Infectious diseases of the oral mucosa Flashcards
Gives examples of infectious diseases found in the oral mucosa
fungal - caniddia
viral
bacterial
Give examples of viral infections which can affect the oral cavity
Herpes simplex
Varicella Zoster
HIV
Hep C
Coxsackie virus
examples of bacterial infections which can affect oral cavity
sti’s
- syphillis
- gonorrhoea
- chlamydia
- tuberculosis
oral candidosis - define
infection of mucosa caused by candida species
Candida - features
can harmlessly colonise mucocutaneous surfaces
can invade deeper tissues and cause infection if conditions are right
- opportunistic infection
Local oral defences against disease
oral mucosa
- physical barrier
- innate immunity - lysozyme, T cells, phagocytes
oral microbiome
- competition and inhibition
saliva
- mechanical cleansing
- antimicrobial peptides - muffins, defensives, histamines
- IgA antibodies
systemic defences against disease
immune system
- adaptive immunity
oral candidosis local risk factors
xerostomia
poor oral hygiene
dentures
smoking
mouth piercings
irradiation to the mouth or salivary glands
inhaled/topical corticosteroids e.g. asthmatics
systemic risk factors for oral candidosis
extremes of age
- neonates, elderly
malnutrition
diabetes
HIV/AIDS
Haematinic deficiency
broad-spectrum antibodies
chemotherapy
haematological malignancy
candida infections - management
investigate and manage predisposing factors
- systemic disease
- smoking
- dry mouth
- steroid inhaler
- denture hygiene
oral hygiene
- toothbrushing
- dentire hygiene
topical antifungals
- miconazole oral gel
- nystatin oral mouthwash
systemic antifungals
- fluconazole capsules
Miconazole oral gel contraindications (same as fluconazole capsules)
warfarin
- increases anti-coagulant effect
stations
- risk of rhabdomylosis and myopathy with some statins
oral candida infections that appear white
- acute pseudomembranous candidosis
- chronic hyperplastic candidosis
oral candida infections that appear red
denture-related stomatitis
acute erythematous candidosis
median rhomboid glossitis
angular chelitis
Acute pseudomembranous candidosis features
‘thrush’
- white flecks resemble breast of thrush bird
commonly seen in neonates
in adults - “disease of the diseased”
acute pseudomembranous candidosis appearance
white slough on mucosa surface
- easily wiped off
underlying erythematous base
acute pseudomembranous candidosis diagnosis
usually clinical
- over diagnosed?
microbiology investigations
- oral rinse or swab
acute pseudomembranous candidosis (oral thrush) management
predisposing factors need to be investigated and dealt with
oral hygiene
topical
- miconazole oral gel
- nystatin oral mouthwash
systemic if topical ineffective or infection is extensive or severe
- fluconazole capsules
chronic hyperplastic candidosis features
candidal leukoplakia
potentially malignant disorder
- up to 12.1%
chronic hyperplastic candidosis clinical signs (candidal leukoplakia(
usually occur on buccal mucosa
- at labial commissure/corner of the mouth
often bilaterally
white or speckled red/white appearance
can occur on tongue - less common
chronic hyperplastic candidosis diagnosis
incisional biopsy with PAS stain
- is there dysplasia?
Why would you give fluconazole before a biopsy for a patient with chronic hyperplastic candidosis?
to allow pathologist to see potential dysplasia more clearly
fungal-related inflammation can give false positives for dysplasia
chronic hyperplastic candidosis management
predisposing factors - treat
systemic antifungal
stop smoking
careful clinical follow up in oral med clinic or GDP
- management of dysplasia as required
denture-related stomatitis features
candida infection of mucosa beneath a dental appliance
common in patients in care facilities
- elderly, dry mouth, high sucrose diet, poor OH
common upper complete denture
- micro-environment
Denture-related stomatitis - how does this occur?
