affecting the
oral and perioral regions
• Both movable and nonmovable oral mucosa may be affected, and acute onset of
generalized gingival inflammation and pain is a classic feature
 MANAGEMENT
• The condition is self-limiting in healthy individuals.
• Antipyetics such as acetaminophen may be used to treat
fever, and anesthetic rinses may be used for palliation.
• Hydration and a bland, soft diet should also be
encouraged.
• Aciclovir (Zovirax) is the preferred drug for treating primary
herpetic gingivostomatitis, used in the following regimen:
• 200 mg tablets or 5 ml sugar free suspension five times daily for 5
days
• For children under 2 years of age, 2.5 ml sugar-free suspension five
times daily for 5 days).
• Lesions generally resolve within 2 weeks of the appearance of
symptoms.
• If the lesions fail to resolve within 10 days, or a recurrence is
suspected, the patient should be referred for exclusion of the acute
leukaemias.
• Alternatively, the diagnosis of erythema multiforme should be
considered.
• Adv : Contagious nature of the virus and potential for spread of
infection to others or autoinoculation to other body sites.
 HERPES LABIALIS
• HSV 1 establishes life-long latency in trigeminal ganglion.
Herpes labialis is the condition caused by reactivation of the
dormant HSV from its latent position in the trigeminal ganglion,
spreading to the perioral skin and resulting in the formation of
erythema and vesicles.
• Internal and external triggers :
• Trauma ( possibly from dental extractions)
• Stress
• Fatigue
• Fever
• Menstruation
• Immunosuppression
• Exposure to heat, cold, or sunlight could cause viral reactivation.
 CLINICAL PRESENTATION
• These rapidly break down to form the characteristic crusted lesions or ‘cold
sores’, which are usually preceded by a prodromal tingling sensation.
• The most commonly affected area is the mucocutaneous junction of the lip, but
intraoral recurrences are not uncommon.
• Dental extractions should be postponed
• Some patients this condition can produce severe pain, which
mimics ‘dry socket’.
• MANAGEMENT :
• In the immunocompetent host, HSL heals within 7 to 14 days
without scarring.
• Aciclovir is the drug of choice for active treatment
• Many patients can prevent reactivation of herpes labialis by the
application of a high-factor sunscreen to their perioral skin in
periods of exposure to strong sunlight.
 HERPETIC WHITLOW
• Herpetic whitlow occurs when HSV infects the subcutaneous tissues of
the finger, producing an erythematous and vesicular eruption at that site
• Pustular lesion of the skin of the finger and hand
• Most commonly contracted by dental workers and medical workers
exposed to oral secretions
• Extremely painful condition, which will prevent affected dental
professionals from undertaking their normal duties for an extended
period of time because of the potential for spreading the virus and
because of the severe pain.
• The institution of adequate cross-infection control protocols
(notably glove wearing) is effective in the prevention of
herpetic whitlow.
• Importantly, previous experience with HSV (e.g. herpes
labialis) does not appear to prevent the occurrence of this
phenomenon.
