Lecture

‫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. 2. 3. 4. 5.

Human Herpes Virus (HHV) Enteroviruses 1. Coxsackieviruses (CSV) Paramyxovirus 1. Mumps virus 2. Morbillivirus Human papillomavirus (HPV) 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 ; 123-

lesion strongly associated with HIV infection. Lesion less commonly associated with HIV infection. 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