candida in 90% of cases
- mixed infections occur - staph, strep
acrylic resin and soft liners = good habitat for candidal adherence
denture trauma potentiates infection
overnight denture wear cultivates biofilm
denture-related stomatitis - diagnosis
clinical diagnosis
- but if not resolving, investigate pre-disposing factors
denture related stomatitis clinical signs and symptoms
pain or discomfort
bad breath
dryness
burning sensation in mouth
redness
denture related stomatitis - classification
Newtons’s classification
1 - localised inflammation (pinpoint)
2 - generalised erythema covering denture-bearing area
3 - granular type
denture-related stomatitis management
denture hygiene
- remove dentures at night
- gentle daily brushing - before and after soaking, after meals with denture cleaning solution (not toothpaste)
- chlorhexidine immersion (for 20 minutes)
- dilute hypochlorite immersion
- microwave disnfection
- alkaline peroxide
re-make if required
brushing palate
antifungals
- if other measures fail
- miconazole gel can be applied to fitting surface before denture insertion
-
acute erythematous candidosis clinical features
aka atrophic candidosis
most commonly presents with associated ‘burning’
palate most commonly affected
acute erythematous candidosis predisposing factors
recent broad spectrum antibiotics
corticosteroids
diabetes
HIV
nutritional factors
acute erythematous candisosis diagnosis and management
diagnosis
- clinical
- oral rinse or swab
management
- medical referral
- topical antifungal
- systemic antifungal
median rhomboid glossitis features
posterior aspect, midline of tongue dorsal
sometimes a kissing lesion on the palate
depapillation in a regular shape
median rhomboid glossitis risk factors
smoking
steroid inhaler
median rhomboid glossitis diagnosis and management
diagnosis
- clinical
management
- predisposing factors
- oral/denture hygiene
- topical or systemic antifungal
what is angular chelitis?
infection of mucocunatneous region around corners of the mouth
- often associated with dermatitis
mixed infection
- candida
- staph and streptococcus
often have associated intra-oral infection
- denture induced stomatitis
angular chelitis signs and symptoms
soreness
erythema
fissuring
crusting
bleeding
at corners of mouth
the role of mechanical factors in angular chelitis
ageing
edentulous
dentures lacking vertical height
all encourage saliva pooling
angular chelitis diagnosis
usually clinical diagnosis
swab for microbiology (culture and sensitivity)
angular chelitis management
predisposing factors
- may require new dentures
- underlying disease or deficiency?
denture hygiene
OHI
topical antifingal - miconazole cream - effective against fungus and some bacteria
topical antibacterial - sodium fusidate ointment
- when clearly bacterial in nature e.g. non-denture wearer
Angular chelitis management -if there is significant associated dermatitis
combined miconazole and hydrocortisone cream/ointment
- cream if wet surface
- ointment if dry surface
human herpes virus features
family of DNA viruses
transmitted in saliva, respiratory secretions, direct contact
often encountered early in life
characterised by latency and re-activation, when immunity drops
HSV1. and HS2 infection features and stages
herpes simples
1 - oral
2 - anogenital
primary infection
- lesions mouth, oropharynx, anogenital regions
latency
reactivation during relative immunosuppression
primary herpetic gingivostomatitis symptoms
fever
malaise
red, fiery oedamatous gingiva
grey vesicles which break down to form ulcers
primary herpetic gingivostomatitis is caused by…
initial infection of HSV1 or HSV2
primary herpetic gingivostomatitis diagnosis
diagnosis
- clinical and history
- viral swab for PCR if uncertain (compliance)
primary herpetic gingivostomatitis management
largely supportive
- fluids
- soft diet
- chlorhexidine to prevent secondary infection of oral lesions
- difflam mouthwash
- paracetamol
When would urgent specialist care with systemic antivirals be indicated for primary herpetic gingivostomatitis patients?
