Dr.

Tahani Abualteen

Infections of the Oral Mucosa II

Bacterial infections: It is surprising how few bacterial infections occur in the oral mucosa despite the wide range of species present normally in the oral cavity This actually reflects the normal defensive mechanisms that are operating in the mouth e.g. the epithelial barrier, the mechanical cleansing and the anti-microbial (by IgA) effects of saliva, immune phagocytic cells into the gingival crevicular fluid . Bacterial infections and their oral manifestation: 1. Necrotizing Ulcerative Gingivitis (NUG) OR Acute Necrotizing Ulcerative Gingivitis (ANUG) 2. Noma (cancrum oris) 3. Actinomycosis 4. Syphilis 5. Tuberculosis (TB) 6. Leprosy 7. Gonorrhea

Necrotizing Ulcerative Gingivitis (NUG) OR Acute Necrotizing Ulcerative Gingivitis (ANUG): This infection is: o Polymicrobial (caused by different bacteria) o Endogenous (caused by bacteria already present in the oral cavity) o Opportunistic (caused by bacteria waiting for a chance "e.g. immunosuppression" to cause the infection) Predisposing factors (local and systemic) involved in the etiology of NUG: o o o o o o o o o Immunosuppression (decreased host resistance, depressed immune responses) Pre-existing chronic gingivitis Trauma Association with AIDS Malnutrition and poverty (predisposes to NUG in children) Smoking Stress, fatigue Poor oral hygiene Overgrowth of associated endogenous flora (fusospirochaetal complex) {F. fusifornis, T. vincentii}

NUG was common among Soldiers, as they had developed many of the predisposing factors (e.g. stress, smoking, poor oral hygiene, Malnutrition ) Occurs predominantly in young adults More common in males than in females Is now relatively uncommon except for HIV patients High recurrence rate if underlying cause is untreated Persistent form is associated with AIDS (all AIDS-related infections are persistent to treatment)

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Dr. Tahani Abualteen

Clinical picture: o Sudden onset of necrosis and crater-like, punched out ulceration of interdental papilla and gingival margins o Ulcerated areas are covered with a grey-green psuedomembrane which is demarcated from the surrounding mucosa by a linear Erythema ** The psuedomembrane consists of necrotic tissue - Punched out ulceration of interdental debris, inflammatory exudate and bacteria papilla and gingival margins o Gingival bleeding - Grey-green psuedomembrane, surrounded by linear Erythema o Pain or soreness of the gums o Halitosis (foul breath) o Salivation o Altered taste (metallic taste) o Malaise, fever and lymphadenopathy may be present in advanced cases Diagnosis is based on: o Clinical picture o Demonstrating the fusospirochaetal complex in a gram-stained gingival smear Differential diagnosis: chronic marginal gingivitis (presence of punched-out necrotic ulcers at the tips of interdental papillae and psuedomembrane are important signs to diagnose NUG) NUG may be an important factor to develop NOMA E.g. Gingivae of teeth may contact the buccal mucosa and necrosis may then spread to involve it causing gangrene and loss of orofacial tissues Treatment: o o o o Identify and eliminate the predisposing factor Gentle debridement of necrotic gingival tissue Chlorhexidine mouth wash & gentle tooth brushing Metronidazole 200 mg 3 times daily for 3 days

Noma (cancrum oris): It is a severe and rapidly destructive gangrene of the orofacial tissue and jaws Usually preceded by NUG, and then followed by rapid spread of necrosis from gingiva to the cheek Almost all cases appear in developing countries (especially Africa) particularly in malnourished children whose resistance has been lowered by concurrent infections such as measles or malaria (i.e. immunosuppressed individuals) Treatment: o Debridement and removal of all necrotic tissue o Followed by cosmetic rehabilitation

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Dr. Tahani Abualteen

Actinomycosis: This infection is: o Chronic Suppurative ( pus-forming) o Polymicrobial (caused by different bacteria) o Endogenous (caused by bacteria already present in the oral cavity amongst which Actinomyces specie, especially Actinomyces israelli, predominate) ** Actinomyces species are anaerobic & Gram positive bacteria Soft tissues of the submandibular region and neck are most commonly involved and Actinomyces bacteria can gain access to this region through an infected root canal or lower third molar socket The infection is characterized by multiple foci of chronic suppuration Clinical picture: o Development of firm painless swelling which eventually softens and suppurates (accompanied by the formation of pus which discharges through multiple sinuses) o These sinuses may release sulphur granules in the pus (yellowish granules composed of bacterial colonies) o The multiple abscesses which eventually form tend to point on to the skin rather than the mucosal surface and are accompanied by marked fibrosis of the surrounding tissues Histopathological picture: o Actinomycotic lesions develop as areas of granulomatous inflammation (histiocytes or macrophages response) surrounded by granulation tissue (immature repair tissue) o Central area of suppurative necrosis (WBCs, debris and bacteria) o Characteristic feature bacterial colonies with radiating striae (rods) projecting into the surrounding neutrophils Treatment: o Antibiotics for 6-8 weeks ": Syphilis " Caused by the spirochaete Treponema pallidum Usually progresses over three stages: primary, secondary and tertiary (if the disease is discovered early and treated properly, the patient may not pass through all of these stages) This infection has now declined significantly thanks to antibiotics (penicillin) Primary syphilis: o Develops usually 2-3 week after the initial exposure to the bacteria o Results in an ulcer referred to as chancre which is characterized by: Usually occurs on genitalia but in minority of patients may present on the oral mucosa (usually the lips) 3/7

