4. Infections and idiopathic conditions of the oral mucosa Flashcards
What is the definition of infection?
Pathological state resulting from invasion of the body by pathogenic foreign species.
Give examples of infective agents apart from bacteria, virus and fungi?
Prions- no nucleic acids
Mycoplasma- no cell wall
Chlamydia- obligate intracellular parasites
Amoeba- Protozoa
Parasites
Name 3 features of viruses?
They do not have their own metabolism so cannot live on their own outside host cells.
Smaller than bacteria.
They have short DNA or RNA molecule, and genomes
What does obligate intracellular parasite mean?
They have their specific hosts and are unable to reproduce outside this host/cell as they do not have their own metabolism. eg. viruses
How do viruses cause damage?
Direct damage by replication, indirect damage by immune system fighting infection
Name 5 ways of detecting viruses?
- Immunofluorescence- detects antigens using specific antibodies
- PCR
- Serology- detects antibodies to viral antigens
- Culture from infected secretions or tissues
- Electron microscopy
What is herpetic stomatitis caused by?
HSV1 and HSV2
How is herpetic stomatitis spread? What age does it affect?
By contact or droplet spread
Common in children and young, but rare in under 6 years old
What is the early phase of infection of herpes simplex like?
May be subclinical and show no symptoms, or mild pharyngitis.
May be symptomatic and show gingivostomatitis.
How long is the incubation period for herpetic stomatitis?
5 days
What features do you get after prodromal symptoms of herpetic stomatitis, and how long does it take?
Occurs 1-2 days after prodromal symptoms
Numerous vesicles appear on mucosa and lips, vesicles ulcerate and can become infected leading to regional lymphadenitis, lesions crust, herpetic whitlow, herpetic keratitis, extra oral lesions on chin due to drooling.
Disappear after 10-14 days.
What is the histology of herpetic stomatitis like?
Empty spaces in the epithelium due to intraepithelial blistering
infected cells undergo ballooning degeneration
cells appear as giant cells as they fuse with neighbouring cells
inflammatory infiltration of epithelium and lamina propria
How does herpetic stomatitis recurrent infection occur?
The viral particle travel from the trigeminal ganglia through axons to nerve endings. They reinfect when in epithelial cells.
What is the most common recurrent infection of herpetic stomatitis?
Herpes labialis- causes lip vesicles after some hours of itching and tingling
What is the appearance of chicken-pox?
Small blisters/ulcers can appear in oral mucosa and soft palate preceding skin rash.
What is chicken pox histologically similar to?
HSV lesions
What is the reactivation of varicella zoster called, and what does it present as?
Shingles- prodromal symptoms followed by unilateral vesicle eruptions, painful, rupture leaving ulcerated areas.
Where is varicella zoster latent?
Sensory ganglia
What is the trigeminal involvement of varicella zoster like?
Mostly opthalmic division
If the 2nd or third division is involved, you can get toothache, facial pain, followed by vesicles
What is the sequel of varicella zoster virus?
Post herpetic neuralgia- when the virus hides in sensory ganglia it can cause fibrosis around the nerves.
What is Ramsay Hunt syndrome?
Occurs when shingles outbreak affects facial nerve- facial paralysis/taste, oral ulceration, external ear neuralgia, tinnitus, vertigo
What is measles caused by? What age group does it affect?
Paramyxovirus. Childhood.
What are the symptoms of measles?
Initially Koplik’s spots- on oral mucosa on labial side against molars - few to 100’s. Disappear when skin rash develops.
Then 1-2 weeks after infection you get prodromal symptoms- fever, cough, conjuctivitis, skin rash.
What infections are caused by Coxsackie type A virus?
Herpangina
Hand, foot and mouth disease
What are the features of herpangina?
Sore throat, dysphagia, fever, headaches, vomiting, abdominal pain
What are the oral features of herpangina?
Small vesicles 1-2mm, on tonsils, soft palate, uvula.
Ulcers with grey base and inflamed periphery.
What do the oral ulcers in herpangina look like?
Ulcers with grey base and inflamed periphery
How long does herpangina last?
2-3 days- self-limiting
What type of itis can you get in Herpangina?
Oropharyngitis
What are the symptoms of hand, foot and mouth disease?
Multiple ulcero-vesicular lesions in palate, tongue, buccal mucosa, skin, hands and feet
How long does hand, foot and mouth disease last?
3-6 days incubation period, infective until rash is gone
What is hand, foot and mouth disease caused by?
Coxsackie A16
How many different types of HPV are there?
Over 200
What are low risk examples of what HPV can cause?
Skin and oral warts- verruca vulgaris
Genital lesions- condyloma acuminatum
What are high risk examples of what HPV can cause?
Papillomas- benign tumours
Leukoplakia- potentially malignant
SCC
Heck’s disease
Cervical carcinomas
What is Heck’s disease?
- high risk effect of HPV
- focal epithelial hyperplasia
What HPV is associated with cervical carcinoma?
HPV 16, 18, 33
What are the features of noma/cancrum oris?
Starts with necrotising gingivitis, extends to lips and cheeks
Rapid gangrene (death and decay of tissues in a living body) of oral-facial tissues in debilitated/malnourished children.
What bacteria is noma/cancrum oris caused by?
Prevotella intermedia
Fusobacterium necrophorum
What is the definition of granuloma?
An organised collection of mature mononuclear phagocytes (epitheliloid cells, macophages) which may or may not be accompanied by accessory features such as necrosis or infiltration of other inflammatory leukocytes.
What is granulomatous inflammation?
Chronic response to antigens that are persistent and irritant
What are the 2 types of granulomas?
Foreign body granulomas
Epitheliloid or hypersensitivity granulomas- cell mediated
What diseases are epithelioid granulomas seen in?
