viral infections MY TOOTHY by mikeholy


									                               ‫بسم هللا الرحمن الرحيم‬

Today’s lecture will be about viral infections.

We have different families of viruses such as; human herpes viruses &
entero viruses including coxackievirus, paramoxivirus & human
papiloma virus & retro virus such as; HIV virus.

We are going to talk about these viral infections because they induce oral
U knows that for the pathogens to cause disease, it must overcome different
defense line & then it will cause disease.
We have different subgroups of human herpes virus& each one induces
different disease such as;
Herpes simplex type 1 >>> induce herpes infection on upper region.
Herpes simplex type 2 >>> induce herpes infection on lower region “genital
Varcilla zoster virus “herpes type 3”>>>induce chickenpox.
Epstein barr virus “herpes type 4”>>>infectious mononucleosis.
paramyxovirus “Herpes virus type 5” >>> mumps & measles.
Herpes virus type 6,7,&8.

              Characteristics features of herpes virus:

1*they are DNA viruses “as u know we have RNA genome & DNA
genome” but the herpes are DNA genome.
As u know the virus cause disease by integrating it’s own genome “here are
DNA genome” into the human cell & this viral DNA will induce synthesis
of new DNA so increase the number of virus & it will cause dissemination
of the disease.
Therefore, we have many viruses that we called it oncogenic viruses because
they are managed to insert there own genome within specific cells, it will
take control of cell cycle, so insertion of this viral genome within cell genes
will induce proliferation of cells, so it will cause growth of tumer & we will
end with cancer or any benign tumer.
2*most of them contracted early at life usually after 6 months of age.
3*transmitted in saliva by droplet or contact with infected patient.
4*they can become latent inside the nerve.
  This is the most important feature of this virus, it means that the virus will
get access through the nerve ending into the ganglia & stay there in non
active form ,in this case they integrate there genes in the cell & stay in non
active form until it’s reactivated for any reason such as; immunosuppression
,ultraviolet light exposure, any other infection ,stress, sun exposure, trauma
,& any type of stimulus that will activate the viral genes to proliferate so it
will induce recurrence of viral infection.
 >>>> here as u can see in the slide “please go back to u’r slide, sorry I
don’t have the slides” this is the virus , it will get access through the nerve
ending to the ganglion ,stay there & it will be re activated later for any of
reasons as mentioned above.

  **** As u know we have different infections that result from herpes
simplex viruses, let us start discussing them one by one.

         1***human herpes virus “herpes simplex type 1”:

  When the individual got affected or exposed to the virus “if he not
immune” ,he will get the disease & the disease will be presented as primary
herpetic gingivostomatities & as the name indicate the virus will induce oral
ulceration & sever gingival inflammation, so most of the lesions present
intraorally & present as non-specific ulcer ,that can exist any where on the
oral cavity such as ; pharynx ,soft palate ,tongue , mucosa & any where plus
gingival inflammation .

 Note: extra-oral & peri-oral herpetic lesion might exist.
 In most cases, this condition is associated with systemic involvement like,
fever, malaise & the patient is not feeling well ,but some times it’s will not
be diagnosed as primary herpetic gingivostomatities “going unnoticed by
general practitioner & parents” & the patient will be told that he has flu or
common cold.
 So the patient got the disease with systemic symptoms which is last for
about a week & recovery from the disease take 10-14 days later.
 Now at this stage the patient is highly infectious because the saliva
containing huge amount of virus so the patient can infect other people who
are not exposed to the virus before.
 Question: if the patient come in contact with other person who have a virus
before “& he used to have herpes labiales” , what will happen?
  Nothing, because he already have the viruses & AB against it & he will not
develop herpes labialis or recurrence “recall the reasons for re activation of
the viruses that mentioned above & as u can notice exposure to the virus
again will not induce recurrence”
 But, if he don’t have primary herpetic gingivostomatities before he will
develop primary herpetic gingivostomatities .


  most of viral infections management “that we will talk about them” is
supportive management & rehydration so we will tell the patient to take
more fluid.
<<<Antipyretic /analgesic either topical analgesic such as ; difflam or
systemic analgesic such as ;paracetamol.
<<<mouth wash to prevent secondary infections.
<<< No need to prescribe aciclovir in immunocompetent patient “normal
patient& not immuno suppressed”