• Lesions often take 2–3 weeks to heal
• MANAGEMENT :
• Aciclovir (200 mg tablets five times daily for 5 days).
Importantly, aciclovir cannot prevent the recurrence of
herpetic whitlow.
 VARICELLA ZOSTER VIRUS
• Varicella zoster virus (VZV) is one of human herpes group of viruses
capable of developing primary and secondary disease.
• Primary exposure to VZV in a nonimmunized person results in an acute
disease known as chicken pox
• Reactivation of VZV dormant in a sensory nerve ganglion results in herpes
zoster (HZ) or shingles in a sensory dermatome
 CHICKEN POX
• Chickenpox (primary infection with varicella zoster virus is contracted by
close contact with other infected individuals.)
• Incubation period : 14–21 days is followed by the
• Rash, mainly affecting the face and trunk, appearing as papules.
• Vesicles then appear, becoming pustules and finally crusts.
• Other clinical features include oral ulceration, cervical lymphadenopathy,
fever, malaise, irritability and temporary anorexia.
 ORAL MANIFESTATIONS
• Most common sites vermillion border and palate –followed by
buccal mucosa
• Gingival lesions may resemble primary herpes
• RARE COMPLICATIONS : Pneumonia and encephalitis (immediate
hospitalization.)
• Supportive measures used in infections with herpes viruses.
1. Adequate intake of fluids
2. Antipyretic medication (e.g. paracetamol elixir)
3. Analgesics (e.g. paracetamol elixir)
4. Topical agents for the prevention of plaque build-up (e.g. 0.2%
chlorhexidine mouthwash), which may also help in the prevention of
secondary infection of the lesions
5. The patient (and carers) should be advised to avoid (if possible) contact
with fingers, genitalia and eyes to prevent inoculation of these areas.
 SHINGLES
• Reactivation of varicella zoster virus from its dormant position in the dorsal root ganglion of
spinal nerves (commonly thoracic region) or the trigeminal ganglion (30%) results in shingles
(Zoster).
• The condition is associated with significant morbidity, and is known colloquially as ‘a belt of
roses from hell’.
• Clinical signs:
• Papular rash, which affects one dermatome, later forming vesicles and then crusts.
• Prodrome :
• Mild fever
• Malaise and pain
• Burning, itching, or paresthesia in the affected area.
• Regional lymphadenopathy and unilateral vesicular rash in dermatome of a sensory nerve.
• ORAL MANIFESTATIONS :
• Intraoral vesicles readily form ulcers and erosions.
• Potential oral complications of HZ include exfoliation of teeth, root resorption, and osteonecrosis
 COMPLICATION :
• Rare
• Postherpetic neuralgia (PHN) :
• Severe, refractory pain following resolution of lesions, is a serious complication of HZ.
• It is most common in the ophthalmic division of trigeminal nerve, and individuals older
than 50 are particularly at risk.
• Ramsey Hunt Syndrome :
• Reactivation of latent VZV in the geniculate ganglion causes Ramsey Hunt syndrome
characterized by cranial nerve 7 and sometimes cranial nerve 8 dysfunction.
• Affected patients may experience a vesicular rash affecting the ear and pharynx,
together with ipsilateral facial paralysis, earache, taste changes, vertigo, tinnitus, and
hearing loss.
DIAGNOSIS AND MANAGEMENT

