Chapter 4 Infectious Diseases

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Chapter 4 Infectious Diseases

• Bacterial Infections

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Inflammatory and immune response to infection

• Inflammatory response is a nonspecific response
  and results in edema and the accumulation of a
  large number of white blood cells ate the site
• Immune system response is highly specific
  Specific antibodies are formed in response to
  specific antigens
• Microorganisms are antigens

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Opportunistic infection

• Decrease in salivary flow
• Antibiotic administration
• Immune system alterations
• Change oral flora so that organisms that are
  usually nonpathogenic are able to cause disease

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Impetigo

• Skin infection caused by Streptococcus pyogenes
  and Staphylococcus aureus
• May itch (pruritus)
• Regional lymphadenopathy may be present
• Normally found on skin (non-intact skin is
  necessary to contract
• Oral manifestation - resembles recurrent herpes
  simplex

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Tuberculosis

• Infectious chronic granulomatous disease
• Usually caused by Mycobacterium tuberculosis
• Primary infection of the lung
• Inhaled droplets containing bacteria lodge in the
  alveoli of the lungs
• Ulcerations can appear when organisms are carried
  in sputum to oral cavity
• Routine dental treatment is deferred for patients
  with active TB
• An antigen called Purified Protein Derivative
  (PPD) is injected into the skin

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Actinomycosis

• Infection caused by a filamentous bacterium
  called Actinomyces israelii
• Formation of abscesses that tend to drain by the
  formation of sinus tracts
• Organisms are common inhabitants of the oral
  cavitypredisposing factors are unknown

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Syphilis

• Caused by the spirochete Treponema pallidum.
• Transmitted by direct contact
• Can penetrate mucous membranes, but needs a break
  in tissue to penetrate it
• Usually transmitted through sexual contact with a
  partner with active lesions
• Blood or transplacental innoculation

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Syphilis

• Stages of Syphilis
• (1) Primary - oral lesion - chancre
• (2) Secondary- oral lesion - mucous patch
• (3) Latent - no oral lesion
• (4) Tertiary - oral lesion - gumma

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Necrotizing Ulcerative Gingivitis
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Necrotizing Periodontal Diseases

• NUG- an acute infection isolated in the gingiva
  (formerly known as ANUG)
• NUP is a similar infection that has progressed
  to include attached periodontal ligament and bone
  loss
• (AAP, 2000)

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Necrotizing Periodontal Diseases

• Signs and symptoms
• Gingiva is painful and erythematous
• Necrosis of interdental papillae (blunted)
• Foul odor
• Metallic taste
• Sloughing of the necrotic tissue presents as a
  pseudomembrane over the tissues

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Necrotizing Periodontal Diseases

• Unique in their clinical presentation, etiology
  and pathogenesis
• If NUP is combined with HIV marginal necrosis of
  the gingiva and a very rapid loss of alveolar
  bone is seen
• severe pain and bleeding without any provocation
• perhaps because of immunodeficiency there have
  been reports of tooth loss in only three to six
  months after onset

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Necrotizing Periodontal Diseases
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NUG

• Acute recurring gingival infection of complex
  etiology
• Characterized by necrosis of the papillae often
  described as punched-out
• Spontaneous bleeding and pain
• Pain is what make necrotizing periodontal
  diseases very different from plaque-induced
  gingivitis and periodontitis

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NUG

• Known by many names over the years
• Trench mouth
• Vincents infection
• Fuso-spirochetal gingivitis
• ANUG (misnomer b/c acute is clinical
  description)
• No chronic form of NUG
• Recurrence

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NUP

• Progression of NUG into the underlying attached
  gingiva causing periodontal pocketing
• Bone loss
• May occur if of recurrences of NUG or
  underlying systemic conditions such as AIDS
• AIDS/NUP originally called HIV_P
• If associated with recurrences conservative
  treatment is very successful
• No so with AIDS patients

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NPD

• One of the few emergency dental hygiene
  appointments
• Extreme pain
• Gross debridement
• Anesthetic helps ease pain during procedure
• Sonic or ultrasonic
• Education about the cause of the disease
• Nutritional counseling
• Vitamin recommendations
• Oral hygiene instruction
• No antibiotics

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Pericoronitis

• Inflammation of the mucosa around the crown of a
  partially erupted or impacted tooth
• Trauma from an opposing molar and impaction of
  food under the soft tissue flap (operculum)
  covering the distal portion of the third molar
• Treatment includes mechanical debridement and
  irrigation of the pocket and systemic
  antibiotics. Extraction of the impacted molar is
  usually necessary to prevent recurrence.