in pregnant women and neonates
recurrent herpes simplex virus features
15% population
usually lips
- herpes labials - cold sore
- but can occur intraorally
Factors which can cause reactivation of HSV
sunlight
- UV radiation
unwell
- fever
tissue injury
stress
immunosuppression
hormones
- menstrual cycle
recurrent herpes simplex virus stages
prodromal period
- pain, burning, tingling, itching
- up to 48 hours before
herpes labialis and/or intra-oral hepres
typically crops of of ulcers
- painful
- scab within 72 hours
- resolution by 10 days
recurent herpes simplex virus diagnosis
mostly clinical
recurrent herpes simplex virus management
avoidance of triggers
antivirals in prodrome period
- acyclovir 5% cream every 2 hour (herpes labialis)
- acyclovir 200mg tablets 5x per day for 5 days (intra-oral herpes)
immunocompromised - specialist referral
recurrent HSV potential complications
disseminated herpes infection
- if immunocompromised
Bell’s palsy
erythema multiforme
herpetic whitlow
- fingers
eye disease
- herpetic keratoconjuctivitis
Varicella-zoster virus features
varicella = chicken pox
- primary infection in children
latency
- in dorsal root ganglion
zoster = shingles
- reactivation - usually adults
varicella signs and symptoms
mainly children
- complication risk in adults
highly contagious
- via respiratory droplets or lesion
fever
malaise
truncal rash
- itch, papules, vesicles, scabs
oral ulcers
varicella management
supportive
referral to specialist care in pregnant women, neonates and immunocompromised patients
zoster features
zoster = belt
recurrence of varicella zoster virus
classically in one sensory dermatome
- trigeminal divisions = face and oral cavity
usually in elderly and immunocompromised
zoster - signs and symptoms
rash in one dermatome - scabs
pain before, during and after lesions
vesicles and ulcers intra-orally
what is a dermatome?
a specific area of skin connected to a single spinal nerve root
zoster diagnosis
clinical
zoster management
acyclovir 800mg tablets
- within 72 hours of onset
- can help healing and minimise post-herpetic neuralgia
refer all patients to GP
immunocompromised = refer to specialist
zoster potential complications
post herpetic neuralgia
- persisting >6 months after mucocutanous healing
burning pain
- treat with gabapentin, amitriptyline or carbamazepine
Ramsay Hunt syndrome
- reactivation within geniculate ganglion
- facial nerve palsy and vesicular rash around ear
- oral vesicles
Epstein Barr virus features
90-95% of population have been infected
transmission in saliva
- “the kissing disease”
establishes latency in lymphoid tissue - primarily B cells
diseases linked to Epstein bar virus
oral hairy leukoplakia
burkitt’s lymphoma
nasopharyngeal cancer
Oral hairy leukoplakia features
Associated with HIV patients when CD4 cell count drops
- also seen in chemotherapy and leukaemia patients
affects lateral aspect of tongue
- warty ridged or smooth white plaques
HIV features
human immonodeficiency virus
RNA virus - blood borne
- sexual transmission, needle stick injuries, splashes, vertical transmission
enters and destroy CD4 T helper cells
increasingly immunocompromised as disease progresses
AIDS - acquired immunodeficiency syndrome
- end stage of untreated disease
HIV treatment
very effective
ART
- antiretroviral therapy
- halt HIV replication
- normal CD4 count and undetectable viral load
- can cause oral hyperpigmentation
PrEP
PEP
HHV 8 diagnosis and management
diagnosis
- incisional biopsy
management
- excision
- treat underlying immonosupression
- cryotherapy
- chemotherapy
oral AIDS defining illnesses
oral candidosis
acute necrotising ulcerative gingivitis
kaposi sarcoma
oral hairy laukoplakia
non-hodgkin’s lymphoma
aphthous-like ulcers
hepatitis C virus features
RNA virus
- infects liver
- chronic infection
spread by blood and body fluids
no vaccine available
curable
- with antiviral medications 8-12 weeks
hepatitis C complications
liver cirrhosis
- dental implications
hepatocellular carcinoma
