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Viral Infections and the Oral Cavity

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Viral Infections and the Oral Cavity Sumamry We promise there's more to know about viral infections than just 'lots of fluids and analgesics'. Viral infections Differential diagnosis Herpes simplex (HSV 1) Primary herpetic stomatitis Herpes labialis Herpetic whitlow Varicella Zoster (HSV 3) Chicken pox Shingles Epstein-Barr virus Infectious mononucleousis (glandular fever) Hairy leukoplakia - For information, please find in the White Lesions lesson Coxsackie Hand foot and mouth disease Herpangina Kaposi sarcoma virus Kaposi sarcoma Parvovirus B19 Slapped cheek (fifth disease) Rubella virus German measles Measles (rubelola) virus Measles RubulavirusReviseDental.com (within the genus Paramyxovirus) Mumps Cytomegalovirus (HSV 5) Primary Herpetic Gingivostomatitis Aetiology and epidemiology Caused by HSV (herpes simplex virus) 1 and HSV2 can sometimes be involved HSV spreads easily through saliva Causes pyrexia, cervical lymphadenopathy Mainly affects children Pathophysiology HSV infects epithelial cells forming intraepithelial blisters Clinical features Blisters that rupture easily producing blood-crusted lips Widespread painful oral ulceration Gingivae are swollen and erythematous Diagnosis Culture of HSV using a swab Clinical examination Management Reassurance Advice on limitation of contact to prevent the spread of infection Analgesics and soft diet advised Dental implications Gingivitis ReviseDental.com Extra Oral Presentation Herpetic Gingivostomatitis Intra Oral Presentation Herpetic Gingivostomatitis Recurrent Herpes Simplex infection Aetiology and epidemiology HSV resides in neural and other tissues Pathophysiology HSV becomes reactivated by factors such as sunlight, trauma, fever, stress, menstruation Clinical features Herpes labialis (cold sore) on the vermillion border of the lips Sometimes starts as a tingling sensation A number of vesicles appear These rupture early leaving an erosion which then crusts over ReviseDental.comThese lesions heal 7-10 days later Intraoral ulceration can also occur Diagnosis Clinical appearance is usually enough Swab or tissue culture can give a confirmation of the diagnosis Management Inform patient about the infectivity of the lesion Dental implications Patient's should not be seen whilst having recurrent herpes simplex infection as it is highly infectious Recurrent Herpes Simplex infection - Cold Sore Chickenpox and Shingles Aetiology and epidemiology Varicella Zoster Virus (VZV) produces chickenpox in childhood The reactivation of latent VZV occurs later in life producing shingles Highly contageous Pathophysiology VZV proliferates within macrophages and then spreads through the blood in the primary infection VZV resides in the nerve ganglia in a latent form Trigeminal nerve is affected in some cases Clinical features InitiallyReviseDental.com with a maculopapular rash Oral lesions on the palace and fauces are present Reactivation of VZV present with sever pain with unlateral vesiculobullous lesions Scars may develop with some sensory deficit Diagnosis Clinical presentation is sufficient A smear can confirm the diagnosis Management No treatment required for chickenpox Antiviral therapy should be considered for shingles Prevention A Vaccination for Shingles is offered by the NHS to patients over the age of 70¹ Chicken Pox Infectious mononucleosis (Glandular fever) Aetiology and epidemiology Epstein-Barr Virus (EBV) causes infectious mononucleosis Pathophysiology EBVReviseDental.com infects B lymphocytes T lymphocytes react and appear as atypical lymphocytes in the peripheral blood Lymphoid proliferation occurs in the blood, lymph nodes and spleen Clinical features Enlargement of lymph node, fever and inflammation of the pharynx Many patients suffer from purpura/ petechiae on the palate with oral ulceration Bleeding and ulceration of the gingivae may present Diagnosis IgM antibody with EBV capsid antigen will appear in serum Paul-Runnell-Davidsohn test and positive Monospot slide test will confirm the diagnosis Management Hospitalisation if severe, otherwise no treatment required Hand, Foot and Mouth disease Aetiology and epidemiology Caused by Coxsackie virus type A16 Most commonly occurs in children Pathophysiology Spread by viral shedding from infected hosts The virus replicates in the lymphoid tissue of the pharynx and lower intestine and spreads to lymph nodes Clinical features There are macular eruptions on the hands and feet and vesicular eruptions on the mucosa of the buccal mucosa, pharynx, soft palate and tongue Usually asymptomatic Diagnosis Clinical presentation and history Management Self-limiting and therefore only analgesics and chlorhexidine will calm any oral discomfort or pain ReviseDental.com Hands Foot and