• Diagnosis of HZ : History and clinical findings.

• Laboratory investigations : Viral culture,PCR

• Management of HZ : (Depends on the age, immune status symptoms, and

clinical presentation.)
• Most patients recover without any ill effects.
• Aciclovir 800 mg tablets five times daily for 5 days
• When indicated, timely intervention with high-dose antivirals
with or without corticosteroids helps control symptoms and
reduces the likelihood of PHN in susceptible patients.
• In patients with Ramsay-Hunt syndrome, the timely
prescription of a combination of high-dose steroids and
aciclovir will often resolve the facial nerve palsy and prevent
a significant proportion of these patients being left with a
cosmetic defect.
• If ophthalmic shingles is suspected, an ophthalmological
opinion should be sought.
 GLANDULAR FEVER
• The most common cause of glandular fever (infectious mononucleosis) is Epstein–
Barr virus (EBV)
• Cytomegalovirus (CMV) can also be demonstrated in a number of patients.
• Glandular fever affects mainly adolescents and is transmitted through the saliva.
• Kissing disease

Severe oral ulceration in glandular fever.

• Prodromal symptoms : 4-5 days, malaise,fatigue,head ache
• CLINICAL FEATURES : General
lymphadenopathy,hepatosplenomagaly,maculopapular skin rash, exudative facial
swelling,fever,anorexia,malaise
• ORAL MANIFESTATIONS :
• Early and common –palatal petechie, uvular edema, pharyngitis, tonsillar exudate,
gingivitis, and rarely ulcers
• DIAGNOSIS :
• The diagnosis of EBV-induced glandular fever relies on the demonstration of levels of
IgM to EBV
• A positive Paul-Bunnel or ‘monospot’ test for heterophil antibodies or the visualization
of abnormal lymphocytes in peripheral blood.
MANAGEMENT :

Treatment usually comprises the supportive measures

1. Adequate intake of fluids
2. Antipyretic medication (e.g. paracetamol elixir)
3. Analgesics (e.g. paracetamol elixir)
4. Topical agents for the prevention of plaque build-up (e.g. 0.2%
chlorhexidine mouthwash), which may also help in the prevention of
secondary infection of the lesions
5. The patient (and carers) should be advised to avoid (if possible) contact
with fingers, genitalia and eyes to prevent inoculation of these areas.
COMPLICATION :
EBV often remains latent in oropharyngeal epithelium and reactivates
in the immunocompromised individual to produce oral ulcers, non-
Hodgkin’s lymphomas (in the facial area) and hairy leukoplakia.
CYTOMEGALOVIRUS
• Relatively rare
• Human herpes virus 5
• Remains dormant in the body
• Complications during pregnancy
• People with a weakened immune system.
• It is the most commonly transmitted virus to a developing fetus.
• CLINICAL FEATURES:
• Asymptomatic
• Fever, myalgia, malasie, headache
• ORAL MANFESTATIONS :
• The most common manifestation of
cytomegalovirus infection of the gastrointestinal
tract including the oral mucosa is ulceration
• Nonspecific painful ulcerations-gingiva & tongue
• Enlargement of parotid and submandibular
gland,dry mouth
• Periodontal disease
• TREATMENT :
• Resolve spontaneously
• Ganciclovir
 HUMAN HERPES VIRUS-8(HHV-8)
• HHV-8 is known as the Kaposi’s sarcoma herpes virus or KSHV.
• It spreads mainly through saliva.
• People with healthy immune systems can carry the virus without any problems.
• Triggers cancers in people with weakened immune systems.
• ORAL MANIFESTATIONS : Hard palate has proven to be the main site of localization of
these lesions, followed by the soft palate, gums and tonsils.
• Prevalence of KS has declined through Highly Effective Antiretroviral Therapy (HAART).
COXSACKIE GROUP VIRUSES
• Primary mode of transmission :
• Fecal-oral route
• Respiratory droplets and patients are most contagious in the first
few days of illness.
• Oropharyngeal viral infections.
• The group is divided into coxsackie group A viruses and coxsackie
group B viruses.
• Group A coxsackieviruses have a predilection for mucocutaneous
tissues and cause herpangina or hand-foot-mouth disease
(HFMD).
• In contrast, group B coxsackieviruses often infect visceral
organs.
• The range of conditions caused by coxsackie
viruses includes:
• Oral ulceration
• Herpangina
• Hand, foot and mouth disease
• Mild febrile illnesses
• Encephalitis
• Meningitis. Vesicular eruptions of herpangina in posterior oral
• HERPANGINA : cavity.

• Common in children
• Coxsackie virus group A
• Self limiting vesicular eruptions in the oropharynx
• eg : Soft palate, Uvula, Tonsillar pillars, Posterior
pharyngeal wall
• Similar to herpes simplex except the lesions more
commonly in oropharynx rather than oral cavity
• TREATMENT :
• Supportive
• HAND,FOOT AND MOUTH DISEASE:
• Common infection in young children
• Painful
• Patients experience low-grade fever and vesicular sores
• Intra orally: Tongue, palate, and buccal mucosa.
• Pyrexia,malaise,vomiting
• TREATMENT :
• Supportive

