20 Infectious stomatitis

Question 1

Impetigo: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis)

Answer 1

Skin infection caused by Strept. pyogenes & Staph. aureus, young children face and extremities, facial lesions usually develop around the nose and mouth, poor hygiene, crowded living conditions, hot & humid climate, Previous trauma, abrasions, insect bites, dermatitis, spread by skin contact, Vesicles that rupture leave light brown “amber” colored crusts “cornflakes glued to surface,” Unlike HSV lesions persist until treated, topical or systemic antibiotics - Mupirocin topica, Cephalexin, dicloxacillin.

Question 2

Scarlet fever: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis often associated with tonsilitis and pharyngitis)

Answer 2

A complication of Strep-Throat - Group A, beta-hemolytic streptococci, children aged 3-12 years, organisms elaborate an erythrogenic toxin that attacks blood vessels, skin rash, fever, palatal petechiae, “strawberry tongue”

Question 3

Rheumatic fever: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis often associated with tonsilitis and pharyngitis)

Answer 3

A complication of Strep-Throat - affects heart, joints, central nervous system, and damages heart valves. Children 5-15. Bacterial or viral in origin: group A, beta-hemolytic streptococci. Tx: Penicillin, amoxicillin, cephalosporin.

Question 4

Syphilis: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis)

Answer 4

Treponema pallidum. Highly infectious. Direct contact with mucosal surfaces. Increased in African Americans, prostitutes and drug abusers. 50-100x higher in US. 1˚ - chancre (painless ulcer at site of inoculation), regional lymphadenopathy. 2˚ - 4-10 weeks later, mucous patches & “snail track” ulcers, Condyloma Lata - maculopapular rash. 3˚ - Gumma - unique necrosis, can be intraorally, glossitis, leukoplakia.

Question 5

What are the characteristics of congenital syphilis?

Answer 5

Frontal bossing, underdeveloped Mx, high arched palate, saddle nose deformity

Question 6

What makes up the Hutchinson’s triad?

Answer 6

1. Intersitial keratitis of cornea 2. 8th nerve deafness 3. Dental abnormalities: Hutchinson’s Incisors (screwdriver-shaped), Mulberry molars

Question 7

Tuberculosis: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis)

Answer 7

Mycobacterium tuberculosis. Acid fast bacillus. Primary infection of lungs. Immunodeficiency contributes to spread. Fever, night sweats, fatigue, weight loss, productive cough, hemoptysis. “Scrofula” - lymph node invovlement. Oral: chronic painless ulceration usually involving tongue or palate, atypical periodontal disease. Biopsy- show granulomas with central areas of necrosis. Tx: Isoniazid & Rifampin

Question 8

Actinomycosis: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis)

Answer 8

Bacterial infection. Actinomyces israelli - normal saprophytic anaerobic inhabitant of oral cavity. History of surgery or trauma. 55% of cases occur in cervicofacial areas. Injury, perio pocket, nonvital tooth, extraction socket, infected tonsil. Abscesses and draining sinus tracts. Colonies of yellow “sulfur granules.” Localized acute infections may be treated more conservatively -removal of infected tissue is sufficient.

Question 9

Necrotizing ulcerative gingivitis: Characteristics, typical population and presentation, etiology and treatment (bacterial stomatitis)

Answer 9

NUG, ANUG, “trench mouth,” Bacillus fusiformis and Borrelia vincetti, high stress, immunodeficiency or malnourished. Young - middle aged, interdental papilla highly inflammed and hemorrhagic, papilla are blunted with “punched out” necrosis that is covered with gray pseudomembrane. Fetid odor & intense pain. Tx: Debridement by scaling or curretage, CHX rinses, antibiotics if fever or lmyphadenopathy is present.

Question 10

Pseudomembranous candisosis: Characteristics, typical population and presentation, etiology and treatment (fungal stomatitis)

Answer 10

Candidiasis - white material that can be wiped off, tangled hyphae, yeasts, dead epithelial cells & debris. Normal or erythematous mucosa underneath, symptomatic, burning sensation to pain. Metallic taste.

