Viral Infections Of Oral Cavity
Question.1. Write short note on clinical features of AIDS.
Answer. AIDS is predominantly lethal type of viral infection caused by the HIV and is characterized by the depletion of T4 lymphocytes in the body.
Clinical staging of AIDS is done by WHO in 1990 and is revised on 2007. So based on the clinical staging following are the clinical features of AIDS.
In Primary Hiv Infection
- Patient is asymptomatic
- There is presence of acute retroviral syndrome, i.e. presence of sore throat, fever, maculopapular rash, headache,myalgia, arthralgia, photophobia.
Clinical Stage 1
- Patient remains asymptomatic
- Presence of generalized lymphadenopathy
Clinical Stage 2
- Presence of unexplained weight loss, i.e. less than 10% of body weight.
- Presence of recurrent respiratory infections
- Herpes zoster or shingles
- Presence of minor mucocutaneous diseases, i.e. apthous ulcers, pruritic eruptions etc.
Read And Learn More: Oral Pathology Question And Answers
Clinical Stage 3
- Presence of severe weight loss, i.e. greater than 10% of body weight.
- Presence of diarrhoea more than a month.
- Presence of pyrexia of unknown origin for more than one month.
- Presence of oral candidiasis which is persistant
- Pulmonary tuberculosis since last two years
- Multiple bacterial infections
- Presence of acute necrotizing ulcerative gingivitis and acute necrotizing ulcerative periodontitis.
Clinical Stage 4
- There is presence of HIV wasting syndrome
- Pneumocystis pneumonia.
- Presence of herpes simplex infection for more than a month.
- Candidiasis extends to esophagus.
- Presence of extrapulmonary tuberculosis
- Kaposi’s sarcoma
- HIV encephalopathy.
Question.2.Classify viral lesions of oral cavity. Describe in detail herpes simplex.
Or
Write notes on herpes simplex.
Or
Write short note on herpes simplex.
Or
Write short note on herpes simplex viral infection.
Answer.
Classification Of Viral Lesions In Oral Cavity
The classification depends on the presence of the major viruses.
1. RNA Virus
- Orthomyxovirus, i.e. inflenza
- Paramyxovirus, i.e. measles and mumps
- Rhabdovirus, i.e. rabies
- Arena virus, i.e. lassa fever
- Calicivirus, i.e. upper respiratory tract infection
- Coronavirus
- Bunyavirus
- Picornavirus
- Reovirus
- Togavirus
- Retrovirus
2. DNA Virus
- Herpes virus:
- Herpes simplex
- Herpes zoster
- EpsteinBarr virus
- Pox virus:
- Smallpox
- Monkeypox
- Adenovirus, i.e. pharynx conjunctival fever
- Parvovirus
- Irido virus
- Papova virus, i.e. papillomas.
Primary Herpes Simplex Infection
It is also known as acute herpetic gingivostomatitis or infectious stomatitis or herpes labialis.
Pathogenesis
As the herpes virus enters in sensory autonomic nerve endings and remains latent in ganglia. Replication of virus occurs and it spread to the mucosal as well as skin surfaces by centrifugal distribution of virions through peripheral nerves.
Etiology
- It occurs during close personal contact, i.e. by sexual contact or kissing.
- Primary infection of newborn is caused by vaginal secretion during birth.
- Dentist may experience primary lesion of figer from contact with the lesion of mouth and saliva of patient who are asymptomatic carrier of HSV also known as herpetic whitlow.
- In cadence varies according to socioeconomic group.
Clinical Features
- It is seen in children as well as young adults.
- Incubation period of virus lies from 5–7 days.
- Patient complains of irritability, fever, headache, nausea,vomiting and pain in oral cavity.
- Cervical and submandibular lymph nodes are enlarged.
Oral Manifestations
- In oral cavity hard palate, tongue and gingiva are commonly involved.
- Oral symptoms are flttning of mucosa, followed by vesicle formation over keratinized mucosa.
- The vesicle consists of clear flid and rupture to leave multiple, small and shallow painful ulcers these are followed by diffuse, large, whitish ulcers which are surrounded by red ring of inflmmation.
