25 May 2017
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Viral infections affecting the mouth – A summary

Viral infections affecting the mouth – A summary

 

Viral infections affecting the mouth – A summary

Herpes virus

About  Herpes virus

  • DNA virus
  • There are 8 Herpes viruses present(H1-8)
  • Characterised by latency and are reactivated in patients with compromised immunity.

Herpes simplex virus (HSV)

  • Herpetic gingivostomatitis is caused by HSV -1
  • HSV-1 typically affects the younger population
  • Ano-genital infection is caused by HSV-2
  • HSV must contact the mucosa or abraded skin to cause infection.

Features of Herpetic gingivostomatitis

  • Soreness of the mouth.
  • Oral vesicles are present which may be widespread and break down to leave oral ulcers.
  • Gingival oedema and erythema
  • Cervical lymph node enlargement especially the jugulodigastric nodes are enlarged bilaterally.
  • Sometimes there maybe fever and/or malaise.
  • Diagnosis is usually clinical.

Management of Herpetic gingivostomatitis

  • Patients have spontaneous remission.
  • Treatment is mainly aimed at reducing fever and controlling pain.
  • Adequate fluid intake is important especially in children.
  • Antipyretics/Analgesics such as paracetamol or ibuprofen help relieve pain and fever.
  • 0.2% CHX mouthwash daily may aid resolution of the painful lesions.
  • The mouth can be very sore and patient should adhere to a soft bland diet as a result.
  • Aciclovir orally or parenterally is only prescribed to immunocompromised patients or in the otherwise healthy if seen early in the course of the disease.

(Note- Antivirals do not reduce the frequency of subsequent recurrences.)

Herpes Labialis/Recurrent HSV-1 infections

  • Up to 15% of the population have recurrent HSV-1 infections
  • They occur mainly in adults
  • Reactivating factors include – fever, sunlight, stress, trauma and immunosuppression
  • HSV-1 is latent in the trigeminal ganglion after primary infection and can be reactivated by the reactivating factors mentioned above.

Features of  Herpes Labialis

  • Lip lesions at the mucocutaneous junction
  • Lesions may be preceded by pain, burning, itching and tingling
  • Lesions begin as macules that become pustules and eventually scab within 72-96 hours
  • The lesions heal without scarring
  • Diagnosis is usually clinical.

Management

  • Spontaneous remission within 7-10days
  • As the condition is both unsightly and uncomfortable treatment is indicated
  • Antivirals will give maximum benefit if given early in the disease
  • Antivirals are also indicated in immunocompromised and patients who have severe and persistent lesions
  • Penciclovir 1% cream or acyclovir 5% cream can be applied in the prodrome to minimize the lip lesion in healthy patients
  • In immunocompromised patients systemic acyclovir or famciclovir may be required.

Herpetic Varicella-Zoster virus

Chickenpox (Varicella)

  • Occurs mainly in children
  • Is highly contagious and is spread by droplets
  • The virus remains latent in the dorsal root ganglia after this infection
  • 50% of the infections are subclinical

Features of Chickenpox

  • Rash – seen mainly on the face and trunk.
  • Fever
  • Malaise
  • Cervical lymphadenitis
  • Mouth ulcers which are not easily differentiated from HSV but there is no associated gingivitis
  • Diagnosis is usually clinical and a rising antibody titre is confirmatory.

Management

  • Most patients will have spontaneous remission within 1 week to 10 days
  • Management is symptomatic e.g.- adequate fluid intake, antipyretics, analgesics, soft bland diet
  • Immune globulin or aciclovir are used in immunocompromised patients.

Shingles (Zoster)

  • Recurrence of Varicella Zoster Virus latent in the dorsal root ganglia
  • Mainly affects the elderly or immunocompromised.

Features of Zoster

  • Pain and rash in one dermatome
  • Unilateral rash usually
  • Mouth ulcers are seen in mandibular or maxillary zoster only
  • Post herpetic neuralgia is when the pain persists long after the rash has healed
  • Diagnosis is usually clinical.

Management

  • Mainly with analgesics
  • Aciclovir orally or parenterally or famciclovir may help with the pain and prevent post herpetic neuralgia
  • In ophthalmic zoster an ophthalmological opinion is important.

Epstein-Barr virus

  • Commonly produces lesions in the mouth and oropharynx.
  • Infection is common among young adults and is often subclinical.
  • More common in the developing world.

Features of EBV

  • Can cause infectious mononucleosis (glandular fever) which is characterized by fever, sore throat, malaise, lymphadenopathy and rashes
  • May have soft palate petechiae and a whitish exudate on oedematous tonsils
  • Recovery can take weeks or months and the virus thereafter remains latent in the pharyngeal and/or salivary epithelial cells
  • It also causes hairy leukoplakia
  • Investigations include blood film which will show large number of atypical mononuclear cells in the blood.

Management

  • No specific treatment available but supportive care should be given
  • Systemic corticosteroids are required if there is pharyngeal oedema severe enough to hazard the airway.

Cytomegalovirus (CMV)

  • Common in lower socioeconomic conditions
  • Infection is common among young children and is usually sub clinical
  • Is contracted from infected saliva or other body fluids.

    Features of CMV

  • Infection in normal children is usually asymptomatic but the virus remains latent thereafter.
  • Virus isolation and serology may be of value in the diagnosis.

     Management

  • Treatment is symptomatic
  • Antivirals are indicated in the immunocompromised patient.

Hand-Foot-And-Mouth Disease

  • Mild viral infection caused by strains of Coxsackie A virus.
  • Characterised by ulceration of the mouth and a rash on the extremities.
  • Common among school children and is highly infectious

Features of Hand-Foot-And-Mouth Disease

  • The small scattered oral ulcers usually cause some pain.
  • The rash consists of vesicles mainly seen around the base of the fingers or toes.
  • History and clinical features are usually sufficient for a diagnosis to be made.
  • The condition resolves within a week.

Note- No specific treatment is available or needed for this condition

MUMPS

  • Caused by the paramyxovirus.
  • Characterized by bilateral swelling of the parotid glands.

Features of Mumps

  • The salivary gland ducts are usually red and inflamed
  • Patients occasionally report a dry mouth
  • The salivary glands involved are extremely tender and painful to touch.
  • Trismus may be present
  • Diagnosis is usually on clinical presentation

Management

  • Symptomatic management
  • General supportive measures which include adequate rest and fluid intake etc.

Measles

  • Is a systemic febrile illness.
  • Caused by Paramyxovirus.

Features of Measles

  • Initial nasal discharge.
  • Koplik’s spots appear on the buccal mucosae – these are white pinpoint spots that disappear after 3-4 days.
  • A mucopapular rash then appears and disappears after a few days.
  • Disappearance of the rash heralds recovery.

Management

  • Symptomatic management
  • General supportive measures which include adequate rest and fluid intake etc.

Reference-

1)      Tyldesley’s Oral Medicine, 5th Edition, Anne Field and Lesley Longman, Oxford University Press 2003

2)      Oral and Maxillofacial Medicine , 2nd edition, Crispian Scully, Churchill Livingstone Elsevier 2008

3)      Cawson’s Essentials of Oral Pathology and Oral Medicine, 8th edition, R.A.Cawson, Churchill Livingstone Elsevier

 

Article by Simranjeet Kaur – Liverpool Dental Student