Question 11

Erythematous candidosis: Characteristics, typical population and presentation, etiology and treatment (fungal stomatitis)

Answer 11

“Acute Atrophic” candidosis, Painful burning sensation, often associated with antibiotics: “antibiotic sore mouth,” usually affects gingiva, loss of filiform papillae on tongue.

Question 12

Chronic atrophic candidosis: Characteristics, typical population and presentation, etiology and treatment (fungal stomatitis)

Answer 12

“Denture stomatitis, Denture sore mouth,” change limited by mucosa covered by denture and confined to denture bearing tissues. Only Mx and in patients who wear dentures 24hrs/day, asymptomatic to symptoms.

Question 13

Chronic hyperplastic candisosis: Characteristics, typical population and presentation, etiology and treatment (fungal stomatitis)

Answer 13

“Candidal Leukoplakia,” indistinguishable from leukoplakia. White lesion that does not wipe off, biopsy if no resolution with antifungal therapy.

Question 14

Angular cheilitis: Characteristics, typical population and presentation, etiology and treatment (fungal stomatitis)

Answer 14

Candida about 90%, rest caused by Strep or Staph. Erythema or fissuring at labial commissures, Uilat or Bilat. Predisposing factors: reduced vertical dimension and accentuated folds at the corners of the mouth.

Question 15

What are the different deep fungal infections?

Answer 15

Histoplasmosis, Coccidiomycosis, Blastomycosis, Cryptococcis, Aspergillosis

Question 16

What is the subcutaneous fungal infection?

Answer 16

Sporotrichosis

Question 17

What are the opportunistic fungal infections?

Answer 17

Zygomycosis (mucormycosis), Often in immunosuppressed/diabetics, biopsy with tissue staining and culture, systemic antifungal medications

Question 18

Histoplasmosis: Characteristics, typical population and presentation, etiology and treatment (deep fungal stomatitis)

Answer 18

Most cause primary lung invovlement, somer are more common in certain parts of the US, Chronic non-healing intraoral ulcers which can mimic squamous cell carcinoma.

Question 19

What are the characteristics of Human papilloma virus (HPV)?

Answer 19

DNA viruses, over 100 types, most adults have buccal epithelial cells containing at least one type, tends to clear in health patients. Can be difficult to distinguish between the various lesions of HPV

Question 20

Papilloma: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human papilloma viruses)

Answer 20

Usually HPV subtypes 6 and 11. Virus-induced benign proliferation of stratified squamous epithelium. Ages 30-50 years. Tongue, lips and soft palate. White/red/normal color “cauliflower” shaped exophytic nodule, sessile or pedunculated. Usually small but can be as large as 3cm

Question 21

Verruca vulgaris: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human papilloma viruses)

Answer 21

HPV subtypes 2,4,6,40. “Common wart” children, usually on skin of hands, oral mucosa: vermillion border, labial mucosa, anterior tongue. Pink/white nodule with rough, pebbly surface, usually less than 5mm

Question 22

Condyloma acuminatum: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human papilloma viruses)

Answer 22

HPV subtypes 2,6,11,53,54,16,18. Teenagers and adults. Oral mucosa, larynx, genitalia, soft palate, lingual frenum. Sexual transmission or self-inoculation. Incubation 1-3 months. Anogenital condyloma infected with HPV-16 and 18 are associated with increased risk of malignant transformation. Pink to white exophytic mass with short, blunted surface projections. 1-1.5cm as large as 3cm. Often occur in clusters

Question 23

Focal epithelial hyperplasia: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human papilloma viruses)

Answer 23

HPV subtypes 13 & 32. “Heck’s Disease” multiple soft, flattened papules clustered together. Most common in children often malnourished and in poor living conditions. 1st described in Native Americans and Eskimos. Labial, buccal and lingual mucosa. Koilocytes and mitosoid cells.

