Wednesday, August 27, 2014

Unmet Dental Needs and Barriers to Care for Children with Significant Special Health Care Need

Unmet Dental Needs and Barriers to Care for Children with Significant Special Health Care Need
Authors: Nelson et al. 
Pediatric Dentistry Vol 33 Jan/Feb 2011
Resident: Margaret Maclin

Purpose: The first known large scale survey of parents of children with special health care needs to determine their child’s: oral health status; access to dental care; perceived environmental and non environmental barriers; and oral health quality of life, accounting for each child’s medical diagnosis and severity of diagnosis. 

Methods: A survey was written by 15 private dentists and the Massachusetts DPH task force on CSHCN which contained 72 questions. The survey contained items on medical diagnosis, description of condition, dental care status - including unmet needs, dental care access, dental care- emergency, general dentistry, pediatric dental specialty care, other specialty care, and hospitalization, dental care transition into adulthood, barriers to dental care; quality of life, background and demographics. The survery was translated into English and Spanish and sent to 3760 families containing children with SHCN. 

- 1,128 surveys were completed. 
- More than 90% of the children had seen a dentist within the past year. 
- 66% saw a pediatric dentist.
- 21% needed intense behavioral intervention. 
- Most families had high education, private dental insurance, and above average incomes, 20% of CSHCN had an unmet dental need. 
- Children with Craniofacial anomalies had twice as many unmet needs and children with cystic fibrosis had fewer unmet needs.
- Children with cerebral palsy, autism, developmental delay and down syndrome had more aversions to dental treatment, more treatment complications due to medical conditions and more difficulty finding a dentist willing to provide care.
- Children with cystic fibrosis, metabolic disorders and hemophilia had the fewest barriers to care. 

Assessment: Its important to note that there are sub pockets of CSHCN that are at higher risk for having unmet dental needs and not just CSHCN as a whole population. Significant influencing factor that was not addressed was diet with these particular children. And the difference between unmet dental needs: first time treatment versus unmet dental needs: recurrent decay or new cavitations. 

Methemoglobinemia in a Newborn: A Case Report

Methemoglobinemia in a Newborn: A Case Report

Authors: Ali Bayat and Ronald Kosinski

Journal: Pediatric Dentistry V 33, No3


Methemoglobinemia is a condition in which the iron within hemoglobin is oxidized from ferrous to ferric, resulting in the inability of hemoglobin to transport oxygen and carbon dioxide. It results in cyanosis and hypoxia, with dark blue appearance of the skin. There are two forms of methemoglobinemia: congenital and acquired. The congenital form is divided into two further categories:
1.     Altered form of hemoglobin that affects the heme-globin bond.
2.     NADH cyctochrome b5 reductase deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency.

Oxidant agents oxidize the iron in hemoglobin, causing methemoglobinemia. Benzocaine, prilocaine, nitric oxide, sulfonamides, aniline dyes, antimalarial, and dapson are considered high risk. Lidocaine, mepivicaine, articaine, bupivacaine, etidocaine, aspirin, acetaminophen, and nitrous oxide are considered substances  with moderate risk of inducing methemoglobinemia. Methemoglobin blood levels of 10% to 20% are usually tolerated with no clinical signs. Levels of 30% to 40% and above are associated with headaches, dyspnea, dizziness, acidosis, arrhythmias, seizures, and comes. Levels of 70% and above are often fatal.

Case Report Summary

Two-day-old female infant twin diagnosed with a natal tooth in the maxillary anterior region. Patient’s medical history: Rieger syndrome, congenital glaucoma, ventricular septal defect, and atrial septal defect with no history of congenital methemoglobinemia or related enzyme disorder. The natal tooth was attached to a vascular bulbous tissue at the gingival level. The patient received 0.5 ccs of 2% Lidocaine with 1:100,000 EPI via local injection to manage pain and control hemorrhage. Approximately 1 hour after the procedure, cyanosis was observed and the patient was diagnosed with methemoglobinemia. The patient was immediately treated with 100% oxygen and 0.7 mg intravascular methylene blue over 5 minutes. Her methemoglobin level was measured at approximately 53% during the incident and was measured again at 17% 30 minutes later and 0.5% 24 hours later.


Even though lidocaine induced methemoglobinemia is a relatively rare malady, clinicians should be aware of this condition to ensure prompt diagnosis and effective treatment.

