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MariaSiponen

Viral Infections of the Oral Mucosa

Essentials

  • Viral infections may cause many different looking changes on the oral mucosa.
  • Ulcerating vesicles are caused by Herpes simplex (HSV), varicella zoster (VZV) and coxsackie viruses.
  • Petechiae can appear in the palatal and pharyngeal area in mononucleosis caused by the Epstein-Barr virus (EBV). Ulcerative gingivitis or mucositis may also occur. In immunosuppressed states, EBV may also cause white coated patches on the side of the tongue, i.e. oral hairy leukoplakia.
  • Various subtypes of human papillomavirus (HPV) cause exophytic hyperplasias whose surface is cauliflower-like (papilloma, condyloma, common wart, Heck's disease) or smooth (Heck's disease).
  • Some papillomaviruses are also associated with squamous cell carcinoma of the base of the tongue and in the pharyngeal area.

Herpes simplex virus (HSV)

  • Infections of the oral mucosa are usually caused by Herpes simplex virus (HSV) type 1. About 10-15% are caused by HSV-2.

Primary infection

  • In almost 99% of the cases the primary infection is asymptomatic or mildly symptomatic.
  • Primary infection is usually contracted in childhood, sometimes only after the age of 20 years.
  • In 1% of patients, primary oral HSV infection presents with a fulminant febrile stomatitis, in which painful blisters and ulcers usually appear in both the gingival region and elsewhere in the oral mucosa (gingivostomatitis; picture 1). The infection may be carried by saliva to the skin around the mouth.

Recurrent HSV infection

  • Recurrence begins as a reddish itching area where clear, small and rapidly rupturing blisters develop. These result in superficial ulcers. Recurring herpes in the mouth cavity is usually located in the gingival rim and in the palate. The ulcers heal spontaneously in about one week.
  • Among the factors activating HSV-1 are common cold, exposure to excessive sunlight, stress or even menstruation. Impaired immunity (e.g. HIV infection, blood transfusion, cancer patients on cytostatic treatment) predisposes to frequent recurrence of HSV and to increased duration of the symptomatic phase and increased severity.

Diagnosis

  • The diagnosis of oral HSV infection is made on the basis of the clinical appearance, or by demonstrating the virus in the scrape from the base of a blister by HSV nucleic acid detection.
  • Examination of serum antibodies is useful only for demonstrating primary HSV infection.

Treatment Aciclovir and Valaciclovir in the Prevention and Treatment of Herpes Simplex Virus in Patients Being Treated for Cancer

Herpes varicella-zoster virus (VZV)

  • In varicella Chickenpox, in addition to the generalized rash with small pustules all over the body, small, yellowish blisters that rupture easily are sometimes found on the oral mucosa, most often in the palate.
  • Of all herpes zoster infections Shingles (Herpes Zoster), about 20% appear in the head and neck region. In the area of the nerves innervating the maxilla and the mandible, herpes zoster often starts with pain localized in the teeth (simulating the pain of inflammatory dental pulpitis). After 3-4 days this is followed by the appearance of blisters both inside and outside the oral cavity. The blisters do not cross the middle line of the body (except in the palate).

Diagnosis

  • The clinical picture is typical. If needed, VZV can be demonstrated from the base of a blister by nucleic acid detection.

Treatment of herpes zoster

Enterovirus infections

Herpangina

  • Usually caused by coxsackie A virus
  • This disorder appears as epidemics (summer and early autumn), usually among children.
  • Symptoms include fever, malaise, abdominal pains, headache and muscular pain. The generalized symptoms appear before the oral symptoms.
  • Oral symptoms include small blisters on the palatal arch, soft palate, uvula and tonsils http://www.dynamed.com/condition/herpangina#HEENT. The blisters burst quickly, and the ulcers heal spontaneously in 7-10 days. The throat is diffusely reddened.
  • The diagnosis is clinical, or the enteroviruses may be detected by nucleic acid detection test.
  • Differential diagnosis
    • In herpangina, no bullae appear in the gingival area, unlike in HSV infections.
    • HSV lesions also last markedly longer and are painful in contrast to those of herpangina.
    • Herpetiform aphthae are not associated with blisters nor general symptoms.
    • In streptococcal tonsillitis, there are no blisters nor diffuse pharyngitis, and the general symptoms are more severe.

