Sign In Viral infections are commonly seen in patients and being confident in diagnosing and treating them is important. Here, we cover all the relevant viral infections that are commonly seen in the dental clinic. We will cover everything from clinical features to treatment.
Herpes Simplex Infections
Viral infections caused by Herpes simplex virus (HSV) are highly contagious.
This is a DNA virus consisting of two types:
- Herpes simplex virus type 1
– Affects the oral mucosa, pharynx and skin
– Causes Primary herpetic gingivostomatitis which leads to Herpes labialis
- Herpes simplex virus type 2
– Predominately involves the genitalia
– Implicated in production of cervical carcinoma
The lesions produced by the two types are however identical
An easy way to remember it is:
- If the lesions are above the belt it’s caused by HSV 1
- If the lesion are below the belt it’s caused by HSV 2
These are viral infections caused by HSV 1. These are the most common viral infections affecting the mouth, mostly infecting young children and adults.
Clinical Features
In early childhood primary infection occurs, recurrent (reactivation) takes the form of herpes labialis aka cold sores.
- Vesicles can be found anywhere on the oral mucosa but most commonly found on the hard palate and dorsum of the tongue.
- Rupturing of the vesicles leaves circular shallow ulcers
- The oral mucosa will be red and sore even if they don’t have any ulcers
- In children they may be marked by gingivitis
- Ulcers are painful making eating difficult
Prodromal symptoms:
- Malaise and tiredness
- Generalised muscle ache
- Sore throat
- At this stage often, the submandibular glands/nodes will also be enlarged and tender
Oral lesions usually resolve in within a week to 14 days.
Apart from intra-oral lesions there may also be lesions of the lips and circumoral skin.
Diagnosis
- Clinically evident
- Swab and smear– to show virally damaged cells (in early stages)
- Blood test– increase in igG antibodies (2-3 weeks after onset)
Treatment
Self limiting and resolves in 10-14 days so focus on alleviating the symptoms
Local measures:
- Nutritious diet
- Bed rest
- Plenty of fluids
- Chlorhexidine mouthwash 0.2% or hydrogen peroxide mouthwash 6%
- Benzydamine hydrochloride mouthwash
Drug treatment:
For immunocompromised patients or severe infections in non-immunocompromised patients prescribe:
- Aciclovir tablets
Note: Only prescribe anti-viral drugs in immunocompromised patients or severe infection in non-immunocompromised patients.
This is more commonly known as cold sores.
The initial infection of HSV 1 causes Primary herpetic gingivostomatitis, the virus will then become latent and will ‘hide’ in a sensory ganglion often of the trigmeinal nerve. The virus will then reactivate at a later date causing the secondary infection which results in herpes labialis.
Triggering Factors
- Strong sunshine
- Menstruation
- Emotional upsets
- Stress
- Common cold
- Local irritation such as dental treatment
Clinical Features
- Usual site is on or near the lips
Changes follow a consistent course as follows:
- Burning sensation
- Erythema
- Vesicles form an hour or two usually in clusters at the vermilion border but can stretch to adjacent skin
- Vesicles will enlarge and release exudate
- After two or three days they rupture and crust over but new vesicles will frequently appear for a day or two, they will eventually scab over and heal without scarring
- The whole cycle may occur over ten days
Treatment
Self limiting and resolves in 10-14 days so focus on alleviating the symptoms
Local measures:
- Nutritious diet
- Bed rest
- Plenty of fluids
- Chlorhexidine mouthwash 0.2% or hydrogen peroxide mouthwash 6%
- Benzydamine hydrochloride mouthwash
Drug treatment:
For immunocompromised patients or severe infections in non-immunocompromised patients prescribe:
- Aciclovir cream
Herpetic Whitlow
- Herpetic whitlow is a viral infection resulting in the formation of blisters around the fingernail.
- It can occur from treating a patient without gloves. If there is a break in keratin then dentists can develop this from herpes infected patients.
- Herpetic whitlow also often occurs in children due to finger sucking when they are infected.
Note: Parents should be advised to wear gloves when applying anti-herpetic drugs to their children
It is not advised to perform dental treatment on such patients suffering from an infection HSV 1.
If dental treatment is necessary then the following precautions should be used:
- No aerosols should be used e.g. ultrasonic scaler, handpieces
- Wear gloves
- Use a rubber dam
Herpetic whitlow can occur from treating a patient without gloves. If there is a break in keratin then dentists can develop this from herpes infected patients.
Herpes Zoster
Herpes zoster, more commonly known as shingles is caused by the varicella zoster virus (VZV).
VZV is a viral infection that can cause 2 diseases in humans:
- Chicken pox (non-immune children)
- Herpes zoster (affect the elderly due to reactivation of the latent virus)
Like the HSV, the VZV remains latent in the relevant sensory ganglion after the chicken pox infection, it then passes down the nerve to the skin/mucous membrane on reactivation causing herpes zoster.
- Initial symptoms (prodromal phase) will also include:
– Pain and tenderness in affected area (note: this pain is often misdiagnosed by patient and dentist for toothache apparently)
– Malaise
– Fever
– The prodromal phase will last for 2-3 days after which vesicles will start to appear
- Vesicular eruption in the area of the nerve distribution
- In case of herpes zoster of the trigeminal nerve (15% of cases)vesicles are present and merging together on one side of the face and mouth up to the midline (normally ophthalmic branch are affected)
– May involve corneal ulceration if the ophthalmic branch is affected
- Within the mouth vesicles behave the same way as with HSV
- Can lead to post herpetic neuralgia if not treated
- Through clinical signs
- Immunodetection – Rising titre (antibody concentration) of VZV-specific IG-M antibody in blood confirms diagnosis (although ineffective during the dormant phase)
- Lymph collected from a blister can be tested by a polymerase chain reaction for VZV DNA or examined with an electron microscope for virus particles.
