Oral Bacterial and Fungal Infections Flashcards

Question

Butterfly pattern similar to that seen in lupus erythematosus is visible on the face, especially the malar area, over the bridge of the nose in this disease...

Answer 1

Erysipelas ** Note: the butterfly pattern may also extend onto the labial mucosa

Answer 2

* Edematous, hot, shiny, red, tender, slightly elevated plaque * May be an orange peel texture due to involvement of superficial lymphatics * Butterfly pattern on face * May have fever, chills, malaise

Answer 3

* NUG (necrotizing ulcerative gingivitis) * NUP (necrotizing ulcerative periodontitis) * Necrotizing stomatitis Note: They are similar clinically, histologically, and bacteriologically. They differ in underlying systemic factors and extent of necrosis.

Answer 4

Gingiva with no loss of perio attachment

Answer 5

Gingiva, PDL, and alveolar bone

Answer 6

Progression beyond the mucogingival junction

Answer 7

* Microorganisms * Reduced host resistance * Atypical reaction to microorganisms

Answer 8

Necrotizing Ulcerative Gingivitis (NUG)

Answer 9

* Treponema spp. * Selenomas spp. * Fusobacterium sp. * B. melaninogenicus ss intermedius (Prevotella intermedia)

Answer 10

Heterogeneous bacterial types

Answer 11

* Presence of spirochetes and fusobacteria is not evidence of primary etiologic importance. * They occur in healthy mouths and mouths with "ordinary" gingivitis and chronic periodontitis.

Answer 12

• Liberated by large masses of gram-negative bacteria • May cause tissue destruction both by direct toxic effects and indirectly by activating and modifying host responses - Indirectly, endotoxins may act as antigen and elicit immune reactions --> activate complement and release chemotoxins --> activate macrophages and lymphocytes --> interfere with cytokines they produce

Answer 13

``` • NUG • It was common in WWI when solders were exposed to: - Smoking - Local trauma - Poor oral hygiene - Poor nutrition - Lack of sleep - Recent illness ```

Answer 14

* Microorganisms * Impaired local and systemic host resistance are of major importance in this disease * Stress: steroid hormones --> alter T4/T8 ratios --> decreased neutrophil chemotaxis & phagocytosis * HIV infection is by far the most important predisposing systemic disease * Measles, chicken pox, tuberculosis, malaria, and infectious mononucleosis are important in some cases

Answer 15

* Primary herpetic gingivostomatitis | * Desquamative gingivitis (MMP etc)

Answer 16

There is non-specific intense inflammation covered by coagulation necrosis and colonies of microorganisms.

Answer 17

* Debridement * Rinses * Antibiotics * Treat any underlying disease

Answer 18

Chlorhexidine, available commercially as Peridex

Answer 19

``` • Metronidazole - Used against a wide range of anaerobic bacteria and protozoa • Tetracycline • Penicillin • Erythromycin ```

Answer 20

* After appropriate therapy, NUG usually resolves more rapidly than most forms of periodontal disease. * NUG may develop into NUP or necrotizing stomatitis.

Answer 21

• Gingivae intially red (hyperemic) and painful. - Linear gingival erythema • Later, punched out erosions of interdental papillae • Covered by grey necrotic pseudomembrane • Ulcerations spread along gingival margin

Answer 22

The zone between the marginal necrosis and unaffected gingiva may exhibit a well demarcated narrow erythematous zone, sometimes designated as "linear erythema"

Answer 23

* Red band gingivitis * Bleeding and pain * In HIV infection * Chronic candidiasis infection?

Answer 24

There is no loss of periodontal attachment (which occurs when NUG develops into NUP).

Answer 25

* Powerful odor | * Fever, malaise, lymphadenopathy, etc.

Answer 26

* Similar clinical presentation to NUG, but also loss of clinical attachment and alveolar bone. * Destructive form of periodontitis. * Gingival ulceration and necrosis with rapidly progressing loss of periodontal attachment.

Answer 27

* Rapid rate of attachment loss (loss of alveolar bone) | * Lack of response to conventional perio treatment

Answer 28

* Edema * Severe pain * Spontaneous hemorrhage

Answer 29

• Deep pockets are not seen because gingival necrosis coincides with alveolar bone loss

Answer 30

necrotizing stomatitis

Answer 31

* Failure to respond to standard treatment for chronic periodontitis suggests underlying disease. * Debridement requires removal of necrotic tissue and extensive providone-iodine irrigation * Antimicrobial therapy: chlorhexidine rinses with metronidazole in severe cases * Follow-up care and long-term maintenance are essential

Answer 32

* Noma | * Cancrum oris

Answer 33

* A rapidly progressive polymicrobial opportunistic infection caused by normal oral flora that become pathogenic during compromised immune status. * A destructive, necrotizing often fatal condition dominated by the same mixed fusospirochetal flora mentioned in NUG

Answer 34

The mechanism for massive necrosis has not been fully elucidated, but the bacteria appear to induce an uncontrolled release of cytokines.