Hand-foot-and-mouth disease

Papillomaviruses (HPV)

  • Currently, over 200 different types of human papillomavirus (HPV) are recognized, of which some cause infections only on the skin and other types exclusively at mucosal sites. The oral mucosa is special in that it is capable of harbouring HPV infections of both the genital types (e.g. HPV 6, 11, 16, 18, 31, 33, 42) and the skin types (e.g. HPV 2, 4, 7, 57).
  • Exophytic, cauliflower-like warts (papillomas, condylomas) are encountered on the oral mucosa of some 0.4% of the population. In children, common hand warts can be transmitted to the oral mucosa, following sucking of the fingers.
  • The aetiological agent of another characteristic HPV lesion, focal epithelial hyperplasia (FEH) is HPV 13 or HPV 32. These lesions are multiple and their surface is smooth or papillary, resembling a small fibroma.
  • In addition to these well-defined clinical lesions, HPVs can also appear on healthy oral mucosa as latent infections (in around 12% of subjects).
  • HPV infection has been established as a risk factor for squamous cell cancer mainly in the pharyngeal and tongue root region.
  • Diagnosis is based on the clinical appearance and on characteristic morphological HPV-induced squamous cell changes in a histological biopsy specimen.
  • Treatment
    • Some of these lesions resolve spontaneously. When appropriate, surgical excision may be carried out, or the lesions can be eradicated by using laser or cryotherapy. Whenever a dysplastic change is detected, its complete removal and follow-up of the patient are warranted.

Epstein-Barr virus (EBV)

Infectious mononucleosis (kissing disease)

  • In typical cases, the symptoms include fever, enlarged cervical and axillary lymph nodes (due to lymphadenitis), and an exudative tonsillitis that does not respond to penicillin. Sometimes, painful ulcers appear in the gingival area or petechiae on the palate. The infection is often associated with enlargement of the spleen and prolonged periods with fever. In 15% of cases, eyelid swelling is seen in the initial phase of the disease.
  • Diagnosis
    • If the rapid tests determining heterophilic antibodies remain negative, EBV-specific antibodies in the serum are analysed. EBV infection increases the number of mononuclear cells in the blood. If needed, EBV can be demonstrated in a tissue specimen by using immunohistochemistry or nucleic acid hybridization.
  • Oral changes due to mononucleosis do not require any active treatment.

Hairy leukoplakia

  • Appears in most cases on both edges of the tongue symmetrically as vertical light stripes.
  • It is caused by an EBV infection.
  • This lesion clearly associates with immunosuppressive states and especially with an HIV infection. Along with the implementation of the HAART treatment HIV Infection the occurrence of hairy leukoplakia has decreased.
  • The lesion is typically asymptomatic and is not associated with epithelial dysplasia or increased risk of oral cancer. A yeast infection can occur secondarily on the lesion. In HIV patients, however, the appearance of hairy leukoplakia is considered a sign of a poor outcome.
  • The differential diagnosis should take into account hyperkeratotic lesions due to mechanical irritation, yeast infections and lichen planus lesions.
  • The clinical picture and histological presentation are typical.
  • The lesion does not require any treatment http://www.dynamed.com/condition/oral-lesions#TOPIC_UQH_YVW_54B. In some cases, aciclovir has been administered according to the scheme used in the treatment of HSV infections.

    References

    • Syrjänen S. Oral manifestations of human papillomavirus infections. Eur J Oral Sci 2018;126 Suppl (1):49-66. [PubMed]
    • Arduino Al-Maweri SA, Kalakonda B, AlAizari NA, et al. Efficacy of low-level laser therapy in management of recurrent herpes labialis: a systematic review. Lasers Med Sci 2018;33(7):1423-1430. [PubMed]
    • de Almeida VL, Lima IFP, Ziegelmann PK, et al. Impact of highly active antiretroviral therapy on the prevalence of oral lesions in HIV-positive patients: a systematic review and meta-analysis. Int J Oral Maxillofac Surg 2017;46(11):1497-1504. [PubMed]
    • de Paula Eduardo C, Aranha AC, Simões A, et al. Laser treatment of recurrent herpes labialis: a literature review. Lasers Med Sci 2013. [PubMed]
    • Patton LL, Ramirez-Amador V, Anaya-Saavedra G, et al. Urban legends series: oral manifestations of HIV infection. Oral Dis 2013;19(6):533-50. [PubMed]
    • Arduino PG, Porter SR. Oral and perioral herpes simplex virus type 1 (HSV-1) infection: review of its management. Oral Dis 2006;12(3):254-70. [PubMed]