Use of Chlorhexidine Gel (0.2%) to Control Gingivitis and Candida Species Colonization in Human Immunodeficiency Virus-infected Children: A Pilot Study

                                                                                    Date: 08/25/14

Article title: Use of Chlorhexidine Gel (0.2%) to Control Gingivitis and Candida Species Colonization in Human Immunodeficiency Virus-infected Children:  A Pilot Study

Authors: Fernanda Campos Machado, DDS, MSD et. al

Journal: Pediatric Dentistry V33/No.2 Mar/Apr 11

Type of Article: Experimental study without a control group

Main Purpose: To evaluate chlorhexidine to control gingivitis and Candida species in children infected with HIV and patient’s acceptance of the therapy.

Overview of method of research: 
·      26 HIV positive children were selected and oral exam established biofilm, gingival indexes and stimulated saliva were collected for Candida ssp. identification.
o   Excluded cases: Children with carious lesions or teeth that required extraction. Children under antifungal treatment or those with orthodontic or prosthetic appliances as well as those with behavioral or cognitive impairment.
·      The children ages 6-13 brushed their teeth for 21 days with chlorhexidine gel (0.2%).
·      Salivary samples, biofilm and gingival indexes were collected as baseline at the start and after 21 days (first re-evaluation) and again after 35 days (second re-evaluation) after ceasing gel use.
·      The children answered a questionnaire about the therapy.
o   Questions regarding flavor, foam, residual taste and dental stains.

·      All children tested positive for Candida and gingivitis.
·      After 21 days Candida counts and gingivitis decreased in 25 and 26 children, respectively.
o   Mean reduction 68% for Candida and 74% for gingivitis.
·      35 days after discontinuing gel, gingivitis and Candida increased in 13 and 16 patients, respectively.
·      Approximately 85% did not experience inconvenience with the gel. 48% thought it was good for tooth brushing.
o   3 children reported dental staining, 1 child complained about flavor.

·      Chlorhexidine therapy may be an option to treat and prevent gingivitis and reduce yeast counts in children infected with HIV.

·      Limitations: modest sample size and the absence of a control group.

Atypical Case of Oral Lichen Planus in a Pediatric Patient: Clinical Presentation and Management

Atypical Case of Oral Lichen Planus in a Pediatric Patient: Clinical Presentation and Management
Author: Moraes, et al
Source: Pediatric Dentistry October 2011
Resident: Avani Khera
Type: Case Report

Purpose: The purpose of this paper was to report an unusual case of lichen planus involving the upper lip in a 7 year old girl.

Introduction: Lichen Planus is a mucocutaneous disease of unknown etiology that is relatively common in adults but rare in children. The LP is associated with the following diseases: Sjrogens syndrome, rheumatoid arthiritis, and dermatomyositis. LP can affect the skin, scalp, nails and mucous membranes and predominately affect adults.  The oral manifestation in adults is more frequently resistant and persistent than the cutaneous type. The varieties include reticular, plaque-like, and atrophic/erosive lesions.  OLP occurs mostly on the buccal mucosa, the gingiva, tongue, floor of the mouth, and retromolar pads.  There is a low incidence or OLP in children. However, a diagnosis of OLP lesions can be made based on clinical features if they are sufficiently characteristic, particularly when presenting in the “classic” reticiular form.  However, a biopsy is recommended to confirm the diagnosis.  The classic treatment is based on topical or intralesional injection of corticosteroids. 

Case Report: A 7 year old Caucasian girl was referred to a clinic in Brazil regarding discomfort in her upper lip. Her parents reported a negative medical hx of diseases related to her hypersensitivity. The patient had received a Hep B vaccine at 1 year of age (brazil’s protocol recommends 3 vaccinations at 1, 2, and 3 months).  Clinical examination revealed atrophy and labial disfigurement of the vermilion border of the upper lip.  Oral examination showed reticular white plaque and hyperkeratotic striae, measuring approximately 1cmx1cm involving the upper lip.  An incisional biopsy confirmed the clinical diagnosis of LP. The treatment consisted of a topical corticosteroid and intralesional injection.  After treatment with the intralesional corticosteroid, a complete re-mission of lesion involving the lip was observed.  The 3 year follow up however revealed asymptomatic lichenoid bilaterally affecting the buccal mucosa.  The patient is currently under recall.

