Viral Infection in the Oral

Cavity
drg. Stephani Dwiyanti, Sp.Perio
Department of Dental Medicine
School of Medicine and Health Sciences
Learning Objective
• Menyebutkan berbagai infeksi karena virus
yang sering ditemukan di mukosa mulut
• Membedakan gejala klinik penyakit akibat
virus di mukosa mulut
• Menetapkan diagnosis & terapi yg tepat
• Menentukan rujukan
Outline
Herpes Simplex Virus

Varicella Zoster Infection

Hand Foot and Mouth Disease

Herpangina

Oral Hairy Leukoplakia

HERPES SIMPLEX INFECTION
Etiology
• HSV-1 (above the waist)
• HSV-2 (below the waist)
Pathogenesis
• initial contact with the virus
• inoculation of the mucosa, skin, and eye with infected
secretions

virus travels along sensory nerve axons

• establishes chronic, latent infection in sensory ganglion • Fever

(trigeminal ganglion) • ultraviolet
• Extraneuronal latency (latent in cells other than neurons such as radiation
the epithelium) → RHL • trauma
• stress
HSV reactivates at latent sites and travels to the mucosa • menstruation

recurrent HSV infection -

localized vesicles or ulcers.
Primary Gingivostomatitis
• usually • 1-3 days viral • Erythema, clusters of vesicles
subclinical prodrome of and/or ulcers:
• children and fever, loss of ➢ keratinized mucosa - hard
teenagers, and appetite, palate, attached gingiva,
young adults malaise, and dorsum of the tongue
myalgia, ➢ nonkeratinized mucosa -
• self-limiting,
accompanied buccal and labial mucosa,
resolves within
by headache ventral tongue, soft palate
10–14 days,
and nausea • Vesicles (1-5 mm) break rapidly to
typical for a viral
• Oral pain form ulcers, with scalloped
illness.
• Eating and borders and marked surrounding
swallowing erythema.
difficulties • Erythematous gingiva
• mouth extremely painful
• Pharyngitis
Recurrent Oral HSV Infection
• Reactivation of HS: asymptomatic shedding, ulcers
• 2 forms: RHL and RIH

Recurrent herpes
labialis (RHL)
• itching, tingling, or
burning
• Pain (first 2 days)
• papules, vesicles,
ulcers, crusting, and
then resolution of
lesions
Recurrent Oral HSV Infection

Recrudescent intraoral Recrudescent intraoral HSV (RIH)

HSV (RIH) in in Immunocompromised
• may occur at any site
Immunocompetent
• ulcers may be several cm in size
• keratinized mucosa
→ mimic RAS
• 1–5 mm single or
• last several weeks or months if
clustered painful
undiagnosed and untreated →
• ulcers with a bright
disseminate
erythematous border
• Presence of 1–2 mm vesicles or
satellite ulcers at the edges of
the main ulcer is a helpful sign
Differential Diagnosis
For PHG Similarities Differences
Coxsackievirus (CV) • Prodromal symtpoms • ulcers generally not
infections (hand–foot– • widespread clustered
and–mouth [HFM] disease) • ulcerations of the oral • generalized gingival
cavity inflammation not present
• Lesion on other site

For RIH Similarities Differences

Necrotising Ulcerative • Fever, malaise, headache, • Widespread ulcers
Gingivitis lymphadenopathy • Poor OH (many local
• Widespread ulceration factors)
on the gingiva
Laboratory Diagnosis
• Gold standard: HSV isolation by cell culture
• PCR/real-time PCR
• Tzanck test
• Direct Fluorescent Antigen Detection Test
• Anti-HSV IgM dan IgG
Management
Definitive Treatment
• Acyclovir – within 48 hours of
symptom onset / 72
Pain control • Children: acyclovir at 15 mg/kg
• Tantum verde five times a day, 7-10 days
• Paracetamol
Primary
• Adults: 400 mg, 5 dd 1, 7-10 days
• Aloclair Gel/Dental HSV
gel super relief Infection

Supportive
• Hydration
• Ice chips or popsicles
• Soft bland diet
• Antipyretics such as ibuprofen
as needed (avoid aspirin
products)
• Oral Care
Management RHL
Definitive Treatment

