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This issue has been thoughtfully crafted and comprises valuable subject matter that is perfect for reading during April’s rain showers. Dimensions of Dental Hygiene is committed to the highest standards of professionalism, accuracy and integrity in our mission of education supporting oral health care professionals and those allied with the dental industry.
The initial outbreak of orofacial herpetic infections—regardless of which virus type causes the condition—is known as primary herpetic gingivostomatitis (PHG). After the initial stage of herpetic infection, the virus enters a latent phase, during which it migrates along sensory nerves and may take up residence in the trigeminal ganglion.2,8 Because there is no known cure for herpes simplex viruses, recurrent infections are common.
Similar to PHG, clustered vesicles appear during recurrent herpes simplex virus infections, although the gingiva is not typically affected. Due to the potential for viral shedding and transmission via saliva, the dental team may be routinely exposed to herpes simplex virus infections in the form of aerosols or spatter. Due to the highly transmissible nature of HSV-1 and HSV-2, treating orofacially infected individuals in the dental office may pose risks to both patients and clinicians.
Necrotizing gingival conditions can initially be mistaken for PHG because they also present with ulcerative lesions on the gingiva.
Erythema multiforme, which is caused by a herpes simplex virus infection in 70% to 80% of cases, may also manifest as intraoral lesions and inflammation. Lamey and Biagioni15 demonstrated that infected individuals had a good grasp in recognizing herpes simplex virus outbreaks, or "cold sores," but only half were aware that the lesions were caused by a virus. Individuals with PHG, because of the painful nature of the virus, may refrain from eating and drinking during the initial outbreak. In order for primary infections to become symptomatic, the virus must penetrate through epithelial cells, replicate, and cause cell destruction.
Over-the-counter lip balms may lessen the symptoms and severity of lip and perioral lesions. When using lip balms or other topical remedies, patients should be advised against using their bare fingers to apply the ointment to minimize the risk of spreading the infection. The use of antiviral therapy for PHG or recurrent herpes labialis is most efficacious if administration begins during the prodromal phase, or within the first several hours of observing a clinical sign of the infection.
Immunodeficient individuals may have an exaggerated response to initial and subsequent herpes simplex virus outbreaks. Dehydration is a frequent complication of PHG, especially in severe cases of intraoral or perioral pain and inflammation.16 However, the potential for more serious complications exists. The clinical appearance, symptoms, and general morbidity of PHG prompt many individuals to seek the assistance of dental professionals in diagnosing the condition.
Cornea editor's corner of the world Herpes simplex keratitis (HSV) is one of the most challenging entities that faces ophthalmologists. A geographic ulcer with fluorescein staining of the base of the ulcer and rose bengal staining of the peripheral terminal end bulbs Source: Vincent P.
Herpes ocular infection is one of the leading causes of infectious corneal blindness in the United States and Europe, according to Vincent P. With these older medications, practitioners were seeing corneal epithelial toxicity in the form of punctate keratitis and even more serious effects. With the availability of ganciclovir gel, treatment preferences for HSV keratitis are now somewhat in flux.
The fact that toxicity is less of a factor makes the decision to use topical therapy alone easier.
The infection with this virus is very common but, in healthy people does not produce disease. Is a member of the herpesviridae family together with herpes simplex, Epstein-Barr, varicella-zoster viruses. Presence of "cytomegalic" cells with reddish-blue intranuclear inclusions surrounded by a clear halo to impart a peculiar owl's eye appearance, hepatocytes, bile duct epithelium, endothelial and connective tissue cells. In cases of congenital hepatitis the picture is that of a severe "neonatal hepatitis" with necrosis and formation of multinucleated giant cell without significant inflammatory cell reaction. In cases of cytomegalovirus mononucleosis, which are rare, the liver shows a prominent diffuse lobular inflammation with lymphocytes, plasma cells and macrophages without significant necrosis. The "gold standard" for diagnosis of CMV is the conventional cell culture based on the appearance of the typical cytopathic effect (CPE) in the infected cells. Notice an area of necrosis with nuclear inclusions in hepatocytes and not much inflammatory reaction. This virus produces infectious mononucleosis in young adults throughout the world and seems to contribute to Burkitt's lymphoma and nasopharyngeal carcinoma. Mononucleosis hepatitis is characterized by peculiar necroinflammatory changes which, at the difference of classical viral hepatitides consist of more inflammation and less necrosis. Another peculiar feature is the presence of a marked regenerative activity of hepatocytes with presence of increased number of binucleate cells, polyploid nuclei and mitotic figures.