- Ulcer is about 2 to 5 mm in diameter. Base of the ulcer is coated with greyish white or yellowish membrane.
- Excoriation of lip is seen with hemorrhage.
- Speech of patient become painful and diffilt.
- Generalized acute marginal gingivitis is present. Gingiva become edematous as well as swollen.
- Small ulcers are seen over gingiva.
- Inflammation is present over posterior part of pharynx and patient feels diffilty in swallowing.
- Patient also suffrs from myalgia or muscle soreness and diffilty in mastication.
Histopathology
- Infected cells are swollen have pale eosinophilic cytoplasm and large vesicular nuclei known as ballooning degeneration.
- Acantholysis is seen and acantholytic cells are known as Tzanck cells.
- Some of the cells contain intranuclear inclusion bodies known as Lipschut bodies.
- Lipschut bodies are eosinophilic, ovoid, homogenous structures in the nucleus which displaces nucleolus and nuclear chromatin peripherally.
- Multinucleated epithelial cells are formed when fusion occur between adjacent cells.
- Intercellular edema is present which leads to the development of intraepithelial vesicle.
- Underlying connective tissue stroma shows chronic inflammatory infitrate.
Treatment
- Symptomatic treatment is done.
- Patient should be kept on antiviral therapy.
Recurrent Or Secondary Herpes Simplex Infection
It is of two types:
1. Recurrent herpes labialis.
2. Recurrent Intraoral herpes.
Pathogenesis
As primary infection is over, virus can no longer recover from the ganglion and viral DNA is seen in ganglionic cells. Humoral and cell mediated immunity is responsible for the recurrence of the disease.
Etiology/Trigger Factors
- Any surgery which involves trigeminal ganglion leads to recurrent herpes.
- Low immunity leads to recurrent herpes.
- Trauma as in exodontias can precipitate recurrent herpes.
- Upper respiratory infection can lead to recurrent herpes.
- Other factors which lead to recurrent herpes are fatigue,pregnancy, fever, menstruation, etc.
Clinical Features
- Recurrent herpes occur at varying intervals.
- Patient complains of tingling and burning sensation, feeling of toughness and soreness before development of vesicle.
- Edema is seen at the site of lesion and is followed by development of multiple clusters of vesicles.
Oral Manifestations
- In recurrent herpes labialis grayish or whitish vesicles are seen which rupture and leave small red ulcers. There is presence of very slight erythematous halo over the lip which is covered by browncolored crustation. Size of crust is 1 to 4 mm in diameter.
- In intraoral type vesicles are seen which rupture and leave small red ulcers with very slight erythematous halo.
Treatment
- Trigger factors should be suppressed or removed.
- Antiviral therapy should be given.
Question.3. Write note on herpes zoster.
Or
Write short note on herpes zoster.
Answer. It is also called as shingles or zona.
- It is an acute infectious viral disease of extremely painful and incapacitating nature, characterized by inflammation of dorsal root ganglion.
Clinical Features Of Herpes Zoster
It affects males and females with same frequency.
- There is prodromal period of 2 to 4 days in which shooting pain, paresthesia, burning and tenderness appears along the course of affcted nerve.
- It may be found on buccal mucosa, tongue, uvula, pharynx and larynx.
- Trigeminal herpes zoster occur during tooth formation causes pulpal necrosis and internal root resorption.
- First branch of trigeminal is most commonly affected.
Oral Manifestations Of Herpes Zoster
- Herpes zoster may involve the face by infection of trigeminal nerve, mainly fist branch.
- There is usually involvement of skin and oral mucosa supplied by trigeminal nerve.
- Lesions of the oral mucosa are extremely painful vesicles which may be found on the buccal mucosa, tongue,pharynx, larynx and uvula.
- This vesicle generally ruptures and leaves the area of erosion.
- Erosive ulcers heal up in a few days without scar formation.
- In herpes zoster, neuralgic pain in oral cavity stimulates tooth ache.
- Pain may persist long after the lesion heals up and the condition is known as postherpetic neuralgia.
