Oral and Peri-Oral Infections Flashcards
1
Q
Acute pseudomembranous candidosis/Thrush
A
Causes:
5% of newborns affected, elderly population, wearing dentures especially if they are not taken out at night and not kept clean or if they have a poor fit, antibiotics, excessive use of antibacterial mouthwash, inhaled corticosteroids, xerostomia, diabetes mellitus, having severe anaemia, lacking iron/folate/vitb12, immunosuppressant, smoking
Clinical features:
Soft, friable and creamy coloured plaques on the mucosa. They can be easily wiped off to expose an erythematous mucosa. Angular stomatitis is frequently associated.
Pathology:
Gram stained smear shows large masses of tangled hyphae, detached epithelial cells and leucocytes.
Diagnosis:
signs and symptoms, blood test to see if thrush is a secondary condition, biopsy to confirm
Management:
- Topical antifungals: miconazole gel or nystatin or amphotericin lozenges
Failure to respond to topical antifungals such as nystatin suggests immune deficiency
- Systemic antifungals: fluconazole or itraconazole
2
Q
Acute atrophic/Erythematous candidosis
A
- Usually associated with a burning sensation in the mouth/ on the tongue. The tongue may be bright red/similar to that seen with a low serum b12, low folate and low ferritin.
- Angular stomatitis is usually the chief complaint.
- Presents following the use of broad-spectrum antibiotics, inhaled steroids, xerostomia or hIV infection
- Affects hard palate, dorsum of tongue and soft palate. Clinically, there is red shiny atrophic mucosa with co-existing areas of thrush.
- Candida from the tongue touched on the palate - “kissing lesions”
- Treatment: topical miconazole gel or itraconazole nystatin suspension, improve denture hygiene and soak dentures overnight
3
Q
Chronic pseudomembranous candidosis
A
Similar to acute pseudomembranous candidosis but is seen in immunocompromised pts and pts who are taking corticosteroids topically/ by aerosols
4
Q
Chronic atrophic candidosis (denture stomatitis)
A
- Characterised by localised chronic erythema of tissues covered by dentures. Lesions tend to occur on the palate and upper jaw but may also affect mandibular tissue.
- Local risk factors: denture trauma, poor denture hygiene and nocturnal denture wearing
- Systemic risk factors: smoking, diabetes, nutritional deficiencies, immune deficiencies, broad spectrum antibiotics, corticosteroid therapy, high carbohydrate diet, xerostomia and radiotherapy.
- Newton’s types classification of denture stomatitis: type 1 a localised simple inflammation/pinpoint hyperaemia, type 2 an erythematous generalised simple type presenting as more diffuse erythema involving part of or the entire denture covered mucosa and type 3 a granular type (inflammatory papillary hyperplasia) commonly involving the central part of the hard palate and alveolar ridge
- Diagnosis requires removal of dentures and careful infection; swabs may be taken for confirmation. A swab from tongue/buccal mucosa show gram-positive hyphae
- Pts with denture stomatitis should clean their dentures thoroughly and leave them out as often as possible during the treatment period. Dentures should not normally be worn at night and using denture soak solutions containing benzoic acid. Brushing the palate with CHX mouthwash/gel. Miconazole gel can be applied to the fitting surface of the denture before insertion (for short periods only) or nystatin pastilles, amphotericin lozenges/fluconazole administered concurrently with an oral antiseptic such as CHX. Denture stomatitis is not always associated with candiasis and other factors such as mechanical/chemical irritation/bacterial infection/allergy to dental base material may be the cause.
5
Q
Chronic Erythematous candidosis (non-denture related)
A
- Clinical form of C.albicans characterised by localised erythema of the oral mucosa with/without associated symptoms.
- Commonly occurs on the dorsum of tongue and the palate and less commonly the buccal mcusoa.
- Associated with chronic use of broad-spectrum antibiotics and corticosteroids, it is also present in pts with HIV infection.