Coxsackie virus features and oral presentations
family of RNA viruses
spread faecal-oral route and saliva
oral presentation
- hand, foot and mouth disease
- herpangina
Hand foot and mouth disease features and symptoms/signs
common
- young children mainly nursery
- clusters
7-10 days
systemic
- fever
- reduced appetite
- malaise
hand
- vesicles/blisters on palms
feet
- vesicles/blisters on soles
mouth
- vesicles/uclers on labial, buccal and tongue mucosa
herpangina clinical signs
numerous vesicles and ulcers
- soft palate
- uvula
- fauces/throat
coxsackie virus diagnosis and management
clinical diagnosis
management
- supportive
- fluids
- paracetamol, ibrupforen
- soft diet
- chlorhexidine to aid oral hygiene
- difflam/benzydamine mouthwash
oral Bacterial infections origins
odontogenic or salivary
- periapical
- periodontal
- pericoronal
- bacterial sialadentis
- STI’s - syphillis, gonorrhoea, chlamydia
- Tuberculosis
Sexually transmission infections - management
refer/signpost
- sexual health clinic
- GP
STI risk factors
previous sti
under 25 years of age
a new sexual partner
more than one sexual partner in the last year
no condom use
paying for sex
socioeconomic deprivation
Chemsex
syphillis features
multi-system disease
- aphthous stomatitis, traumatic ulceration, oral cancer, vesiculobullous disorders
primary, secondary and tertiary
primary syphilis features and signs
chancre at site of inoculation
painless ulcer
usually genital but can be oral
self limiting
- heals by 8 weeks
associated lymphadenopathy in 80%
if untreated, infection spreads lymphoedema’s-vascular
secondary syphilis features and signs
4-6 weeks after initial infection
non specific symptoms
- lethargy
- malaise
- fever
- rash
- musculoskeletal pain
mucosal white patches
‘snail track’ ulcers
tertiary syphilis signs and features
progression from untreated infection
presents 1-30 years after inoculation
granulomatous inflammation
neurosyphilis
- dementia
- cranial nerve palsies
cardiovascular syphilis
- aortic aneurysms
syphilis diagnosis
incisional biopsy
blood test
- high false positives
syphilis management
by sexual health specialist
screening for other STI’s
contact tracing
STAT dose of IM benzylpenicillin
gonorrhoea and chlamydia features and symptoms
sexually transmitted infections
primarily affected urethra, endocervix, rectum and pharynx
- can be asymptomatic
male
- urethral discharge, pain or burning sensation when urinating (dysuria)
female
- altered vaginal discharge, dysuria
Gonorrhoea and chlamydia oral presentation
non specific
uncommonly reported
pharyngitis
Gonorrhoea and chlamydia diagnosis
clinical - oral
specialist
- vulvoanginal or urethral swabs
gonorrhoea and chlamydia management
by sexual health clinic
gonorrhoea
- STAT dose of IM ceftriaxone
chlamydia
- 8 days oral doxycycline
screening for other STI’s
contact tracing
bacteria responsible for tuberculosis
mycobacterium tuberculosis
Tuberculosis - how it infects people
transmission through respiratory secretions
infects macrophages in lung
- can disseminate via bloodstream to almost any organ
tuberculosis signs and symptoms
fever
weight loss
night sweats
cough
haemoptysis
- coughing up blood
tuberculosis risk factors
close contact with TB patient
born in high-prevalence regions
- india, pakistan, somalia, eritrea, Romania
HIV
diabetes
leukaemia
alcohol excess
socio-economic deprivation
homelessness
tuberculosis oral manifestations
ulceration
lip swelling
granulomatous inflammation
- also seen in Crohn’s and orofacial granulomatosis
tuberculosis diagnosis (oral)
incisional biopsy
- H and E staining
- Ziehl - Neelsen stain
tuberculosis management
specialist
- combination antibiotics for 3-6 months
possible investigations for infectious oral mucosal diseases
Blood
- FBC
- Haematinics
- HbA1c glucose
- blood borne virus screen
imaging
- clinical photographs
saliva
- unstimulated saliva flow rate
microbiology
- swab of lesion
- oral rinse
biopsy
- H and E staining
- PAS staining - candida
- Ziehl-Neelssen stain - TB