High power of previous illustration showing the signs of high regenerative activity: binucleate cells and a mitotic figure. Send Home Our method Usage examples Index Contact StatisticsWe do not evaluate or guarantee the accuracy of any content in this site.
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You’ll enjoy reading about the chairside management of dentinal hypersensitivity, how handpieces affect ergonomics, and improving patient comfort during ultrasonic instrumentation. Through our print and digital media platforms, continuing education activities, and events, we strive to deliver relevant, cutting-edge information designed to support the highest level of oral health care. This condition is diagnosed after an incubation period of 2 days to 2 weeks post-exposure.1,2 During this phase, the virus attacks various tissues in the oral cavity and may also affect the lips and perioral skin. Approximately 20% to 40% of individuals who experience PHG have recurrent outbreaks.2 Any condition that poses a threat to the immune system can trigger a reactivation of the dormant virus. Many individuals experience a subclinical initial infection in which no detectable signs or symptoms are noted.
Aerosols in the dental office are produced by handpieces, air and water syringes, air-powder polishers, and ultrasonic scalers.8,10 This presents a high probability for transmission of the virus in the operatory.
Also, infected individuals can easily transmit the same virus to other areas of the body, such as the eyes (Figure 2), nose, fingers, or anywhere there is a break in the skin or mucosal lining.
Patients presenting with PHG or active secondary herpetic lesions should be rescheduled for treatment only after orofacial lesions are healed and no signs of active disease are present.2,4,7,8 In the event that emergency dental care is required during an outbreak of PHG or herpes labialis—in which rescheduling would cause undue harm to the patient—clinicians should stringently follow standard precautions and avoid aerosol production.


The characteristic cratered appearance of the necrotizing gingivitis or periodontitis, however, may be reserved to the interdental papillae, whereas PHG affects all areas of the gingiva. Although fever, malaise, and other flulike symptoms may occur with herpangina, the intraoral vesicular lesions are confined to the soft palate and disappear in less than 7 days.
Not to be confused with PHG, the characteristic presentation of erythema multiforme is target lesions of concentric erythematous rings alternating with normal skin color. Oral health professionals should carefully explain to patients with an outbreak of PHG or other active herpetic lesions that dental treatment can promote the spread of infection to other areas of the mouth, lips, nose, or eyes, as well as to other people.
Patients need to understand the infectious nature of the disease, as well as the risk of spreading infection to other individuals—even in the absence of clinically evident lesions.
Both children and adults should be instructed on maintaining proper hydration during this period.16 Not all patients, however, will experience the typical moderate to severe pain that accompanies PHG, and other symptoms of the initial infection may also be limited or absent. Patients should maintain a nonacidic diet of soft, cold foods and noncarbonated beverages.2 Avoiding spicy foods during oral outbreaks is also good practice. This is when viral replication is at its highest point and the efficacy of antiviral medications will be maximized. Patients undergoing chemotherapy, who have received organ transplants, or been infected by the human papillomavirus will benefit most from systemic antiviral medications.
Patients who had human herpes simplex viruses in their periodontal pockets demonstrated deeper probe readings and greater severity of disease.9 This particular pattern of periodontitis may be due to the effects of herpes simplex viruses on various cells that contribute to immune function. Meticulous oral hygiene should be encouraged for any patient with known herpes simplex virus infections to prevent the risk of severe periodontal diseases. Dental hygienists are often the first clinicians to encounter individuals with these active viral infections, thus, they should be able to perform a differential diagnosis based on key features of PHG in relation to other infections and diseases that present with similar clinical symptoms. A study of the clinical activity of a gel combining monocaprin and doxycycline: a novel treatment for herpes labialis.
Detection of human herpes viruses in patients with chronic and aggressive periodontitis and relationship between virus and clinical parameters.
Erythema multiforme: a review of epidemiology, pathogenesis, clinical features, and treatment. Patient recognition of recrudescent herpes labialis: a clinical and virological assessment.
Safety and effectiveness of an L-lysine, zinc, and herbal-based product on the treatment of facial and circumoral herpes.