Coalesced erosions of hand foot mouth disease on left tongue and

palatal mucosa.
HUMAN PAPILLOMAVIRUS
GROUP
• HPV infections are asymptomatic, and in immunocompetent
individuals frequently cleared within 2 years.
• Therefore, HPV infections do not require treatment.
• The most often recognized lesions are those of squamous
cell papillomas or verruca vulgaris – known more commonly
as simple warts

Intraoral squamous cell papilloma . Multiple cutaneous

squamous cell papillomas.
• The posterior aspect of the hard palate is the commonly
affected site, along with the lips and tongue.
• The lesions have a ‘cauliflower-like’ appearance, and are
often transmitted from another area of skin (usually the
fingers) from the same individual.
• Lesions are diagnosed clinically and will not recur if excised
along with their base.
• Cryosurgery is often used successfully to remove these
lesions
 OROPHARYNGEAL CANCER
• Persistence of high-risk HPV 16 in the posterior oral cavity increases the risk
of oropharyngeal cancers affecting the base of tongue, posterior throat, and
tonsillar structures.
• Clinical signs and symptoms of HPV positive oropharyngeal
cancers :
• Persistent sore throat or hoarseness
• A neck mass
• Bloody sputum on coughing
• Lingual paresthesia or ear pain.
• DIAGNOSIS :
• Biopsy and microscopically examined for dysplastic changes.
• Fine need aspiration of a neck swelling may also be
diagnostic.
• HPV status of oropharyngeal lesions is frequently
determined by testing for presence of HPV DNA or staining
for P16, a surrogate marker for HPV infection.
• Surgery
• Radiation therapy
• Therapies using medication
PARAMYXOVIRUS
• MUMPS :
• Bilateral swelling of the parotid salivary glands although unilateral
swelling is possible and the submandibular glands may be infected.
• Incubation period : 14–21 days.
• Transmission is usually via infectious respiratory secretions.
• Clinical feature : Malaise, anorexia, fever and sialadenitis.
• Normal saliva is evident even though salivary gland ducts are usually
inflamed.
• Patients report a dry mouth and trismus is clinically evident.
• COMPLICATIONS :
• Rare
• Pancreatitis
• Encephalitis
• Orchitis
• Oophoritis and deafness.
• Causative organism - Mumps virus per se, although
coxsackie virus, echovirus, EBV and HIV infections have
all been associated with this condition.
• Treatment : Supportive
• Salivary gland swelling usually resolves within 2 weeks.
• Solid and long lasting immunity follows an attack;
second attacks are rare.
Mumps is now becoming much less common owing to the
use of the combined measles, mumps and rubella (MMR)
vaccine.
MEASLES ( RUBEOLA)
• Measles virus (morbillivirus)
• Incubation period of 7–14 days
• Highly contagious
• Prodromal stage : Nasal discharge, suffusion from eyes

• CLINICAL FEATURES :
• Conjunctivitis , Nasal exudate , cough , fever , malaise and anorexia