- Aciclovir tablets
- Alternatively can give famciclovir or valaciclovir
This helps prevent sharp, shooting pain along the nerve.
Always treat with anti-viral (high dosage) as it can be severe and lead to other complications like post herpetic neuralgia.
Coxsackie Infections
The cocksackie virus is a viral infection that can be divided into 2 categories:
- Group A virus – these are responsible for two infection of the oropharyngeal region
– Hand foot and mouth disease
– Herpangina
- Group B virus – infect the heart, pleura, pancreas and liver
This is caused by the cocksackie virus A16.
It occurs in children under the age of 10 .
Small epidemics often occur in nursery schools/kindergarten during the summer and autumn months as it’s highly infectious
Clinical Features
- Ulceration all over the oral mucosa
- Vesicular rashes on hand (palmar surface) and feet (plantar surface)
- Malaise, abdominal pain and sore throat
Diagnosis
- Observation of clinical features and history assessment
- Can be confirmed via serology (blood tests)
- Swab test for Coxsackie A virus
Treatment
- It is self limiting and resolves in 7-10 days so no specific treatment required
- OTC pain killers to treat fever and malaise
- Advise patient to drink plenty of fluids to avoid dehydration
A painful infection of the mouth caused by cocksackie virus A.
Most common in young, school children
Clinical Features
- Mouth blisters
- High fever
- Sore throat
- Small number of lesions form in the back of the mouth, particularly soft palate and fauces, but also on the tongue and uvula
- Lesions often progress forming red macules to vesicles to ulceration over 7-10 days
Treatment
- No antiviral treatment is available
- Lesion should heal after 3-5 days
- Just supportive treatment is recommended such as cold beverages (avoid dehydration), avoid hot drinks and hot food until illness is over
- OTC pain killers to treat fever and malaise .
Human Papilloma Virus
There are over 100 different HPV, of which 40 affect the genital area.
They are STD viral infections acquired through oral sex of an infected individual.
HPV 16 and 18 is strongly associated with cancer of the cervix.
HPV 16 is associated with oral/oropharyngeal cancer such as kaposi sarcoma (see HIV).
It also leads to the common wart on the skin or oral mucosa. Treatment would be excision.
HPV IS THE ONLY VIRAL INFECTION THAT IS POTENTIALLY MALIGNANT.
HIV Related Infections
Patients suffering from HIV are also liking to suffer from many oral infections.
This is due to the immune system being compromised leading to the patients being unable to fight off infections as well as the average person.
Below are common oral viral infections to expect in HIV positive patients.
- Candidal infections (see fungal infections)
- Oral hairy leukoplakia
- Kaposi sarcoma
- Lymphoma
- RAS (see ulcers)
Oral hairy leukoplakia is caused by the Epstein-Barr virus (EBV) (HHV-4).
Causes
- It is common in patients with HIV due to their weak immune system.
- Patient is taking various drugs- steroid inhalers
- If a patient is HIV positive and is exposed to the EBV they are highly likely to get oral hairy leukoplakia.
Clinical Features
- Clinically it appears as white patches on the tongue. The patches often look hairy due to hair-like extentions which is where the name comes from.
- They cannot be wiped off – this is how they are differentiated from thrush, as they clinically look the same.
Treatment
- It is rarely treated itself, treatment is focused on the underlying condition. It is a sign that the immune system is weak and that the current HIV treatment being received may need to be altered.
This is a cancer caused by an infection with HHV 8 (human herpesvirus).
However patients who are infected with HHV 8 are only likely to get kaposi sarcoma if they are immunocompromised, which is why it is common in HIV infected patients. This can also be the case in patients who have had an organ transplant or who are in old age.
HHV 8 is in the same family of viruses as Epstein-Barr virus.
Clinical Features
Clinically they appear as red/purple lesions on the skin or/and the mucous membrane. Orally they are commonly found on the hard palate.
Treatment:
- Immune system treatment e.g. antiretrovirals in HIV patients – treating the weakened immune system that allowed the cancer to develop is the priority
- Local therapy such as cryotherapy and excision – to treat the lesion itself
- Chemotherapy – if there is no improvement chemotherapy can be given
Lymphoma is a cancer that originates from the lymphatic system.
They can be categorised into Hodgkin lymphoma and non-Hodgkin lymphoma.
People with HIV, have a greater risk of developing non-Hodgkin lymphoma.
However, with both, cells (normally B cells) in the lymphatic system start to divide uncontrollably resulting in the formation of a tumour.
Often shows as a swelling or ulcerative lesion in the mouth.
Treatment focuses on treating the HIV as opposed to the lesion.
Dental Update: Oral Medicine – Ulcers: Serious Ulcers
https://www.dental-update.co.uk/issuesThreeArticle.asp?aKey=1066
Scully, C. (1999). Handbook of oral disease. London: Martin Dunitz.
Jordan, R. and Lewis, M. (2004). A colour handbook of oral medicine. New York: Thieme
Cawson. R A, Odell. E W. (2008). Cawson’s Essentials of Oral Pathology and Oral Medicine. 8th Edition
See also White Patches