Histopathology Of Herpes Zoster
- Herpes zoster is histologically characterized by swelling of infected epithelial cell cytoplasm due to intercellular edema (Ballooning degeneration).
- Margination of nuclear chromatin and formation of intra nuclear inclusion bodies.
- Reticular degeneration of epithelial cells along with the presence of multiple multinucleated giant cells.
Treatment Of Herpes Zoster
Antiviral drugs such as acyclovir is given along with antibiotics to prevent secondary infection.
Question.4. Write short note on aphthous ulcers.
Or
Write note on aphthous stomatitis.
Or
Write short note on aphthous stomatitis.
Answer. Aphthous ulcer or aphthous stomatitis is a common disease characterized by painful, recurrent, solitary or multiple ulcerations of oral mucosa with no other signs of any other disease.
Etiology Of Aphthous Ulcer
- Bacterial infection: Alpha hemolytic Streptococcus and S. sanguis has implicated as causative agent of disease.
- Immunological abnormalities: IgG and IgM binding of epithelial cells of spinous layer of oral mucosa is seen in patients suffering from recurrent aphthous ulcer.
- Iron deficiency or folic acid deficiency.
- Hematological deficiencies, serum iron or vitamin B12 deficiency.
- Allergic factors: Patients may have history of asthma, hay fever, and food or drug allergy.
Clinical Features Of Aphthous Ulcer
- It occurs between second and third decades of life and females are more commonly infected.
- Clinically aphthous ulcer occur in three types, i.e.
1. Minor aphthous ulcer:
- It is a single lesion or in cluster of 1 to 5 lesions.
- Ulcers are painful, shallow, round or elliptical in shape and measure 0.5 cm in diameter.
- They develop over lips, soft palate, anterior fauces,flor of mouth and ventral surface of tongue.
- Lesion is usually surrounded by an erythematous and is covered by yellowish, firous membrane.
2. Major aphthous ulcer:
- They are large and much painful lesions and measure
1 to 5 cm in diameter. - They are most severe and often makes patient ill.
- Only one and two lesions develops at the time and mostly seen over lips, soft palate and fauces.
- Lesions heal slowly and leaves scars, which result in decreased mobility of uvula and tongue.
3. Herpetic ulcer:
- They are multiple, small, shallow ulcers around 100 in number.
- Lesions are painful than would be suspected by their size.
- They are found on any intraoral mucosal surface.
- They are present continuously for 1 to 3 years, with relatively short remissions.
Histopathology Of Aphthous Ulcer
- Fibrinopurulent membrane covers the ulcerated area.
- Intense inflammatory cell infiltrate is present in connective tissue beneath the ulcer with considerable necrosis of tissue near the surface of lesion.
- Neutrophils are predominant below the ulcer.
- Epithelial proliferation along the margins of lesion.
- Cells are present with elongated nuclei containing linear bar of chromatin with radiating process of chromatin extending towards nuclear membrane known as
- Anitschkow cells.
Treatment Of Aphthous Ulcer
Topical and systemic administration of steroids is benefiial.
Question.5. Enumerate ulcerative lesions of oral cavity. Describe etiology, histopathology and clinical features of aphthous stomatitis.
Or
Enumerate ulcerative lesions of oral cavity, describe histopathology and clinical features of aphthous stomatitis.
Or
Describe etiology, histopathology and clinical features of acute aphthous stomatitis.
Answer.
Classification of Ulcerative Lesions
Microbial Origin
- Bacterial:
- Streptococcal
- Tuberculosis
- Syphilis
- Scarlet fever
- Diphtheria
- Typhoid
- Noma
- Fungal:
- Histoplasmosis
- Blastomycosis
- Paracoccidioidomycosis
- Coccidioidomycosis
- Cryptococcus
- Zygomycosis
- Aspergillosis
- Viral:
- Herpes
- HIV
- Poxvirus
- Protozoal:
- Entamoeba histolytica
- Leishmaniasis
- Toxoplasmosis.
Physical Origin
- Cheek bite (Morsicatio Buccarum)
- Traumatic
- Thermal
- Electrical
- Osteoradionecrosis
- Anesthetic.
