Infections of the Oral Cavity



Infections of the Oral Cavity


Vinidh Paleri

Konrad Staines



Introduction

Infections in this region are most commonly of dental origin, consequent to dental caries or periodontal disease. Rarely, underlying odontogenic cysts may become infected and produce a similar clinical picture. While dental infections are outside of the scope of this book, they can spread to the neck spaces and present with serious life threatening illnesses. These are dealt with in Chapter 8 Infections of the oropharynx. This chapter deals with the oral mucosal infections seen in ENT practice.


Viral infections

Viral infections of the oral mucosa may have a varied clinical presentation. The most common viral infections of the oral mucosa are listed in Table 6.1. Other rarer viral conditions with oral manifestations are outlined in Table 6.2.


PRIMARY HERPETIC GINGIVOSTOMATITIS

Human herpes virus (HHV-1) infections of the oral cavity are very common. These are DNA viruses that spread through direct contact. Primary infection most often occurs in infancy or childhood. It typically follows viral entry into the oral mucosa, and may be symptomatic, unnoticed, unrecognized, or asymptomatic. Primary herpetic gingivostomatitis occurs in individuals who lack primary immunity 5-7 days following contact with a source. A vesicular eruption can be preceded by a prodrome of local tenderness. The vesicles are thin walled and short-lived, leaving behind shallow, painful ulcers. A characteristic and diagnostic feature of this infection is the involvement of keratinized mucosa, especially the marginal gingiva (6.1, 6.2). The lesions last 1-2 weeks and settle spontaneously but, despite clinical resolution, viral shedding takes place and these individuals can be a source of infection.








Table 6.1 Common viral infections of the oral mucosa















Virus

Oral mucosal disease


HSV 1 and 2

Primary herpetic stomatitis Recurrent herpetic stomatitis: labialis or intra-oral


Varicella-zoster virus

Chickenpox Intraoral herpes zoster


Epstein-Barr virus

Hairy leukoplakia Infectious mononucleosis


Differential diagnosis mainly consists of noninfective conditions such as herpetiform apthous stomatitis (6.3), erythema multiforme, and Stevens-Johnson syndrome. Infective conditions include acute necrotizing gingivostomatitis, herpes zoster, measles, and other rarer viral infections listed in Table 6.2.

Treatment is usually symptomatic to relieve the pain and maintain oral hygiene. Paracetamol and ibuprofen are effective in relieving pain and pyrexia. Local analgesics such as benzydamine hydrochloride mouthwash or lidocaine (lignocaine) ointment can be used, but their duration of action is short-lived. Chlorhexidine mouthwash or gel helps prevent bacterial superinfection of the ulcerated areas and is therefore indicated. There is no evidence to support the use of topical antiviral agents for the first attack of oral herpes simplex. In severe cases, especially in adults or immunocompromised patients, systemic antivirals (acyclovir and famciclovir) may reduce the duration of symptoms if taken early in an attack and can be used in severe infections. Owing to the high risk of infecting others, appropriate advice on hand washing and limiting contact must be given.









Table 6.2 Other viral infections causing oral mucosal lesions







































Virus

Infection

Systemic features caused

Oral mucosal

Location features


Paramyxovirus

Measles

Malaise, fever, anorexia, conjunctivitis, and respiratory symptoms

Koplik spots (bluish-grey specks on an erythematous background)

Buccal mucosa in the premolar and/or molar area


Coxsackie A1-6, 8, 10, 22

Herpangina

Fever, headache, anorexia, vomiting, and abdominal pain

Punctate macules that evolve into erythematous papules, vesicles, and ulcers

Soft palate, tonsil, posterior pharyngeal wall


Coxsackie A10

Acute lymphonodular pharyngitis

Fever, headache, anorexia, vomiting, and abdominal pain

Papules that do not progress to vesicles and ulcers

Soft palate, tonsil, posterior pharyngeal wall


Coxsackie A16

Hand-foot-mouth disease

Mild fever, malaise, anorexia, and a sore mouth

Oral vesicles, leading to shallow ulcers

Anterior buccal mucosa, the tongue, and the soft palate


HHV-8

Kaposi’s sarcoma (KS)

Malignant vascular tumour found predominantly in HIV positive patients; characterized by blue-red nodules on the skin and/or visceral tissues

Lesions (blue-red nodules) may be asymptomatic; however, progression may result in complications, e.g. pain, bleeding, difficulties in talking or eating

Palate (majority of cases), tongue and gingivae







6.1 (Above left) Primary herpetic stomatitis.






6.2 (Above) Herpetic stomatitis of the premaxilla.






6.3 (Left) Herpetiform apthous stomatitis.



RECURRENT HERPETIC INFECTIONS (COLD SORES)

During the primary infection, the virus also gains entry into the neurones and becomes latent in the trigeminal, vagal, and sympathetic ganglia. At times when the host immunity is compromised or following certain triggers like stress, illness, and sunlight, viral reactivation may occur. Generally this results in a clinical picture of recurrent herpes labialis (6.4) with the vermillion of the lip and adjacent skin characteristically involved. The prodrome is characterized by tingling, itching, or pain, followed by vesicular eruption. These crust over 48 hours and heal without scarring over a week. However, reactivation may also involve oral mucosa (recurrent intraoral herpes) with vesicles developing which burst to leave a cluster of oral ulcers (6.5). Their distribution tends to be localized and unilateral.

While there is no consensus on the use of topical antivirals, best evidence suggests that topical penciclovir 1% or acyclovir 5% must be started as soon as symptoms begin, to be of any benefit. Oral antivirals may be of benefit in severe cases. Prevention is possible in the presence of well-defined triggers, e.g sunscreens when sunlight can trigger an episode. For most patients there is no role for prophylactic antivirals to prevent cold sores.


CHICKENPOX (VARICELLA)

Oral manifestations may include generalized superficial ulceration. The clinical picture may be similar to primary herpetic gingivostomatitis although there tends to be less gingival involvement. Treatment is only supportive.

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Related posts:

  1. Principles and Practice of Anti-Infective Therapy in ENT Infections
  2. Infections of the Nose and Paranasal Sinuses
  3. Tropical ENT Infections
  4. Infections of the Salivary Glands

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Aug 1, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Infections of the Oral Cavity

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