• ORAL MANIFESTATIONS :
• Pharyngotonsillitis
• Koplik’s Spot
HUMAN IMMUNODEFICIENCY VIRUS
• AIDS – characterised by immunosuppression
• Leads to clinical manifestations
• Virus multiples in the lymph nodes and slowly begins
to destroy helper T cells ( CD4 lympocytes)-the white
blood cells that coordinate the entire immune system
after that there will be signs and symptoms
• EARLY INFECTION :
• Signs and symptoms may appear after 2-4
weeks after becoming infected
• Fever
• Headache
• Sore throat
• Swollen lymph nodes
• Skin rash
• LATE INFECTION :
• The person may remain symptom free for 8 or 9 years or
more
• But as the virus continues to multiply and destroy immune
cells,mild infections or chronic symptoms wil appear
• Swollen lymph nodes:
• Often one of the first signs of HIV infection
• Diarrhea
• Weight loss
• Fever
• Cough and shortness of breath
ORAL MANIFESTATION OF HIV
• VIRAL LESIONS :
• Herpes simplex
• Herpes zoster
• Oral warts (Human papilloma virus)
• Cytomegalovirus
• Hairy leukoplakia(Epstein barr virus)
• HAIRY LEUKOPLAKIA :
• Epstein-Barr virus (EBV) is the main cause of hairy leukoplakia
• Corrugated white lesion that usually occurs on the lateral or ventral
surfaces of the tongue in patients with severe immunodeficiency
• It may present as a plaque like lesion and is often bilateral
• The most common disease associated with oral leukoplakia is HIV
infection
• HL lesions vary in size and appearance and may be unilateral or
bilateral.
• Irregular surface
• Prominent folds or projections
• Resembling hairs.
• Lesions occur most commonly on the lateral margins of the tongue
and may spread to cover the entire dorsal surface
• They may also spread downward onto the ventral surface of the
tongue, where they usually appear flat.
• Buccal mucosa- Flat lesions.
• DEFINITIVE DIAGNOSIS :
• Biopsy
• (Can be confused with oral candidiasis)
• Definitive diagnosis of HL requires demonstration of EBV.
• EBV demonstrated in biopsy specimens
• Cells taken from the HL lesion by scraping can be used for a
noninvasive diagnosis using in situ hybridization.
TREATMENT :
• Antifungals
• Antiviral agents
OTHER VIRUS INFECTIONS

1. MOLLUSCUM CONTAGIOSUM :
• Virus of pox group
• Common in children
• Skin or mucosal surface
• Intraorally uncommon
• Rarely reported
• Most frequently on lips,tongue ,buccal mucosa
• Treatment : surgical excision,topical application of drugs
2. CONDYLOMA ACUMINATUM :
• Belongs to same group of HPV
• Oral manifestations :
• Small, multiple, pink nodules
• Tongue, buccal mucosa, gingiva,palate
• Treatment :
• Surgical excision
3. CHIKUNGUNYA :
• Chikungunya virus
• Mosquito borne illness
• Fever ,rashes,arthralgia
• Headache,chills,rigors,nausea,vomiting,fever
• Oral Manifestations : Maculopapular rashes ,gingival
haemorrhages
• Treatment : Self limiting,Symptomatic treatment
4. RUBELLA : (German Measles)
• Rubella virus
• Transmitted by airborne droplet emission
• Malaise,low grade fever
• Morbilliform rash
• Rarely reported now due to routine vaccination since
1970
• Mild self limiting
• No specific treatment required
• CORONA VIRUS DISEASE 2019
(COVID 19):
• Head ache,loss of taste and
smell,cough,fever,running nose
• Symptoms in oral cavity :
• Dysgeusia,ulceration,aphthous
stomatitis often mentioned
CONCLUSION
Viruses have long been known to cause
certain infectious diseases and many of them
produce a long lasting immunity against
reinfection by same virus Several other
viruses have been reportedly associated with
oral lesions in immunocompromised
persons; new technologies will undoubtedly
shed further light in this expanding field.
 REFERENCES
• Oral & maxillofacial pathology:Neville,3rd edition
• Textbook of oral medicine:Burkitts,11th edition
• Shafers text book of Oral pathology,6t edition
• Centers for Disease Control and Prevention epidemiology and prevention of
vaccine-preventable diseases. 13th edition. 2015.
• Weiss A, Dym H. Oral lesions caused by human papillomavirus. In: Clinical advisor.
2011. Accessed November 5, 2016.
• Ananthanarayanan and Panikers Textbook of microbiology (7th edition)
• Cohen JI. Herpes zoster. N Engl J Med 2013;369(18):1766e7.
• Fatahzadeh M, Schwartz RA. Human herpes simplex virus infections: epidemiology,
pathogenesis, symptomatology, diagnosis, and management. J Am Acad Dermatol
2007;57:737e63.
• Fatahzadeh M, Schwartz RA. Herpes simplex labialis. J Cli Exp Dermatol
• 2007;32:625e30.
• Internet sources
THANK YOU
THANK YOU