Note: in some children they have severe gingival inflammation & swelling
“edematous gingiva” so one of the differential diagnosis is leukemia so here
u should review the patient after 4-5 days & see if it’s improved this means
that it’s viral infection & it’s transient,but if it’s not improved,u need to do
further investigations to exclude leukemia because as we said it’s one of the


>>>> u should warn the patient that the disease might recur another time but
with different picture & different presentation “i.e. herpes labiales”.
So u might prescribe topical acyiclovir “for recurrence” & ask the patient to
use it as we will explain later on the lecture.
>>>u should warn the patient that this disease is contagious because the
saliva is full with viral particles so he might infect other people or inoculcate
the virus within other parts of his body as his finger ,any cut in the skin
might infected with the virus or eyes so he should be careful not to
inoculcate the virus to other locations.
Please look to slides as u can see this is herpetic wittlow ,its caused by
inoculation of the virus within the cracks & minor cracks of fingers ,& as
we said it may affect the eyes “i.e. the recurrence” so this is a concern for
the dentist & hygienist, if u are working with patient either having primary
herpetic gingivostamatitis or herpes labials or even we have silent shedding
which means we have high level of the virus within the saliva but without
any clinical presentation sooooooooo u should wear gloves all the time to
prevent herpetic wittlow.

>>> herpetic wittlow & eye involvement could be result from primary
herptic gingivostomtities or recurrence “herpes labiales” & the recurrence is
not necessarily at the same site as the dr. said.

>>>>Remember that herptic wittlow & eye involvement result from auto
inculcation from the saliva.

>>> as we said systemic aciclovir is essential if the patient is immuno
compromised only.

>>>if the primary infection fails to improve after 14 days in this case further
investigation should be conducted because there must be a reason for
immuno suppression.

                       Recurrent herpes simplex:

After the primary infection, the virus will become latent & about 35% of
patient have, recurrence or reactivation of the virus & this will appear
clinically as recurrent herpes & the recurrent herpes can be presented extra
orally “herpes labiales” in most of the cases & in few cases can be presented
intra orally.
Recall cause of recurrence of the virus & one of them is mechanical trauma
such as after scaling because it’s considered minor trauma so u will provoke
the virus.

>>> if the recurrence happened intra orally only the keratinized fixed
mucosa will be affected.
Sooooooo on primary herptic gingivostomatitis the infection can appear any
where, but in recurrence only fixed attached mucosa will be affected & we
use this criteria to differentiate between this condition & Recurrent
Aphthous Ulcer, but how?
RAS will affect mobile mucosa while recurrent herpes will affect fixed
attached mucosa.

>>>before the eruption of the vesicles, tingling sensation will take place
whether intra orally or extra orally, & after 2 days of this sensation there will
be eruption of the vesicles, it will last for about 5 days then it will rupture,
this vesicles might have secondary infection & in this case it will take longer
time for healing.
>>>the recurrence herpes will heal without scaring “in normal conditions”
unless it’s secondary infected.

                                    Notes :

>>>After healing of vesicles it will leave like erythrmatous lesion for like 2
weeks then it will heal completely.
>>>we call recurrence “herpes labials” cause most of the cases will be on
the lip either upper or lower lip but it can affect any other perioral tissues
some times the nasal mucosa & if the patient is immuno compromized for
any reason ,it may be disseminated for wider region but again most of the
cases, it will be on the lip or perioral tissues & less frequently within the
nasal mucosa.
>>> Again as we said the recurrence is not necessarily to reappear within the
same site, so it keeps changing the site of vesicles.

                  Management for recurrent herpes:

  In recurrence, the systemic features are not always present “in most of the
cases not present” but the patient may have slight malaise before eruption of
the vesicles, but again in most of the cases, it will be asymptomatic & we
will give the patient topical aciclovir five times a day.
Acyclovir should be applied once the tingling sensation started so u need to
tell the patient how to use aciclovir.
>> if we apply acyclovir once tingling sensation started the vesicle will
appear but in less number & it will heal faster.

