‫ممم مممم مممممم مممممم‬

Today we r going to talk about viral infections most common in oral cavity, these
types of virus that may infect oral cavity:

1. Human Herpes Virus (HHV)

2. Enteroviruses
1. Coxsackieviruses (CSV)
3. Paramyxovirus
1. Mumps virus
2. Morbillivirus
4. Human papillomavirus (HPV)
5. Human immunodificiency virus

Human herpes virus..HHV:

Until now up to 8 types of human virus are identified , they are:
1. Herpes simplex virus type 1 (HSV-1)(HHV-1)
2. Herpes simplex virus type 2 (HSV-2)(HHV-2)
3. Varicella-zoster virus (VZV) (HHV-3)
4. Epstein-Barr virus (EBV) (HHV-4)
5. Cytomegalovirus (CMG) (HHV-5)
6. Human Herpes Virus 6 (HHV-6)
7. Human Herpes Virus 7 (HHV-7)
8. Human Herpes Virus 8 (HHV-8)

The main characteristics of HHV are :

A-DNA virus: genome of virus can be DNA, RNA, double strand RNA
B-Contracted in early life: usually most affected individuals are at early stage,
most likely after 6 months cuz of drop in immunity that they took from their mothers.
C- Transmitted by saliva
D-Latency : u know how virus spread among epithelium cells and integrate into
genome of human cells DNA and become part of that cell and become latent there
,and then replicate and form new viral DNA and then encapsulated and go to spread
To affect other adjacent epithelial cells.
What happens that these viral particles will enter and can transmit to neuron and stay
latent there for long duration and when it is activated due to stress or ultra violet light
it will go to laysogenic stage where it replicates forming viral bodies that go and
infect another cell.
E-Reactivated by immunosuppressant
 Primary Herpetic Gingivostomatitis (HHV-1)

Mainly affect children with primary infection there is systemic symptoms

like elevating temperature , malaise , fever, inflamed gingiva in the oral cavity so
they can not eat or swallow bcz of the soreness in oral cavity and they need
medical treatment, and the ulcer can appear any where in the oral cavity like the
tongue and can affect the para oral skin.

It takes 10-14 days .

Management:
1-should exclude leukemia in children by doing the blood test to check there is
no increase in white blood cells
2-supportive by giving patient anti pyretics, rehydration and analgesics .

Now the patient is infected and he has the virus in his cells and become latent
where it hides in the ganglia , Here is example of lesion cuz of infected hand by
saliva, if patient has primary infection or recurrent infection he has increase
level of viral in saliva and his saliva is contagious and he can infect him self if he
has break in his finger causing very painful lesion called herpetic wettlaw ( not
sure from spelling ) .
When u examine patient and he has herpes labials or even symptoms are not clear
the patient may have increase in virus number in his saliva so always put gloves
on cuz any break in the skin can get the virus into ur finger u wont get this herpes
stomatitis but u may get this painful lesion.
U can inoculate the virus to ur eyes as we can c here by rubbing the eyes with
fingers contaminated with saliva.
 When recurrent happens most of the patient appear as recurrent herpes labials
where vesicles start to appear after tingling sensation on the lip and the vesicle
start to appear and convert to pustules and then rupture .
Also another place it might appear in the nose but it is less frequently, and we will
have the same appearance in the nasal mucosa.

If the viral affects facial nerve it may lead to bell's palsy which is paralysis of
facial nerve and this is transient with vesicle appearing in the ear and it lasts for
10 days as the infection resolve

Management:
1-supportive
2- Topical acyclovir 5 times daily

The use of acyclovir should be used as soon as the symptoms started like when
there is tingling sensation at this stage the treatment is effective. But when the
vesicle appear or become pustules treatment will be useless.
Dr rima said that when having this tingling sensation we can put ice and the
vesicle wont appear !!!!!

