VIRUSES IN PERIODONTAL DISEASE

MANAL ABU AL GHANAM JB PERIODONTOLOGY

The purpose

The purpose of this review is to give an overview of the viruses involved in oral pathology, to highlight specifically those viruses that may be potentially involved in periodontal diseases, and to evaluate the evidence supporting the hypothesis that viral infection plays a role in the development of periodontal diseases.

Viruses cause many acute and chronic diseases in humans. New viruses are continually being discovered and already known viruses are being implicated in clinical conditions with previously unknown etiologies. Viruses occupy a unique position in biology. They are obligate intracellular agents, which are metabolically and pathogenically inert outside the host cell.

The complete virus particle, called a virion, generally has a diameter of only 30150 nm. Viruses are grouped into 3600 species, 71 families, and 164 genera. Fewer than 40 viral families and genera are identified to be of medical importance in humans.

Viral Structure
1. 2.

All viruses consist of two basic components Nucleic acid (either DNA or RNA but not both) A protective, virus-coded protein coat termed a capsid.

The genome with its protein cover is referred to as the nucleocapsid. Some viruses have additional covering in the form of an envelope that consists of a lipid protein bilayer derived from the cell membrane of the host.

Classification of viruses

Classification of viruses is based on:

The type of the nucleic acid genome (DNA or RNA). The strandedness of the viral nucleic acid (singlestranded or double stranded genome). The presence or absence of an envelope (enveloped or naked).

Since viruses have no capacity to produce energy, reproduce their genomes or make their own structural proteins, their replication depends on their hosts to provide energy, substrates and machinery for replication of the viral genome and synthesis of viral proteins.

Viral infection can lead either to a rapid replication of the agent and destruction of the infected cell, or to a prolonged period of latency.

DNA viruses (except poxviruses) replicate in the nucleus and are more likely to persist in the host, whereas RNA viruses (except retroviruses) replicate in the cytoplasm.

Host response

Key to an effective antiviral host response is the ability to recruit appropriate types and numbers of inflammatory cells and mediators to the site of infection.

Host response

Enveloped viruses typically initiate cell-mediated inflammatory responses and delayed type hypersensitivity, which affect viral replication by killing mammalian cells that express viral proteins. Naked viruses are controlled mainly by antibody, and vaccines are generally effective.

Viral diagnostics

Viral diagnostics is a rapidly changing field in terms of assay principles and available diagnostic kits.

Identification of viruses has traditionally been based on: 1. Cell culture to detect characteristic cytopathic effects, 2. Morphologic determination of intracytoplasmic and intranuclear inclusion bodies, 3. Immunohistochemical techniques, 4. Immunoassays to identify viral antigens in clinical specimens, 5. The measurement of total or class-specific antibodies against specific viral antigens.

RNA-VirusesHIV

Oral lesions related to HIV are often the first clinical signs of this infection and can play a specific role in the diagnosis of patients with unknown HIV serostatus.
(Greenspan, 1994; Patton et al, 1999; Patton and vander Horst, 1999).

Oral candidiasis and hairy leukoplakia have consistently been reported as the most prevalent HIV associated oral disease.
(Shiboski et al, 2001;Holmes and Stephen, 2002; Patton et al, 2002)

RNA-VirusesHIV

Neoplasia such as Kaposis sarcoma and nonHodgkins lymphoma are other oral lesions strongly associated to HIV infection which, together with oral candidiasis, are able to affect the periodontum.
(Langford, 1994)

HIV is associated with the following periodontal conditions: linear gingival erythema (LGE), necrotizing gingivitis (NG), necrotizing periodontitis (NP), and chronic periodontitis.

Linear gingival erythema

Is a distinct erythematous band of marginal gingiva with either diffuse or punctuate erythema of the attached gingiva.
(Holmstrup and Westergaard, 1998)

The prevalence of LGE in HIV infected population varies from 0 to 49% .