Discussion: LP’s etiology remains obscure, however it has been reported as a complication of hepatitis B vaccination in both children and adults. Reactions to MMR and DTap is also related, however these associations remain UNCLEAR.  Mucosal lesions frequently have a bilateral, symmetrical distribution and commonly take the form of minute white papules that gradually enlarge and coalesce to form either an annular, reticular, or plaque like pattern.

Assessment: Good article for Board review discussing Lichen Planus+Pictures

Dental Implications of Osteogenesis Imperfecta: Treatment with IV Bisphosphonate: Report of a Case

Article Title: Dental Implications of Osteogenesis Imperfecta: Treatment with IV Bisphosphonate: Report of a Case
Author: Michael Milano, DMD; Timothy Wright, MS, DDS; Karen J. Loechner, MD, PhD.
Date: Pediatric Dentistry, Volume 33 No. 4 July/August 2011

Major Topic:  Case report of dental treatment of a pediatric patient that was undergoing IV Bisphosphonate treatment of Osteogenesis Imperfecta (OI).

Main Purpose:  To review OI and its common treatment of IV Bisphosphonate and how it relates to  the treatment a pediatric patient who under went multiple extractions, putting them at significant risk of bisphosphonate-associated osteonecrosis of the jaws (BON).

Introduction:  Osteogenesis imperfecta (OI)
·      Mutation of type I collagen w/ connective tissue and extraskeletal manifestations
o   Low bone mass w/ associated bone fragility and a combination of other tissues – ligaments, skin, meninges, tendons, teeth (dentinogenesis imperfecta (DI), sclera
·      Genetically heterogeneous: autosomal dominant, autosomal recessive, sporadic trait
·      OI ranges: 1:5,000 to 1:20,000 live births
·      90% of cases can be confirmed with genetic testing, but only 4 of the 9 clinical types
o   type I – mild form, no major bone deformities, hearing loss relatively common, sclera typically blue
o   type II – severe phonotype, fatal in utero or perinatal due to multiple lung fractures, respiratory failure
o   type III – short stature, failure to thrive, multiple bone fractures that cause deformities, most present with hearing loss and DI
o   type IV- more variability in presentation of traits: short stature, moderate bone deformities, hearing loss and DI (or some combination of)
o   In general – triangular shaped faces with 75% presenting with class III malocclusion
o   DI with OI: teeth have amber-brown to blue-gray or yellow color, opalescent sheen, frequently show attrition subsequent to cracking and loss of enamel, primary affected more then permanent dentition.  Radiographic:  Bulbous crowns with cervical constrictions, root peg shaped and short, with obliteration of the pulp chambers over time
·      Tx:  Palliative, no curative – reduce bone pain, bond fragility, fracture and subsequent bone deformity
o   Gold standard Tx:  IV and oral bisphosphonates
§  Bisphosphonates :
·      originally used to treat myeloma, bone metastasis, Paget disease of the bone, osteoprosis
·      Have been around for the past 40 years
·      incorporate into mineralized bone and inhibit bone resorption by osteoclasts / long half life
·      treatment for pediatric patients is a 3 day IV administration, varying dose and cycle interval with child’s age and is now initiated in infancy
·      Major side effect that affects dental treatement: BON
o   Most studies on post-menopausal/post-chemotherapy women and the incidence is 6/600,000 – no incident reported in children but that could be because of the long action of the drug, thus patients are older when potential problems arise
o   IV treatment has a higher risk for BON then oral, mandible higher incident then maxilla
o   Long-term management – antibiotics (penicillin or clindamycin)and oral antimicrobial rinse (chlorhexdine gluconate)

Case Report:  4y 8m old male of Africana American / Lumbee Native American decent with history of OI and DI, sickle cell trait present to the Graduate Pediatric clinic at University of North Carolina School of Dentistry, Chapel Hill.  At this time patient had initiated IV bisphosphonate (pamidronate) at 4 years old but need central maxillary incisors removed due to severe attrition.  Patient was lost to follow-up and returned to the clinic at 6y 6m of age.  At that time he required several stainless steal crown and multiple extractions.  Patient was treated in the OR under GA.  At the time of surgery, patient had under gone 8 IV treatments and was on Vitamin D and calcium supplements.  Treatment included 9 SSC, both primary maxillary molars and one primary mandibular second molar were extracted.  IV ampicillin was prophylactically administered prior to surgery per physican’s orders.  No antimicrobial mouth rinse was prescribed but could have been.  1 month follow up  all extraction sites were healing with no clinical signs of BON.  Patient is more then 44 months post treatment with no adverse sequela.

