21 July 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.


  • 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.


  • 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.


  • 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.


  • 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.


  • 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


  • 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


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


  • 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.


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


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