• Topical:
Pain control ➢ sunscreen
• Tantum verde ➢ 5% acyclovir cream / 1%
• Paracetamol
Secondary penciclovir cream - applied 5-8x/
• Aloclair Gel/Dental HSV day at the first prodrome or sign of
gel super relief Infection a lesion.
• Systemic:
Supportive ➢ valacyclovir (2 g every 12 hours for
• Hydration one day)
• Ice chips or popsicles ➢ famciclovir (1500 mg single dose)
• Soft bland diet
• Antipyretics such as ibuprofen RIH
as needed (avoid aspirin • Acyclovir (400–800 mg 5x/day for 7–
products) 10 days)
• Oral Care • Valacyclovir (500–1000 mg 3x/day for
• Elimination of Predisposing 7-10 days)
factors
VARICELLA ZOSTER VIRUS INFECTION
• Varicella Zoster Virus
• Transmission by the respiratory route
• incubation period of two to three weeks

latent at the dorsal root ganglia or ganglia of the cranial

nerves
• Elderly
• Immuncompromised
Herpes Zoster / Shingles • patients undergoing
chemotherapy/radiotherapy
• patients taking
immunosuppressive drugs
Post Herpetic Neuralgia
• peripheral and central nervous
• system injury and altered central nervous
system processing
Primary VZV Infection
• generally occurs in the first two decades of life
• low-grade fever, malaise
• Skin: pruritic, maculopapular rash → vesicles → turn cloudy
and pustular, burst, and scab, with the crusts falling off after
1-2 weeks
• Oral: acute-onset ulcerations in the mouth that often pale in
clinical significance when compared with the skin
• severe VZI that may appear atypical, be bilateral, and involve
multiple dermatomes;
Herpes Zoster Infection
• occurs in adults
• More severe prodrome of deep, aching, or burning pain, with
little to no fever or lymphadenopathy
• within 2-4 days: unilateral, linear, and clustered distribution of
the vesicles, ulcers, and scabs in a dermatome supplied by
one nerve.
• Thoracic/lumbar dermatomes the most frequently involved,
followed by the craniofacial area
• heal within two to four weeks, often with scarring and
hypopigmentation
Herpes Zoster Infection
Herpes Zoster Infection
V1 (ophthalmic division) most often affected (herpes zoster ophthalmicus)

V2: midface and upper lip

• prodrome of pain, burning, and tenderness, usually on the palate on one
side.
• several days later → painful, clustered 1–5 mm ulcers (rarely vesicles, which
break down quickly) on the hard palate, buccal gingiva, unilaterally
• Ulcers often coalesce to form larger ulcers with a scalloped border
• heal within 10–14 days, and postherpetic neuralgia in the oral cavity is
uncommon.

V3: lower face and lower lip

• mandibular gingiva and tongue
Laboratory Findings
• Cell culture
• Tzanck test: multinucleated epithelial cells (does not
distinguish between HSV and VZV)
• Direct fluorescent antibody
• PCR and real-time PCR
Herpes Zoster Complication
• Post Herpetic Nerualgia: pain that lingers for 120 days,
sometimes years
• sharp, stabbing, burning or gnawing nature
• Predisposing factors: older age, prodromal pain, and more
severe clinical disease during the acute rash phase

• Ramsay Hunt syndrome → Bell palsy, vesicles of the external

ear, and loss of taste sensation in the anterior 2/3 of the
tongue.
• Eye complication → blindness
• resorption and exfoliation of teeth, and osteonecrosis of the
jawbones, especially in patients with HIV disease
Differential Diagnosis of HZI
Before vesicle/ulcer appear Similarities Differences
Pulpitis • Prodrome pain and • Oral infection (caries,
burning root fragments)