>>>> efficiency of aciclovir depends on when we apply it ,it will be most
effective if we apply it once tingling sensation started & then the efficiency
will decrease until 72 hours after eruption of the vesicles but after 72 hours
of eruption of the vesicles the using of aciclovir will be useless
>>>>it’s important to inform the patient not to use his finger to apply the
cream to prevent herpetic wittlow, he should use cotton roll, not to rub the
cream over the vesicle because in this case u will rupture the vesicles soooo
dissemination of the virus & spread of the infection soooooooo just apply it
over the vesicle using cotton roll.

>>> please look to the pic. In the slides it shows us the intra oral recurrent
herpetic wittlow on attached mucosa such as ; hard palate & gingival.

>>>>in most of the cases, the recurrence will be unilateral because as we
said the virus is latent within the nerve so in palatal area “usually the
posterior part of the palate” will be affected because the virus will come out
through the greater palatine nerve.
>>>the same thing is applied to the gingival lesions & in most of the cases
it’s unilateral but this is not conclusive.

& now how I can differentiate between the recurrence herpes & zoster?
Both of them are unilateral & both of them take place on attached mucosa
but the difference is herpes zoster will be more painful, more severe, the
vesicles are more widely distributed & it will end sharply on the midline,
while recurrent herpes less vesicles, the vesicle will rupture & cause ulcer on
attached mucosa.

Note: recurrent intra oral herpes will appear as recurrent herpes labiales i.e.
first as vesicle then these vesicles will rupture but because of oral
environment, it will rupture faster inside the mouth.

               2**varcilla zoster virus “chickenpox”:

<<infection with this virus for the first time cause chickenpox .
<<it’s very common in children, with skin rash that affecting the face & the
trunk & some oral lesions “again vesicles rupture causing ulcer, mainly at
posterior part of mouth at pharyngeal area & the soft palate”.
<<most of the patient have this lesion & have fever, malaise & the patient
not feeling well so the management is just to control the fever, use analgesic
,rehydration & we give the patient anti histamine just to reduce the etching.

                  Shingle “recurrent zoster virus”:

<<most of the patient they will not have recurrence of this disease in
contrast to herpes simplex disease “35% of the patient affected with primary
herpes simplex might have recurrence & on the young age or adult hood”
but in the herpes zoster the percentage is far much less than that almost 2%
will have recurrence & usually the recurrence is on older age group or the
elderly people.

<<the most commonly affected areas are thoracic, cervical &lumbar
" ‫ ," الحزام الناري‬regarding trigeminal it can be affected & the most commonly
affected branch is the ophthalmic branch.
<<before eruption of the vesicles, when I have reactivation may be we will
have herpetic neurolagia, if this happen we will have severe pain very
similar to dental pain & the patient may come to the dentist seeking
treatment for teeth or complaining of sever dental pain & when u examine
the teeth u found that they are sound & there is no pathosis “note that in this
case the maxillary & mandibular branch of trigeminal are affected” but when
the ophthalmic branch is affected we might have pain on the eyes & referred
pain on the thoracic area.

So just to simplify the things first u will have pain before the eruption of the
vesicles & after almost 2-4 days the vesicles will erupt & the diagnosis will
be straightforward.

<<so it’s similar to herpes simplex but the vesicles are more intensive, more
painful, it will be formed on many region so it’s got the name ‫&الحزام الناري‬
in some instances it may heal with scaring ,this a problem in ophthalmic
because it may cause blindness as result of scaring in the eye.
<<another complication is even after this condition is resolved there is a
small percentage of the patient develop post herpetic nurolagia & it may last
for about 2 months after healing of vesicles.
<<<of course on this disease it’s not enough to treat it with topical aciclovir
or supportive treatment, but we need to use systemic aciclovir with high
doses almost 500mg/5 times daily for about 10 days to help the patient to
over come this disease.
<<<of course, this high dose will reduce the chance of post herptic
<<< we don’t use topical aciclovir cause the disease is widely distributed& it
will not be effective so we use high dose of systemic acyclovir.
<<<we have other preparations of acyclovir such as famciclovir & other
drug & the aim from using this preprations is that, biological life of drug is
longer so I don’t need to repeat the drug 5 times daily instead I can give it
twice daily.
Note: if maxillary & mandibular nerves are infected we will have extra oral
& intra oral manifestation & as we said in intra oral the infection will be so
extensive, so severe & reaching the midline.