NOTE: according to a question that I did not here but the answer was that bell's
palsy is unilateral like if the virus affect the right facial nerve so the right side will
be affected and will have paralysis in facial expression so the patient cant move
his mouth or eyelid

Reccurent can appear intra orally and the most common place is the palate where
the greater palatine nerve gets out of the foramen and then become very painful
when vesicles rupture if the long buccal nerve is affected so the buccal side will
be affected in the molar region or some times the mental nerve so the gingivea in
the labial side is affected . And according to the herpes virus type two it affects
the genital

VZV(chickenpox),,,HHV 3 :

First time infection causes chickenpox where the vesicle rupture in the tongue and
the face and stay latent and most of the time it does not reactivate unless in cases
like immunosuppressant (like taking steroids chemotherapy, sever stress) so
they become affected causing the secondary herpes zoster.
 Treatment:
Supportive , and no need for anti viral and child should be separated from other
children. To prevent spread of the infection

Secondary infection (shingles):

Most common side is thoracic and it can affect any nerve like the thoracic or the
lumber nerve and the patient will have spread of vesicle cuz of this nerve.

30% affected the trigeminal nerve either the ophthalmic ,maxillary or the
mandibular. It affects one side(unilateral) ALWAYS , and can be intra orally or
extra orally .
It can affect the jaws gingiva ,tongue or the palate and its just until midline, the
vesicles are extremely painful and the pain started before the eruption of the
vesicles which is known as neuralgia
The patient come to us with severe dental pain and he thought it is irreversible
palpaitis but when we check the teeth they are normal, the periodontal ligament
and the pulp, and the vesicle after two days start to appear and diagnosis could be
confirmed .

Most complication:
Post herpetic neuralgia , they have pain even if the vesicle disappear so we give
them anti depressant , high dose of systemic acyclovir or famiclovir To control
the severe pain of neuralgia
If the ophthalmic nerve involve the patient should be referred to have ophthalmic
consultation bcz this may affect the vision like scaring in the eyes.

EBV (HHV-4) :

It causes infectious mononecleusis. It is usually sub clinical and no acute

symptoms.
- Lymphadenopathy
- Sore throat
- Fever and malaise then management will be by analgesic
- Rashes

Complications:
1-Hairy Leukoplakia
And it usually affects immunosuppressant individuals

• 2- Nasopharyngeal carcinoma 3- Burkett’s lymphoma

The best of human Herpes virus are 6,7,8 type are the least to have symptoms like
fever, malaise and they don’t have specific symptoms related to the oral cavity.
 Enteroviruses Coxsackieviruses (CSV)

There is no latent phase in these viruses cuz they don’t get into the nerve and stay
there. they are RNA viruses and they are in two groups A and B and with each
group there is sub types . Group A ( 16) may cause hand ,foot and mouth
disease(mouth may be affected intra orally or extra orally) , and another sub type
may cause herpangina

NOTE: hand,foot and mouth disease this affect the human and associated with
mild symptoms and its self limiting condition and is different than hand and foot
which affect the cattle.
Harpangina on the other hand affects the pharyngeal area where the pharynx the
uvula and soft palate and when vesicle rupture quickly they made shallow ulcers.

Paramyxoviruse, Mumps virus

Mostly it is bilateral affected the parotid ,sometimes it is unilateral affecting one

parotid gland and very rare to affect the whole salivary glands(parotid and
submandibular ) . patient complains of severe pain,malaise ,fever ,xerostomia and
sometimes trismus cuz the masseter muscle try to prevent the spread of the
infection by contracting and causing trismus.

Complications( usually if the mumps affect the adults):

Pancreatitis
Encephalitis
Orchitis / Oophoritis ( that may lead to infertility in very rare complications )

Treatment:
Supportive treatment and to isolate the child from other children ,analgesics and
anti pyretics
 Paramyxoviruse
Morbillivirus :

Here the Rashes in measles r very severe covering the whole skin unlike
chikenpox, we have koplik's spots covering the buccal mucosa and similar to
fordyces granules (whitish spots) and these spots are specific for this condition
(measles) and you can use it to diagnose the condition, and we will see
Maculopapular rash and Conjunctivitis.