Discussion:  Informed consent should address potential risk of BON.  Know that IV route of administration have a higher risk of developing BON and that BON is more systemic when compared to osteoradionecrosis, which tends to be more localized.  No published reports of BON in OI sufferers.  OI in children that have been treated with bisphosphonate show delayed tooth eruption of the permanent dentition and increased retention of primary dentition.  The increase in the retention of primary teeth may increase the susceptibility of the patient to dental abscess due the increase longevity and attrition of the primary dentition.  Ideally a dental consultation should be completed before initiation of therapy.  Incases of surgical intervention a oral maxillofacial surgeon should be consulted and prophylaxis use of antibiotics, although there is no specific guideline for use at this time.  Treatment recommendation are empirical due to the lack of long-term randomized clinical trials. 

Osteoporosis: An Increasing Concern in Pediatric Dentistry

Article Title: Osteoporosis: An Increasing Concern in Pediatric Dentistry
Author: Marcio A. da Fonseca
Journal: Pediatric Dentistry
Date: May/Jun 2011
Major Topic: Literature Review- Osteoporosis

Main Purpose: With increasing numbers of children affected by low bone density and osteoporosis, the topic has become an important issue in contemporary pediatrics.

Introduction: Bone fractures are the most common reason for hospitalization between 10 and 14 year olds, and over the past 3 decades there has been an increase in the incidence of fractures in children. Childhood factors, such as lifestyle, diet, chronic illness and medications can all effect bone mineral density in the short and long term impact on peak bone mass.

Osteoporosis is classically defined in adults as a systemic skeletal disease characterized by low bone mass; alteration of ultrastructural quality of bone; deterioration in trabecular architecture; increased cortical porosity reduced cortical thickness and decreased bone width.  Osteoporosis is often difficult to define in children as they are constantly changing in size and shape with increases in bone mass and density. Greatest bone mass acquisition tends to mirror height velocity and is greatest during puberty (90% of peak bone mass is acquired at this time).  Any disruption of this growth would lead to an increased risk of adult osteoporosis and fractures. Excess of deficiencies in GH, TH, PTH, and sex steroids can also lead to decreased BMD.

Bone disorders can be categorized into Primary and Secondary causes of decreased bone mineral density.
Heritable Disorders of CT: Idiopathic juvenile osteoporosis, osteogenesis imperfecta, Marfan syndrone, Ehler-Danlos, Bruck, osteoprosis pseudoglioma syndrome, homocystinuria
Inflammatory Diseases - Inflammatory bowel disease, celiac disease, juvenile idiopathic arthritis, CF, Lupus, dermatomyositis,
Chronic Immobalization - cerebral palsy, neuromuscular disorders, epidermolysis, spina bifida, spinal cord injury, head injury
Endocrine Disturbances - Turner syndrome, anorexia, hypogonadism, GH deficiency, DM I, hyperthyroidism, Cushings, delayed puberty
Hematologic-oncologic disorders – childhood cancer, thalassemia, sickle cell disease
Inborn Errors of Metabolism – protein intolerance, glycogen storage diseases, galactosemia, Gaucher disease
Iatrogenic Etiologies – glucocorticoids, anticonvulsants, chemotherapy, cyclosporine, acrolimus, bone/cranial radiation
Others – chronic renal disease, steroid- dependant asthma
Measuring Bone Mineral Density: DEXA (dual energy X-ray absorptiometry) is a diagnostic tool used in the management of adult osteoporosis. DEXA doesn’t distinguish between cortical and trebecular bone, nor does it differentiate between body types for a certain age (ie short kids vs tall), which may lead to a possible misdiagnosis. In addition, DEXA norms are based off small numbers of reference studies, and predominantly Caucasian subjects were used to generate normal reference ranges. DEXA is however beneficial to use as a monitor during tx.

Treating Osteoporosis in Children: Anticipatory guidance regarding healthy lifestyle  (physical activity, diet, no drugs/alcohol) is of great importance to prevent bone loss and should start from an early age. In severe cases of low BMD, promoting calcium and Vit D intake coupled with weight-bearing physical activity can provide benefits with minimal risk.