6
Q
Chronic hyperplastic candidosis (candidal leukoplakia)
A
- Characteristically occurs on the buccal mucosa or lateral border of the tongue as speckled or homogenous white lesions
- Unlike thrush, the plaque cannot be wiped away but fragments can be detached from firm scraping
- Plaque is variable in thickness and often rough/irregular in texture/nodular with an erythematous background (Speckled)
- Angular stomatitis continuous with intra-oral plaques suggests candidate nature of the lesion.
- Association with smoking and complete resolution appears dependent on smoking.
- Can progress to severe dysplasia (especially in speckled lesions) or maliganncy
- Gram/periodic acid shiff staining: candidal hyphae embedded in clumps
- Biopsy si essential
- Treatment: systemic anti fungal such as fluconazole, avoid use of tobacco, treat iron deficiency or upper denture
- The potential for malignant transformation is low but still exists
7
Q
Chronic mucocutaneous candidosis
A
- Causes frequent/chronic fungal infections of the mouth, scalp, skin and nails.
- Types: familial (limited), diffuse type (candida ‘granuloma treatment antibacterial chemotherapy), endocrine candidosis syndrome (endocrine replacement) and late (thymoma syndrome)
- Symptoms: candidal infections develop and recur or persist usually beginning during infancy but sometimes during early adulthood, fungus may cause mouth infections (thrush), infections of the scalp, skin and nails. Membranes lining the mouth, oesophagus, digestive tract, eyelids and vagina may also be infected. It can also cause 1 or more nails to thicken, crack and become discoloured. A disfiguring rash may cover the face and scalp.
- Many people have this disorder: endocrine disorders e.g. underactive parathyroid gland (hypoparathyroidism), diabetes, underactive adrenal glands (Addison’s disease), hepatitis, autoimmune disorder like graves disease
- Diagnosis: blood test, examination of sample under microscope
- Treatment: anti fungal drugs fluconazole, immune globulin sometimes given
- Little potential for malignant change
8
Q
Angular cheilitis/stomatitis (may be bacterial/mixed)
A
- erythematous fissuring at one or both corners of the mouth and is associated with intramural candidate infection, other organisms: staphylococcus/streptococci
- Facial wrinkling at the corners of the mouth and along the nasiolabial fold esp. in older people leads to a chronically moist environment that predisposes to this lesion. This lesion is worse in long term denture wearers because there is resorption of bone on which dentures at rest leading to a reduction in height of the lower face when the mouth is closed.
- Local causes: dry and cracked lips due to improper moisturising care, infection resulting in AC, vitamin B12 iron/zinc deficiency, reduction in vertical face dimension, ill-fitting dentures
- Systemic causes: angioedema, crohn’s, oedema, orofacial granulomatosis, hermangiomas, lymphangioma
- Treatment: eliminate any predisposing factors e.g. denture care, if systemic conditions then run tests. If candida is cause: nystatin pastilles/amphotericin lozenges. If staph aureus is the cause: fusidic acid cream, if mixed infections use miconazole gel
9
Q
Median rhomboid glossitis
A
- Chronic symmetrical area on the tongue anterior to the circumvallate papillae
- Area of depapillation on dorsal surface of tongue in the midline (can be red, white or yellow) and is asymptomatic and is smooth, shiny and symmetrical
- Biopsy shows candida
- Causes: smoking, HIV, corticosteroid sprays, denture wearing
- Diagnosis: pt should undergo blood test to check for haematinic deficiency disease
- Treatment: topical antifungals nystatin pastilles or systemic antifungals fluconazle
10
Q
Human Herpes Viruses that cause oral and peri-oral infections…
A
- Herpes simplex virus (HSV-1&2): acute herpetic gingivostomatitis, herpes labialis
- Varicella zoster virus: chicken pox, shingles
- Ebstein-barr virus: infectious mononucleosis (glandular fever), oral hairy leukoplakia, nasopharyngeal carcinoma, burkitt lymphoma
- Cytomegalovirus
- Kaposi’s sarcoma herpesvirus (previously known as HHV-8)
11
Q
Acute herpetic gingivostomatitis
A
- Grey blisters which rapidly break down form small ulcers, may be present anywhere on the oral mucosa, most frequently involve the gingiva. They can affect the hard palate and dorm of the tongue. Crusted blisters also appear on the circumpolar skin.
