ORAL PATHOLOGY

Dr. Rafil Hameed Rasheed

 Viral
Infections
 INTRODUCTION
Members of the human herpesvirus (HHV) and human 
papillomavirus (HPV) families are the most common
causes of primary viral infections of the oral cavity.

Nonetheless, many other viral infections can affect 

the oral cavity in humans, either as localized or
systemic infections.
 HUMAN HERPES VIRUS (HHV)

HHV infections are common in the oral cavity. 

They may be primary or recurrent infections. 

Eight types of HHV have been linked with oral 

disease. These types have different disease patterns
in their hosts.
HHV-1, also known as herpes simplex virus(HSV)– 
1, causes primary herpetic gingivostomatitis or oral
herpes.

HHV-2, also known as HSV-2, causes genital 

herpes and occasionally causes oral disease that is
clinically similar to that of HHV-1 infection.

HHV-3, also known as varicella-zoster virus (VZV), 

causes the primary infection chickenpox and the
secondary reactivation disease herpes zoster.
HHV-4, also known as Epstein-Barr virus (EBV), 
causes the primary infection infectious
mononucleosis , and it is implicated in various
diseases, such as African Burkitt lymphoma

HHV-5, also known as cytomegalovirus (CMV), 

causes a primary infection of the salivary glands
and other tissues, and it is believed to have a
chronic form.

HHV-6, which can produce acute infection in CD4+ 

T lymphocytes, causes roseola infantum , a febrile
illness that affects young children
HHV-7 has been isolated from the saliva of healthy 
adults and has been implicated as one cause of
roseola infantum and febrile seizures in children.

HHV-8 is associated with Kaposi sarcoma (KS), 

and evidence links it with body-cavity lymphomas
 HHV-1 (HSV)–1
Oral Manifestation 
 When HHV-1 infection occur, it has different and
distinct oral and perioral presentations of primary
herpetic gingivostomatitis.
primary herpetic gingivostomatitis usually occurs in 
children or adolescents who have not been
previously exposed to the virus. Many primary
infections are asymptomatic.
Symptomatic primary infection, with multiple, 
small, clustered vesicles in numerous locations,
can occur anywhere in the oral cavity, on the
perioral skin, or on the pharynx.
THE AGE
Primary herpes infections typically occur during 
childhood or youth, although occasional cases are
observed in older individuals.

Recurrent HHV-1 infections typically occur throughout 

life and are particularly triggered by stress, illness,
immune compromise, or other factors.
Signs and Symptoms 
1-Headache 
2-fever 
3-painful lymphadenopathy 

4-malaise 
PRIMARY HERPES CAN AFFECT THE LIPS, AND THE
RUPTURED VESICLES MAY APPEAR AS BLEEDING OF
THE LIPS
DIAGNOSIS AND MANAGEMENT
The clinical features are usually sufficient to 
diagnose these conditions. The differential
diagnosis of primary herpetic gingivostomatitis
includes recurrent aphthous ulceration, which
forms ulcers on non-keratinised oral mucosa
without a vesicle phase.
Acyclovir is a potent drug and may be life saving for 
HHV-1 infection and other disseminated infections,
especially in those individuals who are
immunocompromised.

Bed rest, fluids and a soft diet, with antipyretics for 

fever are recommended.
 HHV-2 SECONDARY HERPES LABIALIS
(HSV)–2
Oral Manifestation 
HHV-2 infection is less common in the oral cavity than 
HHV-1 infection, its oral manifestations are clinically
indistinguishable from HHV-1 infection.

Around 15 to 30% of the community is affected by 

episodes of secondary herpes simplex lesions (herpes
labialis) that predispose the patient to recurrent
infection,
as these cause reactivation of the virus, which
subsequently migrates along one of the sensory
divisions of the trigeminal nerve. The lesions are
most often seen at the mucocutaneous junction
of the lip or perioral skin.
Signs and Symptoms 
1-Common colds 
2-influenza 
3- fever 
4-menstruation 
5-emotional upset 
6-stress and anxiety. 
 HHV-3
VARICELLA-ZOSTER VIRUS (VZV)
Herpes zoster usually affects patients older than 
40 years.
Oral Manifestation 
Inside the oral cavity, this may be observed as 
vesicles or ulcerations
that stops sharply 
at the midline. 
Signs and Symptoms 
1-pain 
2-burning 
3-itching that mimics 
a toothache may occur.
DIAGNOSIS AND MANAGEMENT
The clinical picture is often distinctive. Herpes zoster 
may be confused with recurrent Herpes simplex virus
infection. Herpes zoster has a longer duration ,it’s
unilateral vesicles and ulceration, with abrupt ending
at the midline and post-herpetic neuralgia.

The treatment is supportive with topical or systemic 

antipruritics and analgesics that do not contain aspirin.
A high dose of oral acyclovir (800 mg five times daily
for seven days) is recommended for treating both
primary and recurrent infections in
immunocompromised patients.
 HHV-4
EPSTEIN-BARR VIRUS (EBV)
Oral Manifestation 
The virus (usually acquired from infected saliva) 
replicates in the cells of the mucosa and salivary
glands and spreads to the blood stream.