After vesicle/ulcer appear Similarities Differences

Herpes Simplex infection • Fever, malaise, headache, • Less severe pain/burning
lymphadenopathy sensation
• Multiple, grouped • Bilateral
vesicles and ulceration
Necrotising Ulcerative • Fever, malaise, headache, • Disease progression is
Periodontitis lymphadenopathy slow
• Necrosis/ulcers of the • Associated with poor OH
soft tissue (periodontal • May occur anywhere in
tissue) the jaw
• Not self-limiting
Management Definitive Treatment
• Acyclovir – within 48 hours of
symptom onset
Pain control (especially • Children: acyclovir at 15 mg/kg
for PHN) five times a day, 7-10 days
• Adults: 800 mg, 5 dd 1, 7-10 days
• Tantum verde
• Paracetamol
• Aloclair Gel/Dental gel
VZ and • Valacyclovir 1000 mg, 3 dd 1, 7
HZI days
super relief
• Famciclovir 500 mg, 3 dd 1, 7
days
PHN:
• gabapentin
• lidocaine patch
• 0.025%–0.8% topical Supportive
capsaicin • Hydration
• Opioid analgesics and • Ice chips or popsicles
tricyclic antidepressants • Soft bland diet
• Antipyretics such as ibuprofen as needed
(avoid aspirin products) → Reye Syndrome
• Oral Care
COXSACKIEVIRUS INFECTION
• Coxsackie (CV) → RNA virus
• Viruses replicate first in the mouth and then extensively in the
lower gastrointestinal tract, where they shed
• Transmission: primarily fecal-oral route
• usually afflicts children younger than 10 years in summer
• CV infections lead to HFM disease & herpangina
HFM DISEASE
• CVA16 and enterovirus (EV) 71 are the most common
• tends to be seasonal (usually summer), occurs in epidemic clusters, and has
high transmission rates

• Skin rash (red & macular → vesicular) especially

on the hands and feet (dorsa, palms, and soles),
• Low grade fever some on the buttocks
• Sore mouth • Oral lesion : erythematous macules → vesicles →
• Sore throat ulcers
• the tongue, hard and soft palate, and buccal
mucosa but can present on any oral mucosal
surface
HERPANGINA
• CVA (serotypes 1–10, 16, and 22) are the most common

• pain on swallowing → erythema of the

• Low grade fever, oropharynx, soft palate, and tonsillar
headache, pillars.
myalgia (1-3 • Small vesicles form → rapidly break down
days) to 2–4 mm ulcers, persist for 5 to 10 days
• Sore mouth • Lymphonodular pharyngitis → →diffuse
• Sore throat small nodules
• in the oropharynx → sore throat
Laboratory Findings
• culture (usually from the throat or feces), but only CVA9 and
CVA16 grow readily
• Diagnosis is usually made on clinical findings
• Culture and biopsies are rarely necessary for diagnosis
Management
• CV infections are self-limiting (unless complications arise or the patient is
immunocompromised)
• Effective antiviral agents for CV are not available

Pain control Supportive Prevent Disease

• Tantum verde • Hydration Transmission
• Paracetamol • Ice chips or popsicles • Limit contact with
• Aloclair • Soft bland diet others
Gel/Dental gel • Antipyretics such as ibuprofen
super relief as needed (avoid aspirin
products) → Reye Syndrome
• Oral Care
Oral Hairy Leukoplakia
• Second most commonly-associated oral HIV lesion, but not pathognomonic for
HIV
• other states of immune deficiencies (immunosuppressive drugs and cancer
chemotherapy) have been associated with OHL.
• Epstein-Barr virus (EBV) and with low levels of CD4+ T lymphocytes are strongly-
associated with OHL

• Asymptomatic
• frequently encountered on the lateral borders of
the tongue, but may be observed on the dorsum
and buccal mucosa
• vertical white folds oriented as a palisade along
the borders of the tongue.
• white and somewhat elevated plaque, which
cannot be scraped off.
Diagnosis
• based on clinical characteristics
• histopathologic examination and detection of EBV can be
performed to confirm
• Light microscopy of histologic sections → hyperkeratosis,
koilocytosis, acanthosis, and absence of inflammatory cell infiltrate
• light microscopy of cytologic preparations → nuclear beading and
chromatin margination
Management
• can be treated successfully with antiviral medication, but not
often indicated as this disorder is not associated with adverse
symptoms
• spontaneous regression.
• HL is not related to increased risk of malignant
transformation.
• Medication with HAART has reduced the number of HL to a
few percent in HIV-infected patients.
REFERENCE
• Glick M, et al. Burket’s Oral Medicine. 12th edition. India.
Jaypee Brothers Medical Publishers; 2015.
• Laskaris G, Laskaris G. Pocket atlas of oral diseases.
• https://wjla.com/news/local/hand-foot-mouth-disease-
outbreak-johns-hopkins-university
• https://hubpages.com/health/Herpangina
• https://wikem.org/wiki/Beh%C3%A7et%27s_disease