OralMedicine

Raj G Nair

Ali Salajegheh, Anut Itthagarun, Sahar Pakneshan, Michael T Brennan, Lakshman P Samaranayake

Orofacial Viral Infections − An Update

for Clinicians
Abstract: Orofacial viral infections may be less common but appear in different clinical forms. Often these infections get initially treated
by antibiotics which obviously will have limited or no effect. The authors review the current concepts of orofacial viral infections, causative
agents, their classification and clinical manifestations and a basis for treatment.
Clinical Relevance: Most viral infections do not require any specific treatment except in patients who are immunosuppressed or
immunodeficient. Appropriate diagnosis and timely management of orofacial viral lesions are important irrespective of whether it is
localized or a manifestation of a systemic infection.
Dent Update 2014; 41: 518–524

Patients often present with orofacial infections orofacial region is caused by the herpes simplex the herpes simplex virus-1 (HSV-1), herpes
in general medical and dental practice. These virus (HSV). Infection from a virus follows a simplex virus-2 (HSV-2) and varicella zoster virus
infections may be caused by bacterial, fungal or different aetiopathogenic pathway compared (VZV, HHV-3). Beta herpes viruses are grouped
viral pathogens. Viral infections may manifest in with bacteria, fungi and other organisms, as a as cytomegalovirus (CMV, HHV-5), human
different clinical forms and affect all age groups. virus metabolism is dependent on host cells. herpesvirus-6 (HHV-6) and human herpesvirus-7
The most common viral infection affecting the In general, most of the viral infections of the (HHV-7). Gamma herpes viruses consist of
orofacial region are self-limiting in an otherwise Epstein-Barr virus (EBV, HHV-4) and human
Raj G Nair, MSc, PhD, MRACDS(Oral healthy individual, whilst compromised herpesvirus-8 (HHV-8).
Med), Oral Medicine, School of Dentistry individuals may present with a myriad of local Interestingly, most of the viruses
and Oral Health, Centre for Medicine and systemic complications of viral infections. in the Herpesviridae family are known to
and Oral Health, Griffith Health Institute, General dental practitioners cause oral and peri-oral infections, although
Griffith University and Department of should be aware of the wide range of clinical there is controversy as to the true causative
Haematology and Oncology, Gold Coast manifestations of viral infections, which may agent of some of these orofacial infections.1
Hospital, Ali Salajegheh, MD, PhD, School affect the orofacial region as a localized disease Orofacial viral infections are common among
of Medicine, Centre for Medicine and Oral or a manifestation of a systemic viral infection, immunocompromised patients; the most
Health, Griffith Health Institute, Griffith such as the human immunodeficiency virus common being those caused by the herpes
University, Anut Itthagarun, DDS, PhD, (HIV) disease. The aim of this short review is to simplex virus (HSV). Human herpesvirus-6
PDipDS(Paed Dent), Paediatric Dentistry, provide a state-of-the-art, concise account of has been proposed as an aetiologic factor
School of Dentistry and Oral Health, Centre orofacial viral infections of humans and their in recurrent aphthous stomatitis.2 Human
for Medicine and Oral Health, Griffith management. herpesvirus-8 (HHV-8) is the aetiopathogenesis
Health Institute, Griffith University, Sahar Viruses causing orofacial of Kaposi’s sarcoma.3 Varicella-zoster virus is
Pakneshan, MD, School of Medicine, Centre infections less common but occurs in severe forms, as
for Medicine and Oral Health, Griffith Health in herpes zoster.4 Epstein-Barr virus in oral
There are a number of viruses that
Institute, Griffith University, Gold Coast, hairy leukoplakia (OHL)5 and many of the
may produce a subclinical or an overt infection
Queensland, Australia, Michael T Brennan, herpes viruses and certain human papilloma
of the peri-oral, oral, and oropharyngeal region,
DDS, MHS, FDS RCS(Edin), Department of viruses (HPV) are known for their association in
the most common being a group belonging to
Oral Medicine, Carolinas Medical Center, malignant neoplasms.6
the Herpesvirida and the Papillomaviridae family.
Charlotte, NC, USA and Lakshman P
Samaranayake, DSc(hc), DDS(Glas), FDS Alpha herpes viruses
RCSE(Hon), FRCPath(UK), Chair Professor Herpes group of viruses
The herpes group of the Herpes simplex virus
of Oral Microbiology and Dean, Faculty of
Herpesviridae family include eight viruses in As a general rule, herpes simplex
Dentistry, the University of Hong Kong,
three subclasses as Alpha, Beta and Gamma virus-1 (HSV-1) affects the areas above the
Hong Kong.
herpes viruses. Alpha herpes viruses include waistline, and HSV-2 mainly causes genital
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 OralMedicine

