oral manifestations of viral and fungal infections

Good morning……………..

ORAL MANIFESTATIONS OF

AND FUNGAL INFECTIONS

PRESENTED BYRAJAN MANANDHAR ROBINS DHAKAL8th Batch PDCH

What to expect?

1.WHAT IS VIRUS?2.CLASSIFICATION OF VIRUSES3.CERTAIN TERMINOLOGIES4.VIRAL INFECTIONS

A.DNA VIRUS B.RNA VIRUS

5.WHAT IS FUNGUS?6.FUNGAL INFECTIONS

WHAT IS virus?

• The Latin word virus means venom or poison

• Viruses have been defined as submicroscopic entities

which reproduce only within

specific living cells

CLASSIFICATION OF VIRusES

1.DNA Virusesa.Herpes virus

i.Herpes simplexii.Varicella zoster

iii.Cytomegalovirusiv.Epstein-Barr

virusb.Pox virus

i.Small pox ii.Molluscum contagiosum

2.RNA Virusesa.Paramyxovirus

i.Measlesii.Mumps

b.Picorna virusi.Coxsackie

c.Retrovirusi.HIV

CERTAIN TERMINOLOGIES

1.MACULES: Well-circumscribed, flat lesions that are noticeable because of their change from normal color of skin and mucosa

2.PAPULES: Solid lesions raised above the skin surface that are smaller than 1cm in diameter

3.PLAQUES: Solid raised lesions that are over 1cm in diameter

4.VESICLES: Elevated blisters containing clear fluid that are under 1cm in diameter

5.BULLAE: Elevated blisters containing clear fluid that are over 1cm in diameter

VIRAL INFECTIONS

1.DNA VIRUS INFECTIONSA. HERPES VIRUS INFECTIONS

i.Herpes simplexii.Varicella zosteriii.Cytomegalo virusiv.Epstein barr virus

i.HERPES SIMPLEX (ACUTE HERPETIC GINGIVOSTOMATITIS)

• Two immunological types are seen 1.HSV1 causes oral and pharyngeal infections

2.HSV2 causes genital infections

• Prodromal symptoms precede the oral lesions by 1-2 days

• Incubation period :2-12 days

HERPES SIMPLEX contd……

• ORAL MANIFESTATIONS

1. Appearance of generalized acute marginal gingivitis2. Several small gingival ulcers seen

HERPES SIMPLEX contd……

ORAL MANIFESTATIONS CONTD 3. Small thin walled vesicles surrounded by an inflammatory base seen which rupture leaving shallow round discrete ulcers on all portions of oral mucosa 4. Posterior pharynx reveals inflammation 5.Submandibular and cervical

lymph nodes are enlarged and tender

HERPES SIMPLEX contd……

• MANAGEMENT OF ORAL LESIONS1.Antiviral therapy: Acyclovir, famciclovir, valacyclovir2.Suppportive therapy

a.Aspirin for feverb.Fluids to maintain hydration and

electrolyte balancec.Topical anaesthetic eg dyclonine

hydrochloride 0.5% prior to meals if the patient has difficulty eating and drinking

HERPES LABIALIS• Herpes labialis is an

infection of the lip comonly caused by HSV-1

• It causes small blisters or sores on or around the mouth commonly known as cold sores or fever blisters

• The sores typically heal within 2–3 weeks, but the herpes virus remains dormant in the facial nerves, following orofacial infection, periodically reactivating (in symptomatic people) to create sores in the same area of the mouth or face at the site of the original infection known as Recurrent herpes labialis

II.VARICELLA ZOOSTER

• It is responsible for two major clinical manifestations 1. Chicken pox(Varicella) 2. Shingles(Herpes zoster)

• Chickenpox is a generalized primary infection that occurs the first time an individual contacts the virus

• Lesions of localized herpes zoster are seen when varicella zoster virus becomes reactivated

• Prodromal period: 2-4 days• Incubation period: 10-21 days

VARICELLA ZOOSTER contd…

• ORAL MANIFESTATIONS1.Shooting pain, paresthesia, burning and tenderness appear along the course of the affected nerve2.Unilateral vesicles on an erythematous base then appear in clusters 3.Vesicles change into ulcers

VARICELLA ZOOSTER contd…

ORAL MANIFESTATIONS CONTD

4.HZ of the geniculate ganglion i.e.RAMSAY HUNT syndrome is a rare form of the disease characteized by Bell’s palsy, unilateral vesicles of the external ear and vesicles of the oral mucosa

VARICELLA ZOOSTER contd…..