                  3**EBV “herpes simplex type 4”:

<<<EBV will cause infectious mononucleaosis
  <<< Usually the infection will be passed unnoticed “i.e. subclinicl
 <<< We will have lymphoadenopath, fever ,malaise & some times skin
rash is present.
 <<<usually the patient will not seek medical health cause as we said it’s
subclinical infection.
 <<<< but infection with this virus will make complications in immuno
suppressed patient such as; 1* hairy leukoplakia.
                            2*burkitt’s lymphoma.
                            3* nasopharyngeal carcinoma.
 >>>So as we said we call this virus onco virus because it induces cancer or
malignant changes.

 <<< as u know hairy leukoplakia not a premalignant but it’s found only in
immuno suppressed patients.
 <<< While nasopharyngeal carcinoma is caner change.
 <<<<the management for this infection is supportive because it’s
represented as mild viral infection.

 This is all about herpes simplex viruses & now we will discuss entero

                      1* coxsackievirus infections:
 >>> First of all we don’t have latency for this group.

 >>>we have group A&B & different sub types of this huge coxackie
 >>> So first u might be infected with one sub type & become immune
against this sub type, but again u might be infected with other subtype.
 >>>the features for coxackie infections are very similar but we have typical
feature for group A coxackie virus.
 >>> coxackievirus A16 will cause hand ,foot & mouth disease & again
we will have vesicular eruption “this will happen in most of viral infections”
on oral region ,even perioral or inside the mouth or both, hands & foot as the
name imply, the symptoms of this viral infection is not so severe & usually
we will have mild symptoms so it’s self limited.

   >>>>herpangina: here the vesicles & ulcers are mainly localized to
posterior part of the mouth on the pharynx ,it would be represented as small
ulcer , the patient complains of sore throat & it will be last for a days then
it’s self limiting.

                     2**Paramyxovirus infections:

Mumps virus “‫ :”ابو دغيم‬here we will have bilateral involvement of parotid
gland “in most of the cases”& in few instances, we may have submandiular
Please look to the pic. On the slides as u can see here all of the 3 glands are
affected & in very rare instances it will be unilateral.
>>>of course on this infection we will have viral particles within the
salivary gland & this will affect the salivary gland function such as ;
1*hypo salivation: reduced amount of saliva.
2* the orifice of salivary gland it will be inflamed &we will have trismus
which is inability to open the mouth due to contraction of the muscles, to
minimize the spread of infection as one of defense mechanism & this is the
case in pericornities.

so in pericornities we don’t ask the patient to open his mouth widely &
forcefully because if u do this u will break one of the line of defense
mechanism & help the infection to spread.

 >>> The infection will usually affect young age group in schools, all
students’ affected “epidemic infection”.
>>> in very few instances the adult age group “20& 30”will be affected but
in this case u will have complication such as;pancreatitis
,encephalitis,orchitis,oophoritis “affecting the vertality”& deafness.
>>>so it’s dangerous if affecting older age group & the infection should be
controlled aggressively to prevent complications.

>>>again if I have primary herpetic gingivostomatitis & I exposed to
infection again I will got nothing neither primary nor herpes labials except if
I touch the lesion with my hand without wearing gloves I will got herptic
wittlow or if when I do scaling the droplet inter my eyes so I will get herptic
LABIALES “please always remember the predisposing factor for

Note: once I exposed to viral infection I will get AB against this viral
infection so I will be immune to this virus but the problem is that, there is
virus have different subtypes such as coxsackievirus, I mean if I exposed to
cox A 16 I will be immune for it , but I have cox 18, 19…… this is a
problem of common cold virus “adenovirus” the problem that you give the
vaccine and you have Ab for certain peptide but it’s keep changing sooooo
as if u got infection with new pathogen.

Marble virus “measles”: infection with this virus will cause**severe
illness, nasal discharge “it will appear as upper respiratory tract infection”,
fever, malaise, sore throat & macula & papule that present on the body.