- Infection is usually accompanied by febrile illness and bilateral tender cervical lymphadenopathy
- Infection can spread to fingers and conjunctiva
- Symptoms: painful oral sores, fever, halitosis headaches, not being able to swallow
- Transmission via close contact and via saliva
- Resolution within 2-3 weeks, rest, maintaining fluid intake, analgesics and CHX mouthwash to prevent secondary infection. Acyclovir is only beneficial in the early stages of infection during the 1st 24 hours
- Diagnosis clinically, where doubt exists serology performed on samples of acute and convalescent (2-3 weeks after onset of symptoms) blood should reveal a significantt rise in igG antibodies against HSV. Swabs for culture or identification of viral DNA by PCR and smears for cytology may be useful but usually in the early course of the disease
12
Q
Herpes Labialis (cold sores)
A
- After the primary infection, the latent virus can be reactivated in 20-30% of pts to cause cold sores.
- Triggering factors: common cold, febrile conditions, exposure to strong sunshine, menustration, emotional upsets, local irritation such as dental treatment
- Clinical changes follow a consistent course with prodromal paraesthesia or burning sensations then erythema. Vesicles form after an hour/2 usually in clusters along the mucocutaneous junction of the lips but can extend onto the adjacent skin. The vesicles enlarge, coalesce and weep exudate. After 2-3 days they rupture and crust over but new vesicles frequently appear for a day or two only to scab over and finally heal usually without scarring. The whole cycle may take up to 10 days. Secondary bacterial infection may induce impetiginous lesion, which sometimes leaves scars. In immunocompromised pts they may appear as chronic, often dendritic ulcers on the tongue.
- Treatment: Treatment must start as soon as the premonitary sensations are felt. Acyclovir cream 5% is available without prescription and may be effective if applied at this time. Peniclovir 1% applied 2 hourly is more effective in the prodrome.
13
Q
Varicella zoster virus - Chicken pox (non-immune children)
A
- May produce lesions on the oral mucosa, especially the soft palate and fauces which may precede the characteristic skin rash. The oral lesions usually present as small ulcers. Symptoms: nausea, aching, loss of appetite, itchy painful rash all over the body, oral sores
- Diagnosis: based on signs and symptoms, check MH, blood test to check for acute antibody response
- Management: quarantine to prevent the spread and paracetamol to relieve the fever
14
Q
Varicella-zoster virus - shingles (affects elderly due to reactivation of latent virus)
A
- Clinical features: usually affects adult of middle age or over but occasionally even attacks children. The 1st signs are pain and irritation/tenderness in the dermatome corresponding to the affected ganglion. Vesicles often confluent form 1 side of the face and in the mouth up to the midline. Regional lymph nodes are enlarged and tender. The acute phase lasts a week. Pain continues until the lesions crust over and starts to heal but secondary infection may cause suppuration and scarring of the skin. Malaise and fever are usually associated. Pts are sometimes unable to distinguish the pain of trigeminal zoster from severe toothache
- Diagnosis: based of clinical features, the rising titre of VZV-specific IgM antibody in blood confirms the diagnosis but is ineffective during the dormative phase, lymph collected from a blister is tested by PCR for VZV DNA/examined with an electron microscope.
Management: oral acyclovir 800mg 5x daily usually for 7 days with analgesics. Prednisolone may accelerate the relief of pain and healing. In immunodeficient pts, intravenous acyclovir is required and may be justified in the elderly in whom this condition is debilitating.
15
Q
Ebstein barr virus - infectious mononucleosis (glandular fever)
A
- Clinical signs and symptoms: fever, malaise, weight loss, pharyngitis, cutaneous rashes and cervical lymphadenopathy.
- Common in children and young adults, transmitted via saliva. Sometimes referred to as ‘kissing disease’
- Diagnosis: lab tests - paul bunnel test, monospot test, specific test for EBV capsid antigen
- Treatment: analgesics and antipyretic like paracetamol/ibuprofen, good hydration, corticosteroids to relieve upper airway obstruction by decreasing the size of tonsils and lymph nodes in the oropharynx such as prednisolone