If the patient is immunocompetent, cytotoxic T cells 

become activated and a characteristic
lymphadenopathy (notably involving the posterior
cervical nodes) accompanies tonsillitis and
hepatosplenomegaly.
Signs and Symptoms 
1-headache 
2-fever 
3-malaise 
4- myalgia 
5-fatigue 
6-Severe abdominal pain may indicate splenic 
rupture.
 HHV-5
CYTOMEGALOVIRUS (CMV)
Oral Manifestation and Diagnosis 
The virus is shed by glandular secretions, including 
saliva.
Primary CMV infection can be asymptomatic, but it 
can also mimic mononucleosis.
Latent CMV infection may cause esophagitis, which 
is occasionally accompanied by oral ulcerations or
erythema 
The oral ulcerations are clinically nonspecific, and 
a biopsy is required for definitive diagnosis.
 HHV-6
The virus is spread through saliva and possibly by 
genital secretions.

The child with HHV-6 usually does not appear 

seriously ill during this disease.
HHV-6 infection is much more serious in adults and 
can lead to organ involvement

No prophylaxis or treatment for infection with HHV-6 

presently exists. The great majority of HHV-6 infections
are silent or appear as a general mild febrile illness.
 HHV-7 
HHV-7 has been identified in the saliva of adults, 
and this is most likely where the virus persists
chronically.
HHV-8 
Oral Manifestation 
initially, the lesion may appear as a red, purple, or 
dusky patch that enlarges into a plaque and later
progresses into a tumorous mass.
PHARMACOLOGICAL AGENTS AVAILABLE
FOR TREATMENT
 There is, as yet, no medication that prevents HHV1
migrating to the trigeminal ganglion after the primary
infection.

Although the antiviral agent Acyclovir has been found

to be of benefit in limiting the extent of HHV2
infections, it has had less effect on orofacial
HHV1 primary infections in healthy individuals 
 However, it does have an important role in the
management of primary and secondary HHV1
infections in immunocompromised patients and acute
attacks of herpes zoster.
 HEPATITIS C VIRUS (HCV)
The initial diagnostic serologic assay was developed 
for detection of antibodies to HCV (anti-HCV) produced
by infected persons against a recombinant viral
antigen.
Later generations of more sensitive. 
immunoassays have been implemented since 1990. 
Currently, at least six viral agents appear to account 
for the majority of viral hepatitis cases.
 MODES OF TRANSMISSION OF HEPATITIS C VIRUS IN
HEALTH CARE SETTINGS

1-Accidental needle sticks 

2-Blood splashes into eyes 
3-Blood transfusion 
4-Association with contaminated immunuglobin 

5-Organ/tissue transplantation 
6-Infected cardiac surgeon to patients 
Signs and Symptoms 
Disease presentations may include: 

1-jaundice 
2-malaise 
3-fever, anorexia, nausea 
4-abdominal pain 
5-dark (“stormy,”“foamy”) urine 
6-chalky gray stools 
7-rash and arthritis 
HCV THERAPY AND PREVENTIVE APPROACHES
A Combination of chemotherapeutic agents has 
shown promising results in recent years.
Currently, a daily regimen of interferon α-2b plus 
ribavirin for 6 to 12 months has demonstrated a
significant improvement in patient biochemical and
virologic responses when compared with interferon
monotherapy.

Approximately 50% of treated patients have a 

sustained beneficial response, compared with
response rates of 15 to 25%using interferon alone.
An effective vaccine for hepatitis C is not yet 
commercially available.

Multiple factors have hindered research efforts 

directed at prophylactic strategies.

At present, routine use of universal precautions during 

patient care and anti-HCV screening of potential blood
donors appears to be successful in reducing health
care provider, patients and public exposures.
Contraindications to IFN/RBV 
Absolute Contraindications 
1-pregnancy 
2-decompensated liver disease 
3-unstable heart disease 
4-sickle cell 

Relative contraindications 
1-severe psychiatric problems 
2-untreated anemia/neutropenia 
 HIV
HUMAN IMMUNODEFICIENCY VIRUS
 The acquired immune deficiency syndrome
(AIDS) is the most serious expression of
disease resulting from infection with the
human immunodeficiency virus(HIV).

 Oral Manifestation
 Oral manifestations of HIV infection are oral
candidosis and Kaposi’s sarcoma (KS).