Question 24

Herpes simplex viruses: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human herpes viruses)

Answer 24

HSV-1 - oral infections, HSV-2 - genital infections/20% crossover. More than 90% of 1˚ infections are asymptomatic. Acute herpetic gingivostomatitis - Very acute in onset, FEVER, painful gingiva, coalescing vesicles progress to widespread, lesions heal in 1-2 weeks. Recurrent Herpes Simples Infection - Occurs in 15-45% of US population, from latency in trigeminal ganglion, stimuli include: old age, UV light, stress, pregnancy, allergy, trauma, illness, dental therap, herpes labialis “cold sore”. Prodromal symptoms of pain, burning and tingling. Herpetic witlow (fingers). Tx: Acyclovir, Famcyclovir, Valacyclovir

Question 25

What do 5-30% of patients have in their saliva?

Answer 25

They will asymptomatically excrete and will have HSV DNA in their saliva.

Question 26

Varicella-zoster virus: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human herpes viruses)

Answer 26

HHV-3. Chickenpox - 1˚ infection usually in children 5-9 years, 10-21 incubation period, erythema - vesicle - pustule - hardened crust on skin and mucous membranes, recovery in 2-3 weeks, VZV vaccine. Herpes Zoster “shingles” - reactivation of VZV, usually in adults, prodromal phase - intense pain, fever malaise, headache, unilateral eruption of vesicles along the distribution of a sensory nerve classically stops at midline, POSTHERPETIC NEURALGIA - may take months to resolve. “Ramsay Hunt Syndrome” - infection of external auditory canal with involvement of the ipsilateral facial and auditory nerves producing facial paralysis, hearing deficits and vertigo.

Question 27

Epstein-barr virus: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human herpes viruses)

Answer 27

Infectious Mononucleosis “kissing disease” - close contact or saliva transmission, sore throat, fever, lymphadenopathy, tonsilitis, fatigue, enlarged spleen, petechiae on hard/soft palate as prodome, presence of heterophil antibody and elevated white blood cell count. Self-limiting in 4-6 weeks, Tx is symptomatic.

Question 28

Hairy Leukoplakia: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human herpes viruses)

Answer 28

White lesion, usually on lateral border of tongue, cannot be wiped off, often associated with candidal infection, EBV can be identified in situ hybridization, PCR, immunohistochemistry and is the cause. Most commony occurs in HIV+ patients.

Question 29

Cytomegalovirus: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human herpes viruses)

Answer 29

HHV-5 Usually affects newborns, common in AIDS patients, bodily fluid transmission, 90% of infections are asymptomatic but can produce a mono-like illness. Can cause serious complications leading to organ failure, blindness, and severe mental and motor retardation. Oral lesions: chronic ulceration, affects endothelial cells and blood flow, can reside latently in salivary gland cells, cells show “owl eye” appearance.

Question 30

HHV-8: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-human herpes viruses)

Answer 30

Causative virus in Kaposi’s Sarcoma. Reddish-purple flat or raised lesions. Orally most commonly on palate, gingiva and tongue. Before advent of AIDS, this was rare and usually seen in men over 60 years. No most cases are associated with AIDS.

Question 31

Coxsackie A virus Characteristics, typical population and presentation, etiology and treatment:

Answer 31

Viral stomatitis - Herpangina, Hand-foot-mouth disease, acute lymphonodular pharyngitis. Usually kids under 5 in epidemics, fecal-oral route, painful vesicles and ulcers intraorally, Herpangina - hyperplastic lymphoid tissue on soft palate and tonsils in acute lymphonodular pharyngitis. Papules on skin of feet/toes, hands, and fingers. Usually resolves in 7-10 days.

Question 32

Measles: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-Paramyxoviruses)

Answer 32

Rubeola - childhood, highly contagious, skin rash, “Koplik’s spots” may be an early intraoral manifestiation - small red patches with white, necrotic centers, MMR vaccine.

Question 33

Mumps: Characteristics, typical population and presentation, etiology and treatment (viral stomatitis-Paramyxoviruses)

Answer 33

See salivary gland pathology.