Mouth - Macular Eruptions on the Hand Hands Foot and Mouth - Vesicular Eruptions Herpangina Aetiology and epidemiology Caused by Coxsackie type A1-6, A8, A10, A16, A22 or B3 Occurs mostly in infants and young children Pathophysiology Spreads by contaminated saliva Clinical ReviseDental.comfeatures Vesicular eruptions on the soft palate, fauces and tonsils Diffuse erythematous pharyngitis Patients experience dysphagia and sore throat Diagnosis Clinical presentation Management Reassurance, advice patients to rest, use an antiseptic mouthwash and drink plenty of fluids Herpangina Karposi's Sarcoma Aetiology and epidemiology Mass formed by the proliferation of endothelial cells Several predisposing factors including: Genetics ReviseDental.comInfection Immunity Pathophysiology HHV8 - human herpesvirus type 8 is found in all types of Kaposi's sarcoma Clinical features Single or multiple lesions Usually visible on the palate, gingivae and the tongue Large, exophytic and nodular Range in colour: red/ blue Histopathology Mass of spindle cells Diagnosis Biopsy taken for diagnosis Management Lesions may not require any treatment Small lesions may be removed If larger lesions are causing functional or cosmetic problems then chemotherapy may be required for removal Slapped cheek (fifth disease) Aetiology and epidemiology Spread by touching or aerosols (coughing, sneezing) Mostly occurs in childhood Pathophysiology Parvovirus B19 Clinical features Initially a bright red rash on the cheeks Followed by a generalised rash all over the body Fever and flu like symptoms including malaise, sore throat, headache Symptoms resolve within 14 days Diagnosis Clinical presentation and assessment of symptoms Management Fluid intake and analgesia German measlesReviseDental.com - Rubella Aetiology and epidemiology Spread by touching or aerosols (coughing, sneezing) If caught during pregnancy, child may develop congenital defects including auditory, visual, intellectual and cardiac defects. Tooth development will also be affected Pathophysiology Rubella virus 14-21 days incubation Period of infectivity occurs 7 days after onset of the rash Clinical features No specific intra-oral features - may affect the tonsils Rash visible starting behind the ears and spreading around the head and neck, then to the torso Mild fever, malaise, swollen lymph nodes, aching joints and generalised rash Diagnosis Clinical presentation and assessment of symptoms Management Fluid intake, analgesia MMR vaccine for prevention Measles Aetiology and epidemiology Spread by aerosols (coughing, sneezing, breathing) Can live for 2 hours in the air Complications include: Hepatitis, meningitis, blindness, deafness, heart and nervous disorders, encephalitis and squint Pathophysiology Measles virus (rubelola) 7-14 days incubation Infectivity until 4 days after onset of rash Resolves after 7-10 days Clinical features Fever, malaise, cough, nasal congestion, conjunctivitis Red maculo-papular lesions that start on the head 1 in 20 can get pneumonia² Intra-oral: Koplick's spots White speckling surrounded by red margin on the buccal mucosa Oral lesions precede skin lesions and disappear early on Diagnosis Clinical presentation and assessment of symptoms ManagementReviseDental.com Fluid intake, analgesia MMR vaccine for prevention at 12 and 40 months³ Mumps Aetiology and epidemiology Spread aerosols (coughing, sneezing) Complications: meningitis, infertility due to inflammation of the ovaries or testes Pathophysiology Rubulavirus - within the Paramyxovirus Incubation period 16-18 days Clinical features Fever, vomiting, facial swelling, headaches and joint pain Symptoms last 3-7 days Intra-oral: Parotid enlargement leading to unilateral or bilateral facial swelling Opening of the parotid duct (Stenson's duct) appears erythematous and enlarged Diagnosis Clinical presentation and assessment of symptoms Management Fluid intake, analgesia MMR vaccine for prevention Mumps - noteReviseDental.com the characteristic bilateral swelling of the parotid glands Cytomegalovirus (HSV 5) Aetiology and epidemiology Usually asymptomatic and occurs in childhood May produce a mononucleosis syndrome which is similar to EBV Complications include hepatitis, pneumonia Can be acquired congenitally Infects solid organ transplant recipients Pathophysiology HSV 5 Clinical features Sore throat, swollen glands, swollen tonsils, tiredness, and nausea Diagnosis Culture, serology, antigen assays, PCR and cytopathology Management Fluids and analgesics Antivirals for immunocompromised patients Conclusion There are many different viral infections that can have implications on the oral cavity. Many of these infections occur in childhood. Third Party Links References Specific references: ¹www.nhs.uk Singles Vaccinations NHS website. Accessed: 2020 May 16 ²www.cdc.gov
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