• COMPLICATIONPostherpetic neuralgia which is defined as pain remaining for over a month after the mucocutaneous lesions have healed

• MANAGEMENT1.Antiviral therapy: Acyclovir ,famciclovir,valacyclovir2.Therapy for post herpetic neuralgia: Application of capsaicin a substance extracted from hot chilli peppers.If it is ineffective,tricyclic antidepressant or gabapentin is indicated

Iii.Cytomegalo virus infection

• ORAL MANIFESTATIONS1.Non specific ulcerations that usually appear as a single ulcer without prec-eding vesicles on any oral mucosal tissue which are painful and tend to heal poorly

• MANAGEMENT1.Intravenous gancyclovir

iv.Epstein barr virus infection

• ORAL MANIFESTATIONS1.Infectious mononucleosis:

Acute gingivitis, stomatitis,the appearance of white or gray membrane in various areas, palatal petechiae and occasional oral ulcers

Epstein barr virus infection CONTD..

2.Burkitt’s lymphoma:Swelling of the affected jaw or other facial bones,loosening of the teeth and swelling of the lymph nodes which are nontender and rapidly growing in the neck or below the jaw

Epstein barr virus infection CONTD..

3.Nasopharyngeal carcinoma:

Epstein barr virus infection CONTD..

4.Oral hairy leukoplakia: Asymptomatic white lesion most commonly on the lateral borders of tongue

Epstein barr virus infection contd…..

• MANAGEMENTAntiviral therapy: Eg Acyclovir

DNA VIRUS INFECTIONS CONTD…

B. POX VIRUS INFECTIONSi.Smallpoxii.Molluscum

contagiosum

i.Small pox virus

• It is an acute viral disease which before the discovery of vaccination by Jenner, was epidemic in nature.

• On December 9, 1979, the WHO Global Commission for the Certification of Smallpox Eradication declared :

1. Smallpox eradication has been achieved throughout the world

2.There is no evidence that it will return as an endemic disease

Small pox & chicken pox

ii.Molluscum contagiosum

Incubation period : 6 weeks • ORAL MANIFESTATIONS

1.Lesions tumorlike in nature because of the typical localized epithelial proliferation caused by the virus

Molluscum contagiosum CONTD…

ORAL MANIFESTATIONS CONTD2.Lesions hemispheric in shape, usually about 5mm in diameter with a central umbilication which may be keratinized and are normal or slightly red in color3.Sites: Lips, tongue and buccal mucosa4. They are generally not painful, but they may itch or become irritated.

Molluscum contagiosum contd….

• MANAGEMENT1.Surgical excision2.Topical application of drugs such as podophyllin or cantharidin

virAL infections CONTD….

2.RNA VIRUS INFECTIONSa.Paramyxovirus

i.Measlesii.Mumps

I.MEASLES

• Highly contagious viral illness• Incubation period :10-12 days• ORAL MANIFESTATIONS

– Koplik spots (rash on mucous membranes)occur 2-3 days before the cutaneous rashes

– These spots occur on the buccal mucosa which appear as bluish, white specks surrounded by a bright red margin

Measles contd….

• ORAL MANIFESTATIONS CONTD

-Palatal and pharyngeal petechiae as well as generalized inflammation, congestion, swelling and focal ulceration of the gingiva , palate and throat

• COMPLICATIONS1.Bronchial pneumonia2.Encephalitis3.Otitis media

Measles contd….

• IMMUNISATION-Should be administered with mumps and rubella as MMR subcutaneously-2 doses given

a. A first dose is given at 9 months of age

b. Second dose is given at 15-18 months of age for adequate immunity

II.Mumps(EPIDEMIC PAROTITIS)

• It is an acute contagious viral infection characterized chiefly by unilateral or bilateral swelling of the salivary glands, usually the parotid

• Bilateral parotid involvement occurs in about 70% of cases , submandibular gland involvement in 10% of cases

• It is transmitted through droplet nuclei or saliva or fomites

• Incubation period: 2-3wks

Mumps contd….

• ORAL MANIFESTATIONS1.Age: Mostly children between 4-6 yrs2.Salivary gland enlargement, frequently elevating the ear ,which lasts for about 1 week

Mumps contd…

• ORAL MANIFESTATIONS CONTD..4.Pain upon mastication5.Pain and tenderness may be severe during the rapid phase of parotid enlargement and swelling reaches its maximum in about 3 days. It remains at its peak for 2-3days and then gradually subsides

• COMPLICATIONS1.Meningitis 2.Encephalitis 3.Oophoritis 4.Orchitis

• TREATMENTSymptomatic and Vaccination (MMR)

Time to change

• 2.RNA VIRUS INFECTIONS

b.PICORNA VIRUS I. Coxsackie virus

I.HERPANGINA

• Causative agent –Coxsackie virus A4 type • Very contagious and Passed on by:–Unwashed hands– Surfaced contaminated by feces– Sneezes or coughs

• Majority of cases affect young children ages 3-10

• Incubation period : 2-10 days

HERPANGINA CONTD….