Dr. Tahani Abualteen

Shallow painless ulcer Indurated (firm) base Almost always associated with lymphadenopathy Heals spontaneously within 3-6 weeks Microscopically, the ulcer shows an ulcerated granulation tissue with dense mononuclear infiltrate (composed mainly of plasma cells) ** The surface of the ulcer is heavily infected with bacteria and thus transmission of the disease might happen upon touching and examining the ulcer with bare hands Secondary syphilis: o Develops usually about 6 weeks after the appearance of the primary chancre (2-3 months after the initial exposure to the bacteria) o Characterized by: Generalized skin rash is the predominant feature May be accompanied by oral lesions, of which the so-called "mucous patch" is the most frequent ** Mucous patch = flat areas of ulceration Multiple areas of ulceration may coalesce to produce lesions of irregular outline called "snailtrack ulcers" Tertiary syphilis (late-stage syphilis): o Develops usually many years after the initial exposure to the bacteria o May be fatal as disseminates to involve the brain, major blood vessels o Characterized by: Gumma: An area of necrosis associated with delayed type IV hypersensitivity (cell-mediated) reactions to syphilitic antigens Occurs especially on the hard palate leading to perforation into the nasal cavity Histologically, Gumma consists of a central mass of Coagulative necrosis (no pus) surrounded by granulation tissue infiltrated by lymphocytes, plasma cells, macrophages and occasional giant cells. Spirochetes are very little or absent Atrophy and fibrosis of the tongue musculature resulting in breaking up the smooth surface of the tongue by fissures due to endarteritis obliterans (obliteration of arteries ends) The epithelium is now thin and more prone to carcinogens This atrophy may be followed by Syphilitic leukoplakia 4/7

Atrophic glossitis: -

Dr. Tahani Abualteen

Syphilitic leukoplakia: - Hyperkeratosis - A premalignant lesion which may be followed by Sequamous cell carcinoma Sequamous cell carcinoma

Congenital syphilis: o Important cause of miscarriage, stillbirth or neonatal infection o Infected mother will transmit the disease to her fetus since Treponema pallidum has the ability to cross the placental barrier o Characterized by : Collapse of nasal bridge due to infection and destruction of the developing nasal bones producing the saddle deformity of the bridge and the dished appearance of the face Hutchinson triad (Blindness, deafness, dental anomalies) Dental anomalies related to congenital syphilis are caused by infection of the developing tooth germs of the permanent incisors and first molars and they include: - Hutchinson incisors (also called notched teeth, screw-driver teeth): Incisors characterized by central notching of the incisal edge and a tapering "screw-driver" appearance The maxillary central incisors are the most frequently involved Peg shaped laterals (conical and microdontic) Moons or Mulberry molars: Molars characterized by constricted atrophic cups with globular masses of hard tissue on their occlusal surface The first permanent molars are the most frequently involved

Tuberculosis (TB) " ": Caused by mycobacteria, usually Mycobacterium tuberculosis Oral infection is not common, and oral lesions of tuberculosis may present as : o Primary oral infection o Secondary oral infection (associated with coughing-up of infected sputum from pulmonary tuberculosis) and it is a more likely cause of oral lesions Results in an ulcer referred to as "Classical TB ulcer" which is characterized by: o Chronic o Painless o Indurated o Undermined o Covered with grayish-yellow slough o On the tongue

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Other manifestations of Tuberculosis: o Gingival involvement granulomatous inflammation forming exophytic masses or granulating gingival lesions o Tuberculous lymphadenitis most frequently affecting the cervical lymph nodes Diagnosis: o Biopsy, to identify: Granulomas with central necrosis Acid Fast bacilli (either by stain or by culture) o Chest X-ray Treatment: o 2 antimicrobial agents (isoniazide and rifampicin) for 4-8 months Differential diagnoses of a chronic ulcer: 1. Syphilis 2. TB 3. SCC 4. Cytomegalovirus in immune-compromised patients 5. Deep fungal infection Leprosy "" : Caused by mycobacteria, usually Mycobacterium leprae Endemic in tropical areas Two forms of infection exist depending on the immune response of the host to the organism: o Tuberculoid localized infection (good immune response) o Lepromatous widespread infection throughout the body (poor immune response) Oral lesions occur almost exclusively in the Lepromatous type: o Can be identified in 50% of patients o Present as nodular inflammatory granulomatous masses which tend to ulcerate and heal with fibrosis o Hard and soft palates, maxillary anterior Gingivae and the tongue are the most often affected o Oral lesions are usually secondary to nasal involvement Patients may with Lepromatous leprosy may show varying degrees of facial deformity especially in the naso-maxillary complex

Gonorrhea "": Caused by Neisseria gonorrhea The oral mucosa is considered somewhat resistant to this bacterium; however oral lesions do occur in some patients

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Oral lesions are non-specific, present as Erythema, vesicles, ulcers, pain on speaking and swallowing, such lesions have been reported in any part in the oral cavity but mainly the disease results in Tonsillar and soft palatal lesions Granulomatous infections: 1. Actinomycosis: - Endogenous polymicrobial infection - Submandibular swelling - Chronic suppuration - Multiple sinuses draining pus - Sulphur granules in pus 2. Syphilis: - Primary chancre - Secondary snail-track ulcers, mucous patches - Tertiary Gumma, lingual leukoplakia - Congenital Hutchinson incisors, mulberry molars, dished face 3. Tuberculosis: - Oral usually secondary to pulmonary - Painless chronic lingual ulcer 4. Leprosy: - Oral lesions in Lepromatous type - Secondary to nasal involvement - Nodular masses on palate/anterior maxillary gingiva

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