**** it’s more severe, more intense than chickenpox, & intra orally we have
koplik spot on buccal mucosa “present as white spots distributed over buccal
mucosa ”.
*** & we have conjuctivities “red eyes”.
*** usually the children get the infection ,it will last for 10 days then the
patient will recover with immunity to this virus but the complications are
pneumonia & encephalitis.
**** Management is symptomatic & isolates the child from other children,
old people or even adult people who did not get the infection previously.

                      3***Human papilloma virus:

  Again we have over one hundred types & all of them cause warty lesion on
the skin & oral mucosa.

  >> the most common presentation of this virus is verruca vulgaris or
common warts, which is usually appears on the skin but the patient maybe
inoculate the virus into the oral cavity so there will be spread of the viral
infection to the oral cavity.
  Usually the lesion on the mouth appears on the anterior region of the mouth
i.e. on the lip, perioral , on the tip of the tongue or any other area of of ant.
Region of the mouth.
  >>> the clinical presentation of verruca is finger like projection “hyper
keratinized finger like projection ”but it is not always in this form, some
times it may appear as cauliflower appearance “‫ &”مثل الزهرة‬it’s color not
necessarily to be white but it might have similar color to oral mucosa but in
this case how u can differentiate it from oral mucosa?
  Simply, if u pay attention to it u can see that it is separated from surface of
oral mucosa & u can see the nodule within the growth forming the shape
similar to cauliflower.

  Other presentation of HPV infection is focal epithelial hyperplastic, which
is known as heck’s disease “it will be generalized hyperplasic growth,
within the mouth” this is infection affect the child mainly & the child will
come to u having red warty lesions on the cheek in addition to warty growth
on the mouth.
 <<we have other many presentation of this viral infection & as we said all
of this presentation induced by HPV.

  Note : it’s very important to differentiate the disease result from HPV
“which is viral infection” from sequams cell papilloma “which is benign
tumer” because both are look clinically very similar “they are almost
identical” but how u can differentiate between them?
  Papilloma found as solitary lesion on the mouth & the patient didn’t report
any infection or warty lesions on his skin so in this case u exclude viral
infection while in HPV we have history of wart’s ,viral infection& skin &
oral lesion which is multiple.

                                 Treatment :

  1>>> usually the lesions resolved by itself, almost after 1-2 years all warty
lesions are resolved.
 2>> may be we give the patient antiviral if the lesion was so extensive.
 Note : if the lesion was so extensive wart growth then the patient will be
immuno compromised.
  3>> may be we do excision of the lesion if it was on the face or the lip or if
the patient have lesion on the mouth & it cause irritation for the patient we
might excise it & when we excise it we should go deep to remove the whole

             Human inmmuno deficiency virus “HIV”:

  HIV is retrovirus & we have high-risk group such as;
 1*homosexual. 2**history of previous blood transfusion. 3***drug addicts
& other multiple factors.
  All of these factors are unnoticed from the history except for history of
blood transfusion “that’s why we ask every time about history of blood
transfusion” to know if the patient is categorized among high risk group
either for AID’S or hepatitis or not.