Little clinical benefit of early systemic aciclovir for treatment of primary herpetic stomatitis. Failure to detect an association between aggressive periodontitis and the prevalence of herpes viruses. Topical antivirals have had significant toxicity, and the more recent trend has been to use oral antiviral agents to manage HSV keratitis. Hovanesian finds that because ganciclovir is not toxic to the epithelium, successful healing of HSV keratitis is evident to both the patient and the physician at an earlier stage.
Hovanesian pointed out that the new ganciclovir gel, while a real step up for HSV keratitis, is not likely to be a moneymaker for the pharmaceutical company like an antibiotic would be.
The viral particles consist of a DNA core, a icosahedral capsid, adn a surrounding envelop. The infection acquired in the may present a serious illness which begins shortly after birth with jaundice, purpura, hemolytic anemia, thrmobocytopenia, brain damage, microcephaly and paravetricular calcifications.
The infection may produce a chronic disease with abnormal liver function tests and recurrent fever and jaundice.
However, an average of 7-10 days is required for the CPA to develop, which in a critically ill patient is too long. This consists in the incubation of the tissue on a glass slide with antibodies to the virus. Unfortunately, the ubiquitous presence of the virus and the common asymptomatic type infection makes the evaluation of a single measurement of antibody level difficult to interpret.
Their accuracy, when compared with culture or histologic methods, is still being evaluated. Type 1 produces herpes simplex infection especially recurrent blisters around the lips and generalized infections in older children and adults. The infection in childhood is common and asymptomatic but it may rarely cause mononucleosis syndrome. There is marked mononuclear cell infiltration of sinusoids and portal fields contrasting with mild hepatocellular necrosis. The marginal gingiva appears erythematous throughout the maxilla and mandible, followed by the emergence of small vesicles on the gingiva, oral mucosa, tongue, and lips (Figure 1).2 These tiny fluid-filled lesions coalesce and rupture approximately 1 day to 2 days after manifestation, leaving behind ulcerations of various sizes.
Excessive sunlight exposure, illness, trauma, menstruation, and stress can all initiate outbreaks.1,2 Recurrent herpetic infections typically occur at the site of their initial entry into the body, which most often is the lips or perioral skin.
Despite the absence of PHG, these individuals may still be prone to recurrent herpetic outbreaks. Face shields used in conjunction with safety glasses with side shields are highly recommended during routine care of all patients.
While aphthous ulcers may exhibit similar symptoms, these lesions typically present as single ulcerations on nonkeratinized mucosa and do not appear as coalescing groups. These conditions also demonstrate a rapid course of progression, with considerable tissue destruction occurring in as little as 3 days.
The body's natural inflammatory response, initiated by the presence of the replicating virus, also contributes to the disease process.
Application may continue until the lesion has healed.14 Ointments containing L-lysine, zinc oxide, and herbal combinations have also proven effective in treating cold sores. Because the virus stops replicating after approximately 48 hours, the administration of antiviral therapy after this point may not be useful.20 Patients should monitor themselves for prodromal symptoms so treatment can begin immediately. The lack of immune response may trigger more frequent and more severe symptomatic lesions, which may be present for a longer duration than in immunocompetent individuals. Due to the highly infectious nature of this disease—and the potential for extreme discomfort and more severe complications—oral health professionals must be aware of the steps necessary for proper detection and management of orofacial herpes simplex viruses at all stages. Under electron microscopy there are herpes-like virions, defective viral particles and spherical particles called dense bodies. The liver presents cholestasis, fatty changes, focal necrosis with cytomegalic cells in hepatocytes and bile ducts.


Some adults and older children may develop "glandular fever", the so-called Cytomegalic Mononucleosis consisting of a febrile illness of 3-6 weeks duration with lymphocytosis, abnormal lymphocytes but negative Paul-Bunnell test and absence of sore throat and lymphadenitis.
Positive cases show a strong, dark-brown or red staining (depending on the counterstain) in the nucleus of the cell. Type 2 affects the genital tract and produces disseminated infection of the neonate with severe hepatic involvement.
In debilitation, pregnancy, immunosuppression it may produce a disseminated disease which is usually fatal.
The sinusoids are filled and distended with mononuclear cells which are large and sometimes clustered to resemble granulomas sometimes similar to sarcoidosis. Portal tracts are healvily infiltrated by mononuclear inflammatory cells but there is mild erosion of the limiting plates. Maecenas ac tempor odio.Click here to view all articles in other categories not listed above.