Chemical Origin
- Phenol
- Silver nitrate
- Hydrogen peroxide
- Aspirin.
Immunological
- Behcet’s syndrome
- Reiter’s syndrome
- Erythema multiforme
- Erosive lichen planus (Secondary ulcer)
- Lupus erythematosus
- Sarcoidosis
- Cyclic neutropenia
- Ulcerative colitis
- HIV
- Pemphigus
- Epidermolysis bullosa
Metabolic Ulcers
- Diabetes
- Uremia
- Neutropenia
- Sickle cell anemia
- Agranulocytosis
- Crohn’s disease.
Non-specific Ulcers
- HIV ulcers
- Graft Vs host reaction
- Necrotizing sialometaplasia
- Reynaud’s phenomenon
- Bacterial angiomatosis
Neoplastic
- Squamous cell carcinoma
Question.6. Write short note on mumps.
Answer. It is an acute contagious viral infection, characterized by unilateral or bilateral swelling of salivary glands but also affects testis, meninges, pancreas, heart, and mammary glands.
Etiology Of Mumps
- It is caused by paramyxovirus.
- It spreads from human reservoir by airborne infection of infected saliva and possibly urine.
Clinical Features Of Mumps
- It is seen between age of 5 to 15 years.
- It is most common in boys.
- It is preceded by onset of headache, chills, moderate fever,vomiting and pain below ear which lasts for one week.
- Parotid gland is most common site.
- Elongation of parotid gland causes elevation of ear lobule and produces pain on mastication especially while eating sore food.
- Papilla on opening of parotid duct is puff and reddened.
Histopathology Of Mumps
- Microscopic section of diseased tissue reveals presence of degenerative changes in ductal epithelium of salivary gland.
- Interstitial infiltration of lymphocyte and mononuclear cells in glandular lobes and in few acinar atrophy occur.
Treatment Of Mumps
Only symptomatic treatment is done.
Question.7. Discuss in detail about clinical features, histopathology and laboratory investigations of oral herpes simplex infection.
Answer.
Laboratory Investigations Of oral herpes
- Tzanck smear: It is a rapid, sensitive and inexpensive diagnostic method. Smears are prepared from the lesions,from the base of vesicles and is stained with 1% solution of toluidine blue for 15 seconds. Smear shows multinucleated giant cells with faceted nuclei and ground glass chromatin,i.e. Tzanck cells.
- In giemsa stained smears Type A inclusion bodies are seen.
- Electron microscopy show virus particle.
- Fluorescent antibody techniques show herpes virus antigen in smears and sections.
- ELISA is a serological test which helps in the detection of rise in titre of antibodies. It helps in detection in primary infection.
- Virus Isolation: The isolation of herpes virus can be done and can be identifid by various systems.
Question.8. Describe in brief oral manifestations of AIDS.
Or
Write short answer on oral manifestations of HIV diseases.
Answer. Following are the oral manifestations of AIDS:
Classification of Oral Manifestations by EC-Clearing house
Group 1: Strongly associated with HIV infection
- Candidiasis: Erythematous, pseudomembranous, angular cheilitis
- Hairy leukoplakia
- Kaposi’s sarcoma
- Non-Hodgkin’s lymphoma
- Periodontal diseases: Linear gingival erythema, necrotizing gingivitis, necrotizing periodontitis
Group 2: Less commonly associated with HIV infection
- Bacterial infections: Mycobacterium avium—intracellular, Mycobacterium tuberculosis
- Melanotic hyperpigmentation
- Necrotizing ulcerative stomatitis
- Salivary gland disease: Dry mouth, unilateral or bilateral swelling of major salivary glands.
- Thrombocytopenia purpura
- Oral ulcerations NOS (not otherwise specifid)
- Viral infections: Herpes simplex, human papilloma virus,varicella—zoster
Group 3: Seen in HIV infection
- Bacterial infections: Actinomyces israelii, Escherichia coli,Klebsiella, pneumonia.
- Catscratch disease (Bartonella henselae).