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Osteomyelitis

• An inflammatory process within medullary
  (trabecular) bone that involves the marrow spaces
• No change is seen on the radiograph unless the
  disease has been present for more than one week

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(moth eaten) radiolucent lesion with
irregular margins usually in the posterior
mandible fragments of necrotic bone may be
visible in the radiolucent areas
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Tonsillitis and Pharyngitis

• Inflammatory conditions of the tonsils and
  pharyngeal mucosa
• Can be caused by different organisms
• Streptococcal bacterial infection closely
  resembles tonsillitis and pharyngitis that are
  caused by viruses
• Strep throat caused by group A, beta hemolytic
  streptococci are significant

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Strep throat

• Scarlet fever - usually occurs in children
• Tonsillitis and pharyngitis
• Fever, red skin rash, petechiae on the soft
  palate and strawberry tongue
• Rheumatic Fever - childhood disease that follows
  strep infection
• Inflammatory reaction involving heart, joints,
  and CNS
• Heart valve damagebacterial endocarditis
  prophylactic pre-medication is necessary

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Fungal Infections

• Candidiasis
• Moniliasis (Thrush)
• Overgrowth the yeast-like fungus Candida albicans
• Encompasses a group of mucosal and cutaneous
  conditions with a common etiologic agent from the
  Candida genus of fungi most common oral mycotic
  infection
• Part of the normal oral flora especially if
  dentures are worn

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Candida albicans overgrowth can result from many
different conditions

• Antibiotic therapy
• Cancer chemotherapy
• Corticosteroid therapy
• Dentures
• Diabetes Mellitus
• HIV infection
• Hypoparathyroidism
• Infancy
• Multiple Myeloma
• Primary T-lymphocyte deficiency
• Xerostomia

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Types of Oral Candidiasis

• Pseudomembranous
• Erythematous
• Chronic atrophic (denture stomatitis)
• Chronic hyperplastic (candidal leukoplakia)
• Angular cheilitis

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Pseudomembranous Candidiasis
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More candidiasis
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Angular Cheilitis

• Candida organism most often causes
• Appears as erythema and/or fissuring at the
  labial commissures
• Can be caused by other factors (e.g.,
  nutritional, factitial)

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Angular cheilitis
Condition is most often bilateral
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Median Rhomboid Glossitis

• An asymptomatic, elongated, erythematous patch of
  atrophic mucosa of the mid-dorsal surface of the
  tongue due to a chronic Candida albicans
  infection
• Central Papillary Atrophy of the Tongue

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Median Rhomboid Glossitis
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Viral Infections

• Papillomavirus infection
• HPVs identified in oral lesions, normal mucosa
  and implicated in neoplasia
• Verruca vulgaris or common wart - autoinoculation
  occurs through finger contactlooks like a
  papilloma

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Primary Herpetic Gingivostomatitis

• Painful
• Erythematous
• Edematous
• Most common in children 6mos to 6 yrs.
• Perioral skin, vermillion border of lips oral
  mucosa

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Recurrent herpes simplex infection Herpes Labialis

• Form of recurrent herpes simplex
• Papules on the commissure of the lips.
• Most common type of recurrent oral herpes simplex
  infection occurs on the vermilion border of lips
• Cold sore or fever blister

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Recurrent herpes simplex infection

• Intraorally - occurs on keratinized mucosa that
  is fixed to bone
• Most commonly hard palate and gingiva
• Tiny clusters of vesicles or ulcers that can
  coalesce to form a single ulcer with an irregular
  border
• Prodromal symptoms pain, burning, tingling
• Heal without scarring in 1-2 weeks
• Transmitted by direct contact
• Primary infection occurs at the site of
  inoculation
• Amount of virus is highest in vesicle stage

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Herpetic Whitlow

• Herpes simplex virus. Can occur when fulcruming
  on same tooth and instrument punctures finger
• Very painful, even debilitating

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Herpes simplex can also spread to eyes.