lesions or lesions below the waistline, Varicella-zoster virus

although HSV-1 and -2 can affect either area. Chickenpox is the primary infection
Primary infection of HSV-1 occurs either in childhood due to VZV as a droplet infection
during childhood as gingivostomatitis or, if from the nasopharynx. If a child is not exposed
not exposed, then as pharyngotonsilitis in during childhood, an overt infection may
an adult. Latent reactivation of HSV-1 most occur during adulthood. Chickenpox can have
commonly manifests as herpes labialis (or orofacial lesions such as vesicles, especially
the common cold sore) or as atypical forms over the facial skin and the oral mucosa, in
in an immunocompromised individual7 addition to the cutaneous lesions of the trunk.
(Figures 1 and 2). The virus is shed into If not secondarily infected, usually the lesions
saliva and the main mode of transmission on the facial skin will heal without scarring.11
of HSV-1 is through contaminated saliva After chickenpox, VZV remains
and transmission may occur via kissing latent in sensory ganglia until reactivation
a child, for example.8 Both primary and and replication, resulting in herpes
secondary or recrudescent infections are zoster (shingles). Herpes zoster affects
self-limiting. Immunosuppression, ultraviolet those above the age of 50 years or the
sun exposure, stress, changes in weather, immunocompromised and is characterized
Figure 1. Generalized gingival involvement
especially colder months, could all attribute by a unilateral, distinctive painful vesicular
in primary herpetic stomatitis in an
to the initiation of herpes labialis.9 Primary rash over a dermatome, corresponding to
immunocompetent child.
infection is common among children and the sensory ganglion where the VZV was
young adults, either asymptomatic or in latent. Orofacial manifestations are within the
the form of gingivostomatitis, following a ophthalmic, maxillary and mandibular nerve
usual course of fever, headache, irritability, distribution of the trigeminal nerve, with
loss of appetite, lethargy, hypersalivation maxillary and mandibular causing intra-oral
and cervical lymphadenopathy.10 Most of vesicles and painful ulcerations. Preventive
the individuals who suffer from recurrent therapy includes vaccination against VZV
herpes labialis will experience a prodromal (HHV-3).12
phase of tingling, burning sensation, itching, Anti-viral therapy is not indicated Figure 2. Recurrent HSV-1 infections.
mild pain and/or fever. Upper respiratory for chickenpox in otherwise healthy individuals
tract infection may precede the onset of the but may be considered in children 12 years
disease. Clinically, single or multiple small or older, patients with chronic cutaneous Human herpesvirus-6
erythematous papules that develop and form or pulmonary disease, patients on short to Human herpesvirus-6 is one of the
vesicles appear on either upper or lower lip, intermittent courses of aerosol corticosteroids first, so called ‘ancient’ human herpes viruses
which may or may not coalesce. They will and those on long-term salicylates.13 Treatment identified by molecular characterization. The
either rupture or may heal by crusting, leaving is based on symptomatic relief and antiviral main mode of viral transmission is through
no noticeable scar in most circumstances. drugs. In general, antiviral therapy in varicella contaminated saliva. It has been demonstrated
An atypical clinical presentation may occur zoster reduces the acute symptoms of pain that HHV-6 is present in the saliva of a large
in immunocompromised patients. The and malaise, limits the spread and duration proportion of the healthy adult population.15
healing may be prolonged with pain in the of the skin lesions and may prevent the The primary infection is usually asymptomatic
immunocompromised patient. There may development of post-herpetic neuralgia and and commonly occurs during childhood by age
be widespread vesicles with ulcerations reduce ophthalmic complications.13 2 years.16 The clinical form is called exanthema
involving large areas of the lip mucosa and subitum or roseala infantum or ‘sixth disease’.
adjacent cutaneous surfaces of the peri-oral Beta herpes viruses This biphasic disorder usually runs a benign
region.10 Diagnosis is clinical but laboratory course, causing fever, then a maculopapular
Cytomegalovirus
confirmations may be needed in atypical rash on subsidence of fever at the end of the
Cytomegalovirus is known to cause
cases and immunocompromised patients.10 fourth febrile day. Uvulo-palatoglossal junction
mononucleosis-like disease characterized
Antiviral treatment is often recommended for ulcers are useful early signs. The condition
by fever, pharyngitis, lymphadenopathy
the immunocompromised and in moderate requires no antiviral treatment.17 Recent reports
and fever in healthy immunocompetent
to severe infection in otherwise healthy have emphasized the critical role of HHV-6 in
individuals requiring no specific therapy.14 In
individuals. Systemic acyclovir, 200 mg, 5 the aetiology of human oral squamous cell
the orofacial region, the mononucleosis-like
times daily for 7 days or topical application carcinoma. It is, however, unclear whether
disease can present with palatal petechiae and
of 5% acyclovir cream every four hours for 5 the virus acts in combination with other
submandibular lymphadenopathy. This virus
days is the recommended dose. Valacyclovir carcinogens as a so-called co-carcinogen.18
also has been implicated to non-specific oral
1−2 milligrams twice daily may be used as a
ulcers and salivary gland disease, especially
prophylactic treatment, which is most effective
in the human immunodeficiency virus (HIV) Human herpesvirus-7
when initiated early during the prodrome
infected patients.6 Human herpesvirus-7 was first
phase.10
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 OralMedicine