 If it is suspected that patients exhibit any of

these conditions and infection with HIV is
suspected it is advisable to refer the patient.
 Oral involvement may be observed in up to 60
percent of patients have both, skin and oral
lesions.
 Oral KS frequently involves the palate,
the attached gingiva and the dorsum of the tongue.
Oral Candidiasis
HIV Transmission 
Transmission Fluids 
Blood 
Vaginal secretions 
Breast milk 

Ports of Entry 
Broken skin 
Mucus membranes 
Signs and Symptoms 
1-Tiredness 
2- Nausea 
3- Diarrhea 
4- Enlarged lymph nodes in the neck and armpits. 
HOW IS AIDS TREATED?
Antiretroviral treatment can significantly 
prolong the life of people living with HIV.
Modern combination therapy is highly effective 
and someone with HIV who is taking treatment
could live for the rest of their life without
developing AIDS.
It is also important that treatment is provided 
for AIDS related pain, which is experienced by
almost all people in the very advanced stages
of HIV infection.
DISORDERS CAUSED BY VIRUSES
Hairy Leukoplakia 
Oral Manifestation 
is a white "hairy" "coating" on the lateral borders of 
the tongue. It is one of the relatively few conditions
seen in the oral cavity which is associated almost
exclusively with AIDS. Unlike Thrush, it is not easily
scraped off. It is caused by the body's reaction to
the Epstein-Barr virus .

Signs and Symptoms 

It is painless, but patients occasionally complain of 
its appearance and texture.
Treatment 
can be eliminated with a viral antibiotic like 

Acyclovir. 
 HUMAN PAPILLOMAVIRUS LESIONS
(WARTS)
Oral Manifestation 
In the oral cavity, they tend to be somewhat flatter 
than the type occurring on hands, but if they are
dried with air, the tiny projections characteristic of
regular warts become evident.
Diagnosis and Treatment 
There are about 200 different strains of HPV, it’s 
seem to account for the serious rise in the
incidence of oral cancers in younger people, many
of whom do not smoke or drink regularly.
Most strains are relatively harmless 


They may be removed using 

lasers, cautery or cold steel blades. 

 COXSACKIE VIRUS
HERPANGINA

Oral Manifestation 
Herpangina affects children, mainly during summer, 
Patients present with vesicles, ulcerations and diffuse
erythema on the soft palate and tonsillar areas.
Signs and Symptoms 
Herpangina is characterised by a sudden onset of: 

1-Malaise 
2-fever 
3-sore throat. 

The systemic symptoms settle in two to three days 

and the ulcers heal in 7 to 10 days.
DIAGNOSIS AND TREATMENT

The clinical features of Coxsackie virus are 

distinctive. The distribution of the lesions of
herpangina differentiates it from primary herpetic
gingivostomatitis, which affects the gingivae
whereas herpangina is an oropharyngitis.
Herpangina is self-limiting disese and need no 
treatment
Treatment is indicated in very painful cases of 
herpangina, in which case antipyretics and topical
anaesthetics can be used.
 HAND, FOOT AND MOUTH DISEASE
Hand, foot and mouth disease is most commonly 
seen amongst children aged 1 to 5 years.

Oral Manifestation 
In 75% of cases presents with an eruption of 
vesicles on the palms of the hands and on the feet.
Occasional vesicles may also be found on the
proximal extremities and buttocks.
There are also vesicles in the anterior part of the 
mouth.
Signs and Symptoms 
An associated low-grade fever and malaise are 
usually present.

Treatment 
hand, foot and mouth disease are self- 
limiting, of short duration and need no
treatment
 GINGIVOSTOMATITIS
is an infection of the gum and mouth caused by 
HSV-1 and other common childhood viruses.

Oral Manifestation 
The lesions begin as blisters that pop soon after 
they form, leaving the base of the blister.
When this covering peels off, a tender ulcer is
formed. It will look grayish or yellowish with a red
border.
Signs and
Symptoms

As with herpangina,
fever and illness
appear before the
mouth sores
These painful sores
often make it
difficult to eat.
 PRINCIPLES OF MANAGEMENT

1-Confirm the diagnosis 

2-check medical considerations 
3-ensure adequate hydration 
4-Prescribe medication for pain relief and revention 
of secondary infection.
 DIAGNOSIS
 The diagnosis is made most commonly on clinical
grounds but a number of special tests are available to
provide confirmation.

 1-Direct examination of a smear made after scraping

a spatula over a lesion will show evidence of viral
damage to epithelial.

 2-Viral culture is a sensitive method which

determines precisely which type of virus is present.
 3-Serological demonstration of a rising antibody
titer – a greater increase in antibody titer to the
virus demonstrated between serum obtained in the
acute phase of the infection and in the
convalescence phase -is diagnostic but depends on
obtaining two blood samples.
 WHEN TO REFER ?
 1-When a patient exhibits severe lesions with
dehydration
 2-Any evidence of ocular or other extra-oral
involvement or when they are
immunocompromised,they should be referred
to either a specialist in oral medicine or an oral
maxillofacial surgery.
 HOW CAN PEOPLE PREVENT ORAL
INFECTIONS?
1-Frequent hand washing and avoiding exposure to 
people who are sick whenever possible helps prevent
the spread of viral infections.

2-Visiting a dentist regularly (every 6 months) for teeth 

cleanings and check-ups.

3-Brushing teeth twice daily. 

 4-Fluoride toothpaste is recommended for children.

 5-Anti-tartar toothpaste is recommended for adults.



 6-Brushing the gums and tongue gently.

 7-Flossing daily.


 8-Brushing teeth after eating sugary or starchy foods.

 REFERENCES

1- Burket’s Oral Medicine 

2-Textbook of Oral Medicine 
3- ArticleSA Fam Pract 2006 