Actinomycosis, syphilis, turberculosis, leprosy
What is actinomycosis?
Granulomatous condition
Involves suppurations that can form anywhere on the body but mostly includes cervicofacial, throacic and abdominal tissues
What bacteria is actinomycosis caused by?
A. israelii- anaerobic, gram positive
What does cervicofacial actinomycosis look like?
Infected tooth socket, root canal, firm swelling and in the middle there is abscess formation which is filled with pus. The pus will discharge to the skin, with sulphur granules.
What is the histology of actinomycosis?
Abscess formation, PMN, granuloma formation at periphery with multinucleated giant cells.
What is the H and E staining of actinomycosis like?
Radiating A israelli colonies stained with haemotoxylin in the centre, and eosin in the periphery, associated with giant cells.
What causes syphilis?
Treponema pallidum- bacteria
How many phases are there of syphilis?
Three
Primary infection- heals in 3 to 6 weeks
Secondary phase- 1.5 to 3 months
Tertiary phase- years
What is the primary infection of syphilis like?
Shallow, painless ulcer with indurated base, affecting genitalia mainly, some in oral mucosa and lips.
Granulation tissue with plasma cell infiltration.
What is the secondary phase of syphilis like?
Occurs 1.5-3 months after primary infection.
Skin rash, mucous patches, ulceration that coalesce- snail track ulcers.
What is the tertiary phase of syphilis like?
Occurs years after secondary infection.
Palate perforation, endarteritis obliterans, atrophic glossitis (smooth surface and fissures), hyperkeratosis, syphilitic leukoplakia, SCC
What is the histology of tertiary phase of syphilis like?
Gumma- coagulative necrosis, granulation tissue, plasma cells, macrophages, giant cells.
What is congenital syphilis?
If a woman is pregnant during the time of her infection, the baby can get mulberry molars (hypo-mineralisation) or Hutchinson’s incisors (notch in incisor)
What is tuberculosis caused by?
Mycobacterium tuberculosis, M bovis
What types of oral tuberuculosis are there?
Primary oral TB- rare
Secondary to pulmonary disease- more common.
What is clinically seen in TB which is secondary to pulmonary infection?
Infected sputum causes painful chronic, undermined ulcers.
Classical ulcers in tongue, covered by greyish-yellow material but might appear in other locations.
What is the histological appearance of TB?
Granulomas- giant cells, epithelioid cells, lymphocytes, caseating necrosis (not always)
What can be used to detect TB in samples?
Acid fast organisms by Ziehl Neelsen method.
What is leprosy caused by?
Mycobacterium leprae
What are the 2 types of leprosy?
Lepromatous widespread infection
Tuberculoid localised infection
Which type of leprosy causes oral features and what are they?
Lepromatous widespread infection
50% oral lesions, secondary to nasal involvement, nodular masses called lepromas in tongue, lips, hard palate. They ulcerate and heal with fibrosis.
Which type of people are erythema migrans most common in?
Those who have psoriasis, stressed, gastic problems, use some toothpastes.
What does erythema migrans appear like?
Lesions in oral mucosa that evolve with time- margins of lesion outlined with white line.
Partial loss of filliform papillae.
What is the histology of geographical tongue?
Neutrophil infiltration in the borders of lesion, chronic infiltrate in the centre and desquamation of epithelium. No candida.
What is orofacial granulomatosis?
A term to describe the common clinico-pathological manifestations of different disorders.
Recurrent or persistent enlargement of lips, cheeks, diffuse swelling
Non-caseating epithelioid granulomas and oedema
What are possible causes of orofacial granulomatosis?
Crohn’s disease, sarcoidosis, granulomatous infections, melkersson-rosenthal syndrome, allergic reactions, idiopathic
Which part of the body does Crohn’s disease commonly affect?
Terminal ileum, but can involve any part of the GI tract
What are non-oral manifestations of Crohn’s?
Abdominal pain, absorption and nutritional deficiencies, anti-diarrhoea
What is the histology of Crohn’s?
Fibrosis and focal infiltration with lymphocytes and plasma cells, lymphoedema, dilated lymphatics, non-caseating (poorly forming granulomas), giant cells can be missing
What are the oral manifestations of Crohn’s?
Swelling of lips and cheeks
thickening of bucco-labial mucosa
cobble stone appearance, polypoid tags
apthous or linear ulcers
glossitis secondary to iron, B12 or folate malabsorption
What is the histology of sarcodosis?
Non-caseating granulomas, no acid fast organisms
What are the symptoms of sarcoidosis?
Bilateral hilar lymphadenopathy
pulmonary infiltration
skin and eye lesions
rare to affect oral mucosa
malaise, cough, arthralgia, shortness of breath
Increased ESR
What is Heerfordt syndrome?
When a pt has sarcodosis along with:-
- fever
- uveitis
- parotitis
- facial paralysis
What are the symptoms of Melkersson-Rosenthal syndrome?
Facial swellings
Unilateral facial palsy
Fissured tongue
Cheilitis granulomatosa
What is amyloidosis and how can it affect the oral cavity?
Deposition of eosinophilic, hyaline (fibrillar) protein in the tissues in any organ.
In the oral cavity it causes macroglossia and gingival enlargement
What does amyloid stain with?
Congo Red or crystal violet
- congo red stains within connective tissue
What are examples of systemic amyloidosis?
Secondary to chronic inflammatory diseases, malignancy, plasma cell dyscrasia
What are examples of local inherited neuropathies amyloidosis?
Familial
CJD
Familial Alzheimer’s disease
What are examples of acquired localised amyloidosis?
Sporadic Alzheimer’s, sporadic spongiform encephalopathies
What does localised amyloidosis mostly affect?
The brain tissue so they present as neuropathies or encephalopathies, leading to degeneration of brain tissues