(Porter et al, 1989; Klein et al,1991; Slots and Rams, 1991; Lamster et al, 1997; Pattonet al, 1998; Schuman et al, 1998; Ranganathan et al, 2000).

Necrotizing gingivitis , Necrotizing periodontitis , and Necrotizing stomatitis

Necrotizing gingivitis (NG), Necrotizing periodontitis (NP), and Necrotizing stomatitis (NS) may be different stages of the same disease. NG results in the destruction of one or more interdental papillae and remains confined to the marginal gingiva. NP extends beyond the marginal gingiva, involves the periodontal ligament and the alveolar bone, leading to loss of attachment. NS extends past the mucogingival line into the mucosa and osseous tissue.

Necrotizing gingivitis

Necrotizing periodontitis

Herpesviruses

Research has identified more than 5000 different strains of herpesviruses. Of the approximately 120 identified different herpes viruses, eight major types are known to infect humans. Humans are the only source of infection for these eight herpesviruses.

Herpesviruses

Human herpesviruses are classified into three groups (, , ) based upon details of tissue tropism, pathogenicity, and behavior under conditions of culture in the laboratory. Herpesviruses are typically highly selective in regard to the specific tissues or organs they infect, reflecting their strong tendency to tissue tropism.

Most herpesviruses are ubiquitous agents that often are acquired early in life and infect individuals from diverse geographic areas and economic backgrounds.
(Contreras et al,1999)

Herpesviruses can cause serious infectious diseases and be tumorogenic .

(Alford et al,1979)

Herpes simplex viruses

Infections HSV-1 and HSV-2 are worldwide spread and usually affect skin and mucosa. Other herpetic diseases of clinical importance occur through ophthalmic, neurologic and, more rarely, organ system infection.
(Whitley and Roizman, 2001).

HSV-1 and HSV-2 can both be found in oral-facial and genital infection.
(Rabenau et al, 2002; Buxbaum et al, 2003)

Herpes simplex viruses

HSV are transmitted by close person-to-person contact by mucosal secretion or lesions. HSV-1, principally shed in the saliva, is transmitted directly (kissing) or indirectly (infected utensils or hands) and is mainly involved in oral-facial infections and encephalitis. HSV-2 is usually transmitted sexually and causes genital infection.

Herpes simplex viruses

Other ways of transmission include autoinoculation by fingers to the eyes or genital tract and transmission from infected mothers to neonates. HSV infections are endemic in all human populations, the epidemiology varies between countries and type of population. Acquisition of HSV especially HSV-2, is largely dependent on the socio-economic status, sex, age and ethnic origin.
(Fleming et al, 1997)

Primary herpetic infection

The most common gingival disease of viral origin.

(Kuzushima et al, 1991; McMillan et al, 1993).

It may run an asymptomatic course in early childhood but can give rise to more severe manifestation with increase of age.

The clinical manifestations are: 1. Gingivitis. 2. Vesicles that leave ulcerations. 3. Cervical lymphadenopathy . 4. Fever.

(Amir et al, 1999).

Healing takes 1014 days. Pain can compromise food intake.

Primary herpetic infection

Treatment includes: 1. Maintenance of fluid and food intake. 2. Antipyretic 3. Analgesic treatment 4. Topical antiseptics to prevent bacterial superinfections. Acyclovir treatment seems to shorten the duration of all clinical manifestations.

(Amir,2001)

Primary herpetic infection

Reactivation of herpes simplex virus can occur subclinically but about one-third of individuals become prone to clinical recurrences .
(Young et al, 1988; Lowhagen et al, 2002).

Reactivation can occur at any time and may be triggered by : 1) immunosuppression 2) stress 3) trauma 4) ultraviolet irradiation 5) fever

Recurrences are usually found at the mucocutaneous junction of the lips (herpes labialis) but can also be intraoral typically on the palate or the gingiva (recurrent herpetic gingivostomatitis in immunocompromised patients)
(Leigh, 1988; Nikkels and Pierard, 1999).