Additionally, there is never a vesicular stage.2 Herpes zoster, or shingles, is the reactivation of the varicella zoster, or chickenpox, virus, and is not PHG. Patients will also frequently experience crusting and bleeding of the lips, which may look similar to a severe case of PHG with perioral lesions. This sequence of events may dictate the severity of infection observed.4 Adults with PHG, however, will often present with more severe symptoms than children.
In a small study, this particular blend of ingredients demonstrated a significant reduction in lesion healing time.17 Products containing benzalkonium chloride are also available, but more research is needed to support their efficacy and safety. This is especially important among those who have experienced severe PHG or subsequent orofacial herpes simplex virus outbreaks. Systemic antiviral medications may reduce the morbidity and mortality rates due to HSV-1 infections in immunocompromised individuals.
Signs and symptoms of this condition include fever, headache, and altered consciousness.21 Patients with PHG should be advised to monitor themselves for any progression of current symptoms, and to seek immediate medical attention if their condition deteriorates or signs of viral encephalitis develop.
Perinatal infection can be contracted in utero, from infected maternal genitalia and from breast milk.
Infected cell may become cytomegalic but since the infection may not produce morphological changes, the absence of large cells and of intranuclear inclusions do not exclude the infection.
Fatality is high but some patients may recover completely or may come out with permanent brain damage. The picture is similar to that of infectious mononucleosis and can be confused with acute viral hepatitis. This assay requires the incubation of the sample submitted with a monoclonal antibody, labeled with a fluorescent tag. Disseminated herpes infection is commonly seen in immunocompromised patients (vesicular eruptions, encephalitis, esophagitis, keratitis). The liver lesions are similar to those of herpes simplex, necrotizing with viral inclusions in hepatocytes. The difference is attributed to the exposure to a large quantity of viruses by deep kissing. The sinusoids are swollen adn the liver cell plates, in some areas, may be compressed and atrophic. This herpetic infection is typically seen in older adults, whereas PHG most often presents in children, adolescents, or young adults.
In these cases, systemic antiviral therapy should be considered for routine administration to limit the potentially severe effects and to further reduce the spread of infection. I have asked two corneal experts to comment on their approach to HSV keratitis and how, if at all, this new medication has changed their management. However, in doing this he cautions against pushing too deeply with the swab since this could push the viral antigen deeper into the stroma. After a period of incubation of 24 or 48 hours, positive cells display nuclear apple-green fluorescence under the microscope. The virus is a typical member of the Herpesviridae family: DNA core, a icosahedral capsid with 162 capsomers, a surrounding envelope, 120 nm in diameter. Practically all pirmary infections are asymptomatic but the infected individuals excrete the virus in the urine and saliva for months and years and are infectious. Similar symptoms may appear in the so-called Postperfusion Syndrome which develops after massive transfusions from multiple donors in both positive and negative individuals for anti-CMV antibodies.
Groups of hepatocytes surrounding these areas contain intranuclear eosinophilic viral bodies (Cowdry type A inclusions). It is found in lymphoid tissues and in the epithelium of the nasopharynx and probably of the cervix. Obviously, the sinusoidal infiltration reflects the mononucleosis picture of the peripheral blood. The virus may be reactivated from the latent state by decreased imune response usually induced by disease or drugs especially by immunosuppressant therapy where reactivation of a primary infection and not re-infection appears to be the norm.
The white cells of 5% of blood donors contain CMV virus therefore infection by blood transfusion occurs in a large number (60%?) of patients. After infection, the lymphocyte under the influence of the viral genome produce new antigens which are deposited on their surface.
Because of the wide distribution and the asymptomatic occurrence of CMV infection it is crucial to test donors for organ transplantation. T lymphocytes react to these antigens, become blastoid and form the atypical lymphocytes of the peripheral blood seen in these patients who at this piont develop the full symptoms of infectious mononucleosis which, evidently, is immunopathologically mediated. An infected organ under immunosuppressive therapy will reactivate the virus with disastrous consequences.
Some individuals cannot mount this t-lymphocytic reaction will succumb to the primary EVB infection.
This is the case of those suffering of X-linked lymphoprolipherative disorder, Duncan's syndrome.



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