- Epithelioid (bacillary) angiomatosis (Bartonella henselae)
- Drug reactions: Ulcerative, erythema multiforme, lichenoid,toxic epidermolysis.
- Fungal infections other than candidiasis: Cryptococcus neoformans, Geotrichum candidum, Histoplasma capsulatum, Mucoraceae (Mucormycosis/Zygomycosis),
- Aspergillus flvus.
- Neurologic disturbances: Facial palsy, trigeminal neuralgia
- Recurrent aphthous stomatitis.
- Viral infections: Cytomegalovirus, Molluscum contagiosum.
Description Of Oral Manifestations
- Candidiasis is the most common oral manifestation of HIV infection. All the three types, i.e. erythematous, pseudomembranous and hyperplastic forms are seen. Erythematous candidiasis is seen when the CD4 count drops below 400 cells/mm3 and pseudomembranous develop when CD4 count drop below 200 cells/mm3.
- Hairy leukoplakia: Presence of soft painless plaque on the lateral border of tongue with corrugated surface.
- Kaposi’s sarcoma: Single or multiple bluish swellings are seen with or without ulceration over gingiva and palate.
- Angular cheilitis: Linear fisures or linear ulcers are seen at the angle of mouth.
- Linear gingival erythema: It is firy red band along the gingival margin and attched gingiva with profuse bleeding.
- Necrotizing ulcerative gingivitis: Destruction of interdental papillae is seen.
- Necrotizing ulcerative periodontitis: There is advanced necrotic destruction of periodontium, rapid bone loss, loss of periodontal ligament and sequestration.
- Oral ulcerations: Single or multiple major recurrent aphthous ulcers are seen with white pseudomembrane surrounding the erythematous halo.
- Non-Hodgkin’s lymphoma: It is the malignancy of HIV-infected individuals. It occurs in extranodal locations and CNS is the common site. Intraosseous involvement is also seen.
- Mycobacterial infection: Mycobacterial infection in form of tuberculosis is seen.
- When present tongue is affected most commonly. Affected areas show common ulcerations.
- Herpes simplex virus: Recurrent or secondary herpes simplex infection is seen in the patients. Herpes simplex lesions increase when CD4 cell count drops below 50 cells/mm3.
- Herpes zoster: It is common in HIV-infected individuals.
- Orally, involvement is severe and leads to sequestration of bone as well as loss of teeth.
- Histoplasmosis: It is the fungal infection caused by histoplasma capsulatum. Sign and symptoms of disease are fever, weight loss, splenomegaly and pulmonary infiltrate.
- Molluscum contagiosum: It is caused by poxvirus. Lesions are small, waxy, domeshaped papules which demonstrate central depressed crater.
Question.9. Write short note on herpes stomatitis.
Answer. This is a contagious viral infection, which produces ulceration and inflammation of mouth and gums.
It is a contagious viral illness caused by herpes simplex virus (HSV1).
This condition is probably a child’s fist exposure to the herpes virus.
Clinical Features Of Herpes Stomatitis
- Occur in children of 2 to 4 years.
- Irritability and refusal of food due to difficulty in swallowing.
- High fever
- Vesicles on the tongue, buccal mucosa, gums, and skin around the mouth. The ulcers are very painful.
- Mucosa becomes red, swollen, and bleeds easily.
- Vesicles breakdown to form ulcers.
- Secondary bacterial infection may occur with enlarged lymph nodes and difficulty in swallowing.
- It is self-limiting and lasts between 7 to 10 days.
Prevention Of Herpes Stomatitis
Approximately 80% of the population carry the HSV which makes it difficult to prevent children contracting the virus.
Parents should avoid kissing their children when they have a cold sore. Also avoid sharing glasses, food and utensils.
Complication Of Herpes Stomatitis
A secondary herpes infection of the eye may occur, i.e. herpetic keratoconjunctivitis.
Treatment Of Herpes Stomatitis
- Acyclovir, which fihts the virus causing the infection.
- A mostly liquid diet of cool/cold nonacidic drinks.
- Numbing medicine (viscous lidocaine) applied to the mouth if there is severe pain.
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