Implications of Osteoporosis in Dental TX: Pediatric dentists should be meticiulous in their Md Hx taking. Dentist should be careful when using restraints with child diagnosed with osteoporosis as bone fractures may result. Extractions should be done carefully as to avoid any unnecessary jaw fractures. Dentists should be aware of the patient’s current therapy. Bisphosphonate therapy may lead to BRONJ (avoid surgical procedures during IV Bisph therapy). Elimination of all potential sources of odontogenic and mucosoal infection must be done before the patient starts therapy with bisphosphonates. Patients taking PO bisphosphonates have a much lower risk of developing BRONJ than those receiving IV tx, thus this does not preclude them from dental therapy (implants, extractions, or other surgical modalities). There are no reported cases of BRONJ developing from primary tooth extraction. However, it is always important to consult with the child’s physician prior to any surgical therapy.
Bisphosphonates can also inhibit tooth movement – posing a problem for otho therapy (reduced osteoclasts). It is suggested that ortho tx be avoided in patients with high risk, such as those patients receiving or have received IV Bis. The drug is also associated with delayed tooth eruption with OI and with ulcers when pills come in contact with oral mucosa.

Tuesday, August 26, 2014

Impact of Advances in Diabetes Care on Dental Treatment of the Diabetic Patient

Author: Mealey, BL
Compendium 19(1):41-60, 1998
“Classic 100 Articles”: Article 65
Resident: Hofelich

Diabetes Mellitus:
  • Disease of metabolic dysregulation, primarily carbohydrate metabolism; impaired insulin secretion or function results in elevated blood glucose levels (BG)
  • Range of BG for a healthy person is 60mg/dL to 150 mg/dL.
  • Insulin allows glucose to be removed from blood for cell/tissue storage; it is produced in pancreatic beta cells.
  • DM is characterized by a lack of endogenous insulin (Type I/IDDM) or tissue resistance/abnormal insulin secretion (Type II/NIDDM).
  • Type I/IDDM: has absolute requirement for exogenous insulin and patients can develop DKA (fat broken down for energy that results in formation of harmful ketones); DKA can lead to coma; reduced average lifespan by 1/3 with a  median age at death of 49 years.
  • Type II/ NIDDM: not subject to DKA; more than 90% of patients have type II; pancreatic insulin secretion can be low, normal, or high; insulin resistance is a common trait
  • Five complications classically associated with diabetes: retinopathy, nephropathy, neuropathy, macrovascular disease, and impaired wound healing.
The Diabetes Control and Complications Trial was a study to determine whether intensive insulin therapy could prevent development of microvascular complications. The results of the study showed that improved glycemic control (with instensive insulin treatment) both inhibited the onset and delayed the progression of microvascular complications of IDDM.

Medical Management of Diabetes:
IDDM: exogenous insulin in many forms: subcutaneous injection, insulin infusion pumps; insulin is classified as rapid, short, intermediate, or long-acting.

NIDDM: Diet modification, insulin, oral agents; Sulfonylurea, biguanides (Metformin), glitazones (Troglitazone), alpha-glucosidase inhibitors (Acarbose)

Dentistry and Diabetes:
  • Primary assay to evaluate long term (over 6-8 weeks) control is hemoglobin A1C (HbA1c/HbA1). Normal values are 4-6%, >7% indicates increasing need for improved diabetes control
  • Dental practicioners should encourage patients who self-monitor to bring glucometer to dental office for each visit; postpone procedures if patient has markedly low or elevated BGLs.
  • Most common complication of insulin therapy is hypoglycemia. Can be caused by excess insulin injection, skipping meals while taking usual dose of insulin, stress; symptoms are confusion, shakiness, tremors - can lead to coma or death. 
  • Emergency treatment of hypoglycemia is critical – always have PO, IM, and IV sources of readily absorbed carbohydrate in office.
  • Best time to treatment patients: before or after peak insulin levels because hypoglycemic reactions are more likely to occur when insulin levels are high.  Determine when patient ate, the type of insulin or oral med taken, and how much and when they took the medication.
  • Be aware of sedation medications that require patient to be NPO for 8-12 hours – insulin regimen/doses may need to be decreased.
Good review for management of type I/IDDM which can be seen in the pediatric population – lists many helpful questions and brings up many important points that dentists should consider when treating this population.