• ORAL MANIFESTATIONS

1.Lesions start as punctate macules which quickly change nto vesicles involving the posterior pharynx ,tonsils, faucial pillars and soft palate2.Vesicles rupture into small 1-2mm ulcers

HERPANGINA contd…

• MANAGEMENTThe disease is usually mild and heals without treatment in 1 week

• SUPPORTIVE TREATMENTa.Fluids for proper hydrationb.Topical anaestthetic when

eating or swallowing is difficult

• 2.RNA VIRUS INFECTIONS

C.RETRO VIRUS I.HIV

HUMAN IMMUNODEFICIENCY VIRUS(HIV)

• Acquired immunodeficiency syndrome(AIDS) is caused by the HIV and is characterized by immunosuppression, which leads to a spectrum of clinical manifestations that include opportunistic infections, secondary neoplasm and neurologic manifestations

HIV contd…..

• Infection is transmitted vertically from mother to child

• Window period– The time between viral infection and

seroconversion– HIV is present in body fluids and can be

transmitted, but the HIV serology is nonreactive

HIV contd…..

1.Fungal infections a.Oral Candidiasis

2.Viral infections a.Herpes virus infections

3.Bacterial infections a.Linear gingival erythema b.Necrotizing ulcerative gingivitisc.Necrotizing ulcerative periodontitis

4.Non specific ulcerationsa.Apthous ulcersb. Drug induced ulcerations

5.Kaposi’s sarcoma6.Non Hodgkin’s

lymphoma7.Oral hairy

leukoplakia

ORAL MANIFESTATIONS

HIV contd…..

LINEAR GINGIVAL ERYTHEMA• 2-3 mm distinct band

of fiery redness at the marginal gingiva around the teeth

HIV contd…..

NECROTIZING ULCERATIVE GINGIVITS

-Spontaneous gingival bleeding-Mild to moderate gingival pain

HIV contd…..

NECROTIZING ULCERATIVE PERIODONTITS

-Deep seated bone pain -Spontaneous gingival bleeding-Halitosis -Tooth mobility

HIV contd…..

APTHOUS ULCERS-Recurrent,round,shallow and painful ulcers-Typically found on non-keratinized oral mucosa

HIV contd…..

• KAPOSI’S SARCOMA-Human herpes vius type 8 is involved-Manifests as red-blueor purple-blue maculesor nodules-Most common site is palate

HIV contd…..

• NON-HODGKI N’S LYMPHOMA-Presents as a large, painful, ulcerated mass on the palate or gingival tissues

HIV contd…..

• ORAL HAIRY LEUKOPLAKIA-Corrugated surface of the epithelium on the lateral margin of the tongue

HIV contd…..

• DIAGNOSIS1.Viral culture2.Polymerase chain reaction3.Enzyme linked immunosorbent assay4.Western blot analysis

What is fungus?

• A fungus is a member of a large group of eukaryotic organisms that includes microorganisms such as yeasts, molds and mushrooms

• The cell wall consists of chitin• The study of fungus is known as

Mycology

Fungal infections

1.Candidiasis2.Histoplasmosis

candidiasis

• It is an opportunistic infection caused by a yeast like fungus, Candida albicans

• It is classified as i. Mucocutaneous candidiasis

-Oral candidiasis-Candidal esophagitis-Intestinal candidiasis

ii. Systemic candidiasis

Candidiasis contd…

• CLASSIFICATION OF ORAL CANDIDIASIS1.Acute

a. Acute pseudomembranous b. Acute atrophic

2.Chronica. Chronic hyperplasticb. Chronic mucocutaneousc. Chronic atrophic

Candidiasis contd..

ACUTE PSEUDOMEMBRANOUS-Soft ,white elevated plaques resembling milk curds-Can be easily scrapedoff , exposing red areas

Candidiasis contd…

• ACUTE ATROPHIC-A type of erythematous candidiasis-Occurs as a sequelae to a course of broad spectrum antibiotics-Lesions appear red or erythematous-The only variety which is painful

Candidiasis contd…

CHRONIC HYPERPLASTIC-Lesions consists of firm , white persistent plaques -Leukoplakia type of candidasis

Candidiasis contd…

CHRONIC MUCOCUTANEOUS 1.Familial 2.Localized 3.Candidiasis endocrinopathy syndrome4.Diffuse

Candidiasis contd…

CHRONIC ATROPHIC-Occurs in edentulous patients with ‘denture sore mouth’

Candidiasis contd…

TREATMENTAntifungal agents

-Topical agents : Eg-Nystatin or Clotrimazole

-Systemic agents : Eg- Fluconazole

histoplasmosis

• Also known as Darling’s disease

• It is a generalized fungus infection caused by the organism Histoplasma capsulatum

Histoplasmosis contd..

• ORAL MANIFESTATIONS1.Nodular, ulcerative or vegetative lesions on the buccal mucosa, gingiva, tongue, palate or lips 2.The ulcerated areas are usually covered by a nonspecific gray membrane and are indurated

Histoplasmosis contd…

• TREATMENTAntifungal agents Eg: Amphotericin B

references

1.Shafer’s Text book of Oral Pathology2.Burket’s Oral Medicine3.Text book of Pedodontics-Shobha

Tandon4. http://www.medicinenet.com5. http://www.askdrsears.com6. http://www.vaccineinformation.org

Thank you