identified in 1990 and is closely related to HHV- the oral cavity.22,26 Management may include infections.33
6. It establishes latency in macrophages and intra-lesional injections of cytotoxic drugs and There are several orofacial
T-lymphocytes and reactivates frequently with surgery is warranted only to restore aesthetics, manifestations associated with HIV disease and
asymptomatic virus shedding through saliva. such as the labial gingivae, for example. these are among the earliest manifestations
Most children acquire infection by the age of Anti-retroviral therapy or highly active anti- and considered important indicators of HIV
3−4 years, and seronegative individuals are at retroviral therapy (ART/HAART) has significantly infection, with some carrying a prognostic
risk of infection at any age. The spectrum of improved the management of orofacial KS value. Oral manifestations of HIV/AIDS have
diseases caused by primary HHV-7 infection associated with AIDS.22 been classified into three groups, based on the
is similar to HHV-6, with milder clinical clinical features and intensity. Viral infections
presentation.19,20 Severe complications due to relevant to this review are as follows:
HHV-6 and 7 are treated with ganciclovir and its Human papilloma virus (HPV)  Lesions that are ‘strongly associated’ with HIV
derivatives or foscarnet and cidofovir.21 The Papillomaviridae family are a infection such as hairy leukoplakia, Kaposi’s
group of double-stranded circular DNA viruses sarcoma and Non-Hodgkin’s lymphoma;
commonly found in the oral and oropharyngeal  Lesions that are ‘less commonly associated’,
Gamma herpes viruses
mucosa, tracheo-bronchial mucosa and ano- such as HSV, HPV and VZV; and
Epstein-Barr virus genital region. They are grouped into more than  CMV and molluscum contagiosum, which
Epstein-Barr virus has been known a hundred types and HPV type 16 and 18 have are classified as ‘lesions that are seen’ in HIV
to cause both local and systemic infections and been implicated in oral, oropharyngeal and infection.33
benign and malignant diseases of the orofacial tonsillar carcinomas.27 More recently, there has
region. They include infectious mononucleosis been an increasing understanding of the risk
or glandular fever, OHL and malignancies such factors of HPV in oral cancers, especially the risk Coxsackie virus
as lymphomas (non-Hodgkins and Burkitt’s) and of oro-genital sexual activity.28-30 Coxsackie virus causes hand, foot
nasopharyngeal carcinoma.22 Orofacial manifestations of HPV are: and mouth disease (strain A16) and herpangina.
Clinical features of infectious  Verruca vulgaris or the common wart on the These viruses can pass through the oral mucosa
mononucleosis are pharyngitis, cervical peri-oral skin; and small intestine and the regional lymph
lymphadenopathy, generalized arthromyalgia  Oral papilloma (squamous cell papilloma) of nodes. Clinical features of hand, foot and mouth
and associated fever and malaise. Symptomatic the oral mucosa (Figure 4); disease include, a mild prodrome followed
treatment is indicated, such as anti-pyretics,  Focal epithelial hyperplasia; and by sparse distribution of vesicles with an
analgesics and anti-inflammmatories, with  Condyloma accuminatum, a sexually erythematous halo affecting the oral mucosa,
no specific anti-viral drug treatment. Oral transmitted disease.31 hands and feet. Painful ulcerative lesions occur
hairy leukoplakia is a classic feature of Management of HPV infection anywhere in the oral cavity, but are commonly
immunosuppression, HIV disease and iatrogenic depends on the clinical presentation, such as
immunosuppression, such as cancer therapy. papilloma, usually using complete surgical
Clinically, lesions appear as white corrugated excision and/or topical drug therapy. Laser and
patches commonly on the lateral border of the cryotherapy are not recommended owing to
tongue and gingiva.23 lack of a tissue for histopathological evaluation
Lymphomas may present as a and a possible seeding of the lesion to the
swelling and/or an ulcer in the oral cavity surrounding area in the process.22,23 Two HPV
and orofacial region. Lymphomas and vaccines are currently available and have a clear
nasopharyngeal carcinomas obviously need role in preventing many ano-genital cancers
more aggressive cancer therapies, depending and conditions related to HPV infection. The
on the type and stage of the disease.24 effectiveness of HPV vaccines in preventing oral
HPV infection and cancer is unknown. Studies Figure 3. HIV disease or AIDS-associated KS
Human herpesvirus-8 are underway to evaluate the long-term efficacy affecting the oral mucosae.
Human herpesvirus-8 is associated of the vaccine against both ano-genital and
with Kaposi’s sarcoma (KS), especially in non-ano-genital endpoints.32
patients with HIV disease or acquired immune
deficiency syndrome (AIDS).25 HHV-8 has been
found in all the different types of KS affecting Human immunodeficiency virus
humans, hence is known as Kaposi’s sarcoma Human immunodeficiency virus
herpes virus or KSHV. Kaposi’s sarcoma, seen infection is pandemic and the disease has
in HIV disease or AIDS-associated KS, is usually become more of a chronic viral infection due
asymptomatic with either purple or bluish to the advent of multiple drug therapy using
macules or swellings affecting the orofacial ART or HAART. The disease may progress to
skin and oral mucosae (Figure 3). In the oral a serious and debilitating stage of AIDS with
cavity, the hard palate is the most common Figure 4. Oral papilloma (squamous cell
increased viral load and a significant decrease in
site, though it could be on other areas of papilloma) of the oral mucosa (HPV).
the CD4 cells, leading to several opportunistic
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 OralMedicine