Monday, August 25, 2014

Herpesvirus Infections

Anna Abrahamian
August 27, 2014

Article Title: Herpesvirus Infections

Author: Martin S. Greenberg, DDS

Journal: Infectious Diseases and Dentistry

Date: April 1996

Major Topic:  Herpes Group Viruses

Type of Article: Classic 100 (#52); Overview

Main Purpose:  This article reviewed the virology and general characteristics of herpes infection.

There are more than 80 known viruses of the herpes group – 7 of these are known to cause infection humans: HSV I, HSV II, CMV, VZV, EBV, HHV-6, and HHV-7.  Features common to all seven of these herpes viruses are:
1)   Four layers: a)inner core of double stranded DNA, b) a protein capsid, c) the tegument, and d) a lipid envelope.
2)   They cause a primary infection the first time the virus is contacted by the patient then have a latent period in the nuceli of the specific body cells for the life of the infected individual
3)   After reactivation, herpes viruses cause localized symptomatic or asymptomatic recurrent infections.
4)   Transmissions is by direct intimate contact with saliva or genital secretions
5)   Virus particles are shed in the saliva of asymptomatic hosts (constant reservoir).
6)   Herpes viruses can transform cells (only EBV is strongly associated with malignancy in humans  -  nasopharyngeal carcinoma, B cell lymphomas.

Herpes Simplex Virus 1 (HSV 1): most frequently transmitted by saliva, causes a majority of cases of oral, pharyngeal, eye, and CNS infections. Peak infection period between ages of 2 and 3 years old. Primary infections are usually subclinical (vague upper respiratory tract type symptoms), but when symptomatic, patients can experience fever, chills and nausea and lymphadenopathy. Vesicles and ulcers of the oral mucosa for 1-2 days later. 20% have recurrent infections found on the lips or the keratinized oral mucosa.

Herpes Simplex Virus 2 (HSV 2): present in genital secretions and causes a majority of genital and anal infections. Incidence of primary HSV2 increases after sexual activity begins.

Both HSV-1 and HSV-2 are usually diagnosed clinically, but viral cultures, cytology smear, and serology can be used, especially in the evaluation of immunocompromised patients.

Cytomegalovirus (CMV): frequent cause of asymptomatic infection in humans. Clinical presentation is rare except in neonates and immunocompromised patients. Transmitted during birth (vaginal secretions), saliva, blood or sexual contact. Symptoms of primary infection include hepatitis, pneumonia, lymph and spleen involvement, myocarditis. Confirmed with viral culture from the tissue lesion. One characteristic histopathologic change is “owl eye cells” – prominent intranucleolar and intracytoplasmic inclusions.

Varicella-Zoster Virus (VZV): causes two distinct infections – a) primary infection (chickenpox), and b)recurrent infection (shingles).  Chickenpox is usually a benign illness of children that is spread by direct contact with skin lesions or nasopharyngeal secretions.  Adults have a mortality rate 15x higher than children because of the increased incidence of encephalitis.  One serious complication of chickenpox in children is Reye’s syndrome (progressive encephalopathy following aspirin administration).  Shingles typically occurs in older patients or immunocompromised individuals.  After primary infection, VZV becomes latent in dorsal root or cranial nerve ganglia (most commonly affected nerves are C3,T5, L1, and L2).  The virus can be fatal in immunocompromised patients. Acyclovir is used to treat shingles and is dosed at 4x the strength compared to HSV treatment (800mg 5x/day). When herpes zoster involves the ophthalmic division of the trigeminal nerve, eye involvement can be a serious complication.

Epstein-Barr Virus (EBV): transmitted by saliva/blood. Primary infection is seen in childhood with subclinical symptoms or in young adults that causes infectious mononucleosis (“kissing disease”). Clinical symptoms may not appear for up to 8 weeks. Lymph node and spleen involvement are very common. Diagnosis is usually with a blood test (increased lymphocytes) – EBV causes a proliferation of large atypical T lymphocytes.  EBV has been associated with Burkitt’s lymphoma and nasopharyngeal carcinoma.  An important oral lesion caused by EBV is oral hairy leukoplakia (seen in immunocompromised individuals, but also in immunocompetent individuals using topical corticosteroids on the oral mucosa.)

Human Herpes Virus 6 (HHV 6): transmitted by saliva, typically causes roseola (self-limiting fever and rash). Virus has an affinity for CD4 lymphocytes.

Human Herpes Virus 7 (HHV 7): transmitted by saliva, recently discovered, no clear/specific clinical disorder associated with the virus. Also associated with CD4 cells.