Varicella Zoster Virus

Varicella zoster virus is found in a worldwide distribution. Annual epidemics are more prevalent in temperate climates, occurring most often in late winter and spring. VZV is responsible for two universal human diseases: 1. Varicella (chickenpox) in childhood. 2. Herpes zoster in aged and immunocompromised persons.

Varicella Zoster Virus

VZV enters by inhalation and replicates in the mucosa of the respiratory tract. Dissemination occurs via bloodstream and lymphatics and the virus multiplies in mononuclear leukocytes and capillary endothelial cells. The cutaneous rash results from the multiplication of the virus in epithelial cells, following which it ascends the axons of various sensory nerves and remains latent in their ganglions.
(Arvin, 1996)

Varicella Zoster Virus

Varicella is usually acquired during the first 5 10 years of life. Varicella appears suddenly with or without prodormal fever and malaise. Vesicles and ulcers first appear in the mouth (usually on the palate and the tongue but also on the gingiva) followed by a cutaneous rash that spreads from the head and the trunk.

Varicella Zoster Virus

Lesions in the mouth are painful whereas lesions on the skin are painless but itchy, which may lead to secondary bacterial infection and permanent scars.
(Kolokotronis et al, 2001)

Neurologic complications are uncommon but potentially serious .

(Hasler et al, 2002)

Varicella Zoster Virus

Zoster results from reactivation of virus that remain latent in sensory ganglia. Lesions are similar to those found in varicella but usually remain confined to a single dermatome and are thus unilateral. Intraoral lesions can be found if the third or second branch of the trigeminal ganglion is involved.
(Arvin, 1996)

This may lead to alveolar bone necrosis .

(Smith et al, 1984; Arikawa et al, 2004).

EpsteinBarr Virus

EpsteinBarr virus affects over 90% of humans.

(Cohen,1997)

Usually transmitted by oral secretions or blood. The virus replicates in epithelial cells or B cells of the oropharynx. Nearly all seropositive persons actively shed virus in the saliva.
(Yao et al, 1985)

Whereas EBV infection in children is most often subclinic, EBV infection in adults results in infectious mononucleosis.

Infectious Mononucleosis
Common symptoms of infectious mononucleosis: 1. Fever, lymphadenopathy 2. Pharyngitis. 3. Oral ulcers. 4. Palatal petechia. 5. Less commonly gingival ulcerations can be diagnosed

(Rivera-Hidalgo and Stanford, 1999)

EpsteinBarr Virus
EBV has also been associated to other diseases: 1. Cancers (Nasopharyngeal carcinoma) 2. Auto-immune diseases

(Thorley-Lawson and Gross, 2004)

3.

Oral hairy leukoplakia,(OHL) is the main lesion associated to EBV.

Oral Hairy Leukoplakia

Non-malignant hyperplasic lesion of epithelial cells which shows evidences of non-cytolytic active EBV replication .
(Triantos et al, 1997)

Clinically OHL appears as a raised, white, corrugated lesion that most often develops on the ventral-lateral aspect of the tongue and may be unilateral or bilateral .
(Schiodt et al, 1987)

Human Cytomegalovirus

Most common cause of congenital and perinatal infections. HCMV is found in many body secretions including saliva, urine, semen and breast milk.

HCMV infection, although generally subclinical,is responsible for cytomegalovirus inclusion disease and mononucleosis. Under immunosuppressive conditions it can give rise to a wide variety of clinical manifestations.
(Landolfo et al, 2003).

Herpesviruses: an etiologic factor of periodontal diseases?

Herpesviruses: an etiologic factor

The involvement of herpesviruses in the etiology of periodontal diseases is suggested by their presence in gingival tissue, gingival cervicular fluid (GCF) and subgingival plaque, in the presence of periodontal disease. The hypothesis is challenged by several arguments regarding sampling, methods and interpretation.