• Inform patients with herpes to be very careful
  not to self inoculate. If they have open
  vesicles it can be spread to other areas of the
  body such as eyes or mucous membranes around
  genitalia.
• Learn table 4-2 on differences between aphthous
  ulcers and herpes simplex (page 142)

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Herpes Zoster

• Caused by the Varicella-Zoster virus
• Common name is Shingles
• Respiratory aerosols and contact with secretions
  from skin lesions transmit the virus
• Unilateral distribution of oral and skin lesions
• Painful vesicles that progress to ulcers
• Same virus that causes Chicken Pox (Varicella)

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Epstein-Barr Virus Infection

• Infectious Mononucleosis
• Most common in late adolescents and young adults
  in upper socioeconomic classes (transmitted by
  close contact)
• Hairy Leukoplakia
• Most common in HIV infected people
• Nasopharyngeal carcinoma - rare neoplasm
• Burkitts Lymphoma - rare neoplasm

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Coxsackievirus infections

• Herpangia - vesicles on the soft palate fever,
  malaise, sore throat, difficulty swallowing
  (dysphagia)erythematous pharyngitis
• Mild to moderate and resolves in less than 1 week
• Hand-Foot and Mouth Disease - occurs in epidemics
  in children less that 5 years of age
• Painful vesicles and ulcers anywhere in mouth
• Lesions resolve spontaneously within 2 weeks

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Human Immunodeficiency Virus (HIV) Acquired
immunodeficiency syndrome (AIDS)

• Most individuals experience an acute disease that
  occurs shortly after infection with HIV
• Sexual contact, blood or blood product
• contact, infant to mother
• Acute disease resolves and no signs or symptoms
  of disease exist for some time
• Most patients eventually have a progressive
  immunodeficiency

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HIV AIDS

• of CD4 lymphocytes decreases
• Fatigue, opportunistic infections (oral
  candidiasis)
• As the immune system becomes profoundly
  deficient, life threatening opportunistic
  infections and neoplasms occur
• Most severe result of infection with HIV is AIDS

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AIDS Diagnosis

• See table 4-3 (page 147)
• Severe CD4 lymphocyte depletion
• Pneumocystic carinii pneumonia
• Esophageal candidiasis
• Kaposis sarcoma
• Pulmonary tuberculosis
• Recurrent pneumonia
• Invasive cervical cancer

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Oral Manifestations

• Most common oral lesion associated with HIV
  infection is Oral Candidiasis

Unexplained oral candidiasis should be referred
to a physician for a cause. Very early sign of
developing immunodeficiency.
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Herpes Simplex and HIV
Treated with Acyclovir an antiviral medication
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Acyclovir Resistant Herpes Simplex in HIV patient
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Herpes Zoster in HIV infected person
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Oral Hairy Leukoplakia - Epstein-Barr Virus
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Papillomavirus Infections and HIV
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Kaposis Sarcoma

• Opportunistic neoplasm that occurs in patients
  with HIV infections
• HHV-8 associated with this neoplasm
• Neoplasm is a mass of newly formed tissue in
  which the growth of tissue is uncontrolled and
  progressive

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Kaposis Sarcoma
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Lymphoma in HIV patients

• Non-Hodgkins Lymphoma
• Malignant tumor
• Non-ulcerated, necrotic or ulcerated masses

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Gingival and Periodontal Disease in HIV infected
persons

• Linear Gingival Erythema (LGE)
• NUP

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Apthous Ulcerations and HIV
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Mucous melanin pigmentation

• Probably AZT pigmentation
• AZT is chemical ingredient in many AIDS drugs
  such as Retrovir, Combivir and Trizivir,