  >>>HIV it attacks certain cells in the body & again genes of the virus is
integrated within the genes of the cells “the target cells are T lymphocyte &
not any other cell”.
  Soooo it targets T lymphocyte & integrate its genetic material within it so
the T cell will be busy & only do replication for viral genetic material by this
the virus will spread & disseminate & the T cells will be non functioning.
  This means that the patient will be immuno suppressed because as we said
the T cells will be non functioning, non replicating & only replicate the viral
  >>> Transmission of this disease by saliva is very rare so u are not at risk
to get the disease from the saliva “there is no report of transmission through
the saliva” usually the transmission is by blood & body fluid but not through
the saliva because the saliva contains enzymes, protease & this enzyme will
destroy the viral particle.
  >> the problem with this disease is that the reported cases very small, while
the real number is much larger than reported so the Dr. advice us to consider
all the patient as carrier or suspected not only for AID’S but for any other
viral or bacterial infection especially that the protection not very difficult all
what u have to do is to wear mask & gloves.
 >>>one bad practice some dentist do is dealing with the first patient using
gloves & then go to another patient with the same gloves on this case the
dentist protect him self because he is wearing gloves but he transmits the
disease from one patient to another which is very unethical.
 ***Not any patient infected with HIV is AID’S patient because the patient
will pass through different sages until he get AID’s stage.
  **** in the first contact with the virus the patient might develop acute
HIV infection similar to any other viral infection which include ,fever,
malaise, not feeling well & this symptoms might lasts for certain time for
example weeks or so….
 ***of course not all patient develop this acute stage, some go to sub
clinical stage (the patient will not feel that he has any viral infection).
  *** so HIV infection might be asymptomatic which might last for a years
(the patient having the virus, the virus is replicating , but it’s not causing any
problem with number of lymphocyte, i.e. the activity of replication is not to
the maximum) so the patient might live normal life for many years some
times 10, 20 years, here the patient is having the virus & can infect other
people but as we said there is no symptom presented clinically.
  **** the HIV disease start when the number of CD4 T cells dropped, in
this case the patient could affected with number of diseases such
as;pnuomonia, candidosis, & bacterial infection………..
  ****the final stage will happen when the number of CD4 T cells dropped
below 200cell/ml, at this stage the patient is severely immuno compromised,
he will have all types of disease at typical presentation such as; candidal
infection which is chronic resistant to treatment, extensive viral infection,
malignancies, all types of infection & cancer.

                       Oral feature of HIV disease:

 Group one: strongly associated with HIV.
 Group two: commonly associated with HIV.
 Group three: possibly associated with HIV.

  & any other rare disease, for example, we know this disease is very rare,
it’s more common on HIV patient “this is exactly what is the Dr. said”.
 & now let’s start discussing them one by one.

 Group one which include:1****candidosis(any form of candidal
infection “thrush, erythrematous, hyperplastic”).
 U should always remember that candida is the disease of diseased .
 So if I have patient & he is young, or adult, he don’t have any systemic
disease, no predisposing local factors & he has candidal infection here u
should suspect immuno suppression such as; AID’s.
 2*** hairy luokoplakia which is caused by EBV & highly affecting people
who have immuno suppression such as; AID’s.
 3***HIV gingivitis, will be as red inflamed line at the margin of the
 4***Necrotizing Ulcerative Gingivitis: as u know that this disease is
multifactoril, the definite reason for it is unknown, it’s bacterial in origin but
we might have immuno suppression as predisposing factor, so if u see NUG
affecting periodontitis or gingivitis, this is one of the common presentation
for AID’s.
 5***Kaposi sarcoma: tumor of endothelial cells, this type of lesion is very
rare normally, it’s usually affecting elderly people, but now it’s more
prevalent in AID’s patient.
 6***non-hodgkin’s lymphoma.

       Group 2: Lesion less commonly associated with HIV

  Is any form of ulceration (RAS, atypical ulcerative lesion on the mouth,
thrombocytopenia purpura, any salivary gland disease, any viral infection
such as; cytomegalovirus or herptic virus, this infection in HIV patients will
be more extensive with atypical presentation of the disease, for example the
herpes labials will affect the whole face of the patient with extensive

vesicles eruption & may be the same thing present with varicilla zoster virus
which will recurrent with high frequency).


 First thing I should do is aggressive treatment of infection so I will give the
patient systemic antifungal, systemic antiviral in high doses for long period
of time & I do this just to control the symptoms of infections.

  To control the virus itself i.e. the HIV virus, we have anti retroviral
therapy, I have azidothymidine, which contains protease inhibtor, nucleoside
reverse transcriptase inhibitor, non-nucleoside reverse transcriptase
  This drug (azidothymidine) will prevent transcription of viral genome. as
we said the viral DNA will be inserted into the cells so it will be proliferated
& the virus will spread to the other cells so this drug will inhibit this
 This drug is effective, but how much efficient is different from patient to
patient, they are very expensive so they are limited to the rich country such
as UK, USA, & there is some country can’t afford this treatment such as
 Antiretroviral drug will delay the AID’s stage, improve the quality of the
patient life but as u know it will not cure the disease.

                               That’s all…….

                            Wala’a AL-zboun.


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