Complications:
Encephalitis
Pneumonia
Management : again isolation and symptomatic

Human papilloma virus (HPV)

We have over 100 types of it and all of them cause warty growth in the skin and oral
mucosa. 1-.Most common is Verruca vulgaris ‫ الثالول‬causing common wart and can
affect the oral cavity if the patient sucks his fingers which will inoculate this viral
from skin to the oral cavity .
Treatmen : excisions
And this virus also cause 2- Focal epithelial hyperplasia (Heck’s disease)
And it is not very common . The warty growth in the mouth is different than
verruca vulgaris cuz the colour is similar to the normal mucosa it is reddish not
white . But we have over growth and we can see hyper plastic growth when we
take biobsy but the epith covering is normal there is no hyper keratinization., and
it is associated with red mark on both cheeks we call it slapped cheek rash

Another question that I did not here but I guess it was about treatment of Heck's
disease and the dr answered that we can give antiviral and if we did not this disease is
self limiting while in verruga vulgaris we need to excision this growth.

Retroviruses
Human immunodeficiency virus (HIV)
 It is an RNA virus , and it can spread by homosexuals or history of blood
transfusions so they check blood in blood banks before transfusions, drug addict
and multiple partners . This virus attacks CD4T cells ( helper ) and the dr here
mentioned the difference between it and CD8 which is associated with cytotoxics .
And also this virus affects brain glial cells which may lead to dementia and
neurological disorders.
Transmission by blood and semen but by saliva is very rare cuz of secretary
protease1 , Peroxidase,Thrombospondin-1 which act as inhibitor to prevent
spread of this virus through saliva . but we should be careful while extraction or
perio treatment cuz it may spread by blood. And the number of HIV is much more
than that present in studies.

HIV clinical feature : they are 4 stages,,

The first stage is acute HIV infection( the moment when viral enter the body and
start to replicate ) not all individual have acute stage , in acute stage it is similar to
any viral infection there is malaise ,fever , patient not feeling well . at this stage
there is rapid viral replication so in these symptoms u cant diagnose that the
patient have HIV infection bcz they are sharing to all infections and even if u
study number of virus or antibody test there is no enough number of viral or to
confirm ur diagnosis so this acute HIV infection is un noticeable .

NOTE: , some patient have viral in the body but don’t pass to acute stage and
don’t have symptoms.

The second stage, it is HIV infection where the HIV replicate and found in
virulence number in the body , the patient is asymptomatic at all and this may last
for several years up to 15 years.
We said HIV disease when the patient start to show symptoms of opportunistic
infection, fungal, viral , tumor,,,,,, and this is bcz the number of CD4 and T cells
dropped severely , the normal number is from 500 to 1500 cells/ ml , and bcz of
this drop they affect with pneumonia and candidacies .
We said the aids patient when CD4 and T cells dropped less than 200 cells/ml
And there is severe symptoms and he is resistant to treatment .

Oral feature :
They are three groups ;

1- lesion strongly associated with HIV infection.

2- Lesion less commonly associated with HIV infection.
3- Lesion possible associated with HIV infection.

GROUP 1:
Most common is- candidiasis (erythematous , hyper plastic, thrush)

-hairly leukoplakia ( we said it is common on EBV when the

immunity dropped)
-HIV gingivitis (they have typical linear red line at the margin of the
gingiva )
-NUG
 -HIV periodontitis(amount of destruction in the periodontal is not
reflecting the amount of calculus, we may have minimal amount of calculus with
severe destruction in the PDL .
- Kaposi sarcoma and non Hodgkin lymphoma
And ALL of them strongly associated with HIV infection.

In group 2 there is lesions less commonly associated with HIV infection which are
1-atypical ulceration ( ulcer that not related to other cause ,it is not traumatic ulcer
not recurrent ulcer )…
2- Idiopathic thrombocytopenic purpora.
3- salivary gland disease usually the HIV patient complains from dry mouth
( xerostomia) and unilateral or bilateral swellings of major salivary glands ..
4- viral infections like ( cytomegalovirus but it is not very common ,,herpes simplex
virus and it is common and wide spread in normal humans but when the lesion
become very severe and recurrent and the patient normally have herpes labials like
once every two to three months and not responding to antiviral treatment so we will
suspect with HIV .