Herpesviruses: an etiologic factor

Evidence for a potential role of herpesviruses in the etiology of periodontal disease:
1.

Virus detection in gingival tissue; Cultured epithelial cells and fibroblasts from clinically healthy human gingiva are susceptible to HSV infection, suggesting that those cells could be a reservoir for the latent virus.
(Zakay-Rones et al, 1982)

Using an indirect immunofluorescence assay, HSV-1 antigens could be detected in 4 out of 14 gingival biopsies from periodontally diseased patients .
(Ehrlich et al, 1983)

Herpesviruses: an etiologic factor

2. Higher frequency of virus detection in the gingival tissue of periodontitis sites than in healthy sites; In the 20 patients with periodontitis in the study of (Contreras et al 1999), HCMV was detected in 13 biopsies, EBV in 10, HSV in 7 and HHV-6 in 2. A later report from the same group (Contreras et al, 2000) showed that herpesvirous in gingival tissues could be detected in periodontally healthy or diseased subjects by PCR.

Herpesviruses: an etiologic factor

3. Higher frequency of herpesvirus detection in GCF from periodontaly diseased sites than from gingivitis/healthy sites: Parra and Slots (1996) investigated the presence of HCMV, EBV, HSV and HIV in GCF samples from 30 patients with advanced periodontitis and 26 subjects with gingivitis; 78%of advanced periodontitis patients were positive for at least one of the five tested viruses.

Herpesviruses: an etiologic factor

4. Higher frequency of virus detection in subgingival plaque from periodontaly diseased than from healthy sites; Saygun et al (2002) examined the occurrence of HCMV,EBV and HSV in patients with chronic periodontitis and the relationship between these viruses and clinical parameters.

HCMV DNA was detected in 44.3% of chronic periodontitis patients and 14.3% of healthy persons. EBV DNA was found in 16.7% of chronic periodontitis patients and 14.3% of healthy persons. HSV DNA in 6.7% of chronic periodontitis patients and not at all in healthy patients.

Herpesviruses: an etiologic factor

5. Detection of activated herpesvirus in the GCF of periodontal lesions; A study was performed in 11 young adults with clinical and radiographic signs of localized periodontitis (Ting et al, 2000). Six patients were 10 14 years of age. Five of them were HCMV positive.

Herpesviruses: an etiologic factor

6. Interaction of herpesviruses with periodontal pathogens; Several studies examined a possible association between potential periodontopathic bacteria and herpesviruses in subgingival plaque. The subgingival detection of EBV, HCMV and other viruses could be associated with an increased presence of periodontal pathogens and periodontitis.
(Contreras et al, 1999a; Hanookai et al, 2000)

Model for herpesvirus-related periodontitis

Challenges for the hypothesis

1. Investigators Most clinical association studies have been carried out by the same group of investigators. (Contreras and Slots,1996, 1998; Parra and Slots, 1996; Contreras et al,1999a,b, 2000, 2001; Hanookai et al, 2000; Ting et al, 2000; Kamma et al, 2001; Slots et al, 2002; Kamma and Slots, 2003; Kubar 2004; Saygun et al, 2004)

Challenges for the hypothesis

2. Method

Gene amplification by PCR allows the detection of very small quantities of microorganisms or viruses through selective manipulation of DNA fragments.
(Burkardt, 2000)

Quantitative real time PCR might be a more appropriate method, allowing not only the detection, but also the quantification of a virus.
(Kubar, 2004)

3. Sample population In diseased sites, higher volume of GCF can be collected, and samples may contain blood cells more easily.

In addition, such samples may contain increased quantities of subgingival biofilm. Thus, samples from diseased sites are more likely to contain viruses present in blood, independent of a specific association with the local disease process.

Conclusions
As we move into an era of thinking of a network of causation in periodontitis, the need is growing for well-designed studies to delineate the relative importance of the various types of infectious agents, the multiple and complex pathogenic pathways, and the genetic and environmental factors contributing to the disease.

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