found on the hard palate, tongue and buccal turns red, lasting for 6−7 days. Other features diagnosis with appropriate management, if
mucosa. The exanthem (mucosal lesions) begins include Herman spots on tonsils as bluish-grey required.
as 2−8 mm erythematous papules, a short areas. Treatment is mainly based on supportive
vesicular stage and yellow-grey ulcers with an measures such as fluids and anti-pyretics.
Conflict of interest and sources of funding
erythematous halo. Lesions may coalesce, the Current active immunization is two doses of
statement
tongue may become red and oedematous and live-virus measles vaccine for all healthy children
The authors wish to state that
painful, interfering with oral intake. Oral lesions before they begin school.36
they had no conflicts of interest or disclosures
heal without treatment within 5−7 days.34 Molluscum contagiosum is a
to make. Ethical approval was not required or
No specific treatment is necessary except for disease due to a large DNA virus. Patients who
applicable.
isolation of the patient, especially children, to are immunocompromised or deficient, such
avoid spread of the disease in a community.34 as the HIV infected, are more prone to this
Herpangina is also a disease of disease entity. The clinical presentation includes References
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typically occur in the late winter and early lesions in the absence of constitutional
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herpes zoster. Part 2: therapy and prevention.
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days.34 Pinpoint raised red lesions on the soft an important differential of oral and orofacial 15. Aberle SW, Mandl CW, Kunz C, Popow-Kraupp T.
palate may coalesce and the entire oropharynx lesions, which warrants appropriate and timely Presence of human herpesvirus 6 variants A and

522 DentalUpdate July/August 2014

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 OralMedicine

Orofacial signs and Usual site* Disease associated Possible virus associated Underlying factors to
symptoms be considered

Erythema Lips, oral mucosa Erythema multiforme HSV

White patch Oral mucosa, lips Erythema multiforme HSV

Vesicle and/or bullae Oral mucosa Herpes simplex infection HSV-1 Gingivostomatitis in a
child (primary)
Phryngotonsilitis in an
adult (primary)

Lips HSV- herpes labialis HSV-1 Secondary infection

Latent

Localized depending on Herpes zoster VZV Past history of

the affected nerve chickenpox

Oral mucosa, lips, hand Hand foot and mouth Enterovirus

and foot disease

Oral mucosa Pemphigus vulgaris? HSV? CMV?

Ulcer/erosion Lips Erythema multiforme HSV?

Oral mucosa HIV disease CMV
Oral mucosa Behçet’s syndrome HSV? CMV? Immunodeficiency
Soft palate/oropharynx Herpangina Coxsackie
Palate or any oral surface Lymphoma EBV Immunosuppression,
HIV

White growth Oral mucosa, peri-oral Papilloma HPV Sexually transmitted

region diseases

Lateral border of the Hairy leukoplakia EBV HIV

tongue, attached gingival

Prodromal Lips Herpes simplex secondary HSV

tingling sensation infection

Face, oral mucosa and lips Herpes zoster VZV Immunosuppression

(unilaterally) HIV

Pain Localized lip lesion Herpes simplex HSV Immunosuppression

Localized depending on Herpes zoster VZV Past history of

nerve involved chickenpox

Pigmentation (with or Palate, gingiva Kaposi’s sarcoma HHV-8 Immunosuppression,

without swelling) HIV

Swelling Palate, oral mucosa Lymphoma EBV Immunosuppression, HIV

Salivary (parotid) glands Mumps Paramyxovirus

Table 1. Orofacial manifestations of viral infections in immunocompetent and immunocompromised individuals.

*Oral mucosa = non-specific site; includes mucosa covering the entire oral cavity, including tongue.

July/August 2014 DentalUpdate 523

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 OralMedicine

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