How to deal with this patient :

They take medications for there infections , simple bacterial infection should be
treated aggressively with antibiotics and viral infections should be treated with
systemic anti viral for prolonged time and high doses .

Antiretroviral therapy: this is to prolong the inspected life of the patient like :

*Azidothymidine (AZT), protease inhibitor

*Nucleoside reverse transcriptase inhibitor: u know that RNA virus needs the
reverse transcriptase to convert RNA to DNA and then get it in the nucleus of the
human genome and then replicating and spreading so inhibiting this step by
transcriptase inhibitor this will prevent the spread ( RNA to get into nucleus )
*Non-nucleoside reverse transcriptase inhibitor
So nucleoside or non nucleoside transcriptase inhibitor both of them will inhibit the
reverse transcription and integration into nucleus

The problem with these medication that they are expensive , and now they start to
give them in combination , as we said we give these medication to prolong the life of
the patient but when the patent is in the final stages like Aids patient they start having
resistant to treatment and they start to have deterioration in their mental ability cuz
the viral affects the neuronal cells .
Another question and the answer was that some individuals have resistant to this
virus so they may live long to 20 years without moving to HIV disease stage , maybe
it is genetic character in these individuals so they can control the virus but not to
eliminate it .

‫اخيراااااااااا‬...‫تم بحمد ال‬

DONE by: LINA KETTANEH, MARAM RAHMOON

 ‫باعتبارها اول محاضرة و ان شاء ال آآآخر محاضرة نكتبها‪ .. .‬نحب نوجه احلى تحيه لوقت التخرج إلى اعز‬
‫الناس على قلوبنا‪ ....‬البابا و الماما ‪ ‬و عيد ام سعيد لكل المهات‪.‬‬
‫و اجمل التحيات من مرام إلى ) عبد ال و اماني و جوجو و وسيم ( و من لينا إلى ) سونيا وابراهيم ) هيمو( و‬
‫محمد(‬

‫و اكبر تحية إلى ‪ ) group B2‬نور حمدان‪ ...‬افضل ‪ assistant‬لعام ‪ ...2009‬و ربى ابو ريمة‪ .‬ميمنة‪ ,‬فكرية)‬
‫سلمات (‪ ,‬ميشيل ) السم الفني ( ‪ ,‬ملك(احلى ‪ ,( assistant RCT‬نادية ‪ ,‬فاطمة و سهير و فرح و فاطمة و‬
‫اسمى و اسيل مومني و رفاعي و دعاء ردايدة ‪ ,‬محمود مصاروة‪ ,‬نازيرول‪ ,‬محمد خزعلي(‬

‫و للزميلت و الزملء‪:‬‬
‫داليا المغربي‪ ,‬فرح‪ ,‬شهد‪ ,‬اماني الحمدي‪ ,‬هبة‪ .‬ريهام‪ ,‬اماني عفانة‪ ,‬سكينة‪ ,‬عبد ال حلحولي و معاذ و اياس و‬
‫عوضي‪ ,‬و محسن ‪ ,‬انس ‪ ,‬امين محاجنة‪ ,‬ايمن‪ ,‬رونزا‪ ,‬شيرين‪ ,‬نور جيوسي دينا كمال و فاطمة اسعد و ايسر‬
‫طشطوش‪.‬‬

‫و من ‪ group A1‬مروة ‪ ,‬ايمان‪ ,‬مجد‪ ,‬باسل‪ ,‬عمار‪ ,‬امين ما عدا محمد شعبان ‪‬‬
‫و إلى الماليزيات نو ر *‪ 6‬و عين زبيدة و نور حليم‪.‬‬

‫و ل ننسى رول‪..my bestttttttt friend...‬هناء مرزوق‪,‬نور سينو‪,‬عمرو لحلوح‪.‬‬

‫و اكيد شكر كبير لزين العابدين و منتصر تفاحة على الجهود الجبارة في نقل المحاضرة على الفلش ‪‬‬
‫يعطيكم العافية‪.‬‬

‫و بالنهاية احلـــــــــى تحية لممم ممممممم على الدعم المعنوي الذي قدمته من تشويش‬
‫و ازعاج‬