Answer 35

* It occurs mainly in developing countries, especially in children with malnutrition and systemic diseases. * Occasional cases occurred in association with AIDS in this country. * The concept that it always develops from pre-existing NUG has been challenged.

Answer 36

* NUG | * necrotizing ulcerative mucositis

Answer 37

Necrotic zones may also occur in soft tissue not contiguous with gingivae, especially in areas of trauma

Answer 38

``` • There are extensive areas of discolored necrotic tissue • Initially, destruction involves soft tissue but it may spread into bone, causing osteomyelitis. • Necrosis does not follow tissue planes but spreads through anatomic barriers such as muscles. • Common manifestations include: - severe pain - fetid odor - fever - malaise - tachycardia - increased respiratory rate - anemia - leukocytosis - regional lymphadenopathy ```

Answer 39

``` Distant sites: • scalp • neck • ear • perineum • vulva ```

Answer 40

An ulcerative pharyngitis, which may occur with NUG but is more often separate from it.

Answer 41

* Local wound care * Penicillin and metronidazole * Control of underlying disease

Answer 42

An antibiotic against a wide range of anaerobic bacteria and protozoa

Answer 43

1. Necrotizing ulcerative periodontitis 2. Necrotizing ulcerative gingivitis 3. Necrotizing stomatitis 4. Linear gingival erythema (probably a form of candidiasis) Note: there may be altered host immunity in addition to diminished resistance

Answer 44

* Borrelia * Gram-positive cocci * beta-hemolytic streptococci * C. albicans * Cytomegalovirus

Answer 45

* Primary * Secondary * Latency * Tertiary * Congenital

Answer 46

• Men who have sex with men

Answer 47

* T. pallidum penetrates intact mucosa * In hours, enters lymphatic & blood vessels * Causes systemic infection and metastatic foci (but not clinical disease) long before primary lesions appear.

Answer 48

* Chancre at site of inoculation, some weeks after exposure * Erythematous macule --> Papule --> Indurated nodule --> Central crater * +/- pain * Regional lymph nodes painful and enlarged

Answer 49

~ 2 to 6 weeks

Answer 50

T. pallidum

Answer 51

Antibodies appear 1 to 4 weeks after chancre.

Answer 52

* Spiral T. Pallidum is too thin to be seen with conventional stains on smear or biopsy. It can be seen with silver stains, dark-field examination and immunofluorescent techniques. * Only immunofluorescence is reliable in the mouth because other spiral organisms are present. Specific immunofluorescence antibody demonstrates T. Pallidum T. Pallidum in smear or tissue. * Non-specific serologic screening tests are positive after 3 weeks but negative during the latency period. * Specific serologic tests are positive throughout life.

Answer 53

* Venereal Diseases Research Laboratories (VDRL) | * Rapid plasma regain (RPR)

Answer 54

* Fluorescent treponema antibody absorption (FTA-ABS) | * T. Pallidum hemagglutination assays (TPHA)

Answer 55

• Histology is not specific • Probably an immune response to T. pallidum • Proliferative endarteritis in all stages: - Endothelial proliferation and hypertrophy - Intimal fibrosis - Perivascular lymphoplasmacytic infiltrate

Answer 56

• Chancre surface epithelium ulcerated • Lamina propria: - Increased vascularity - Dense plasma cell & lymphocyte infiltrate in perivascular pattern

Answer 57

* Usually multiple lesions * May appear before chancre resolves * Mucous patches. Mucosa appears grey-white due to intense exocytosis and spongiosis. Necrosis of this epithelium produces an ulceration which is irregular in outline. It is surrounded by erythema. They may be multiple and sometimes painful. "Snail-track" ulcers are confluent mucous patches. * Papules (some of which are "split papules") * Condyloma lata are papules which enlarge to become red-brown, broad based elevations having a flat top with a lobulated or warty surface. They are up to 3 cm in diameter. The surface exhibits papillary epithelial hyperplasia. The connective tissue shows endarteritis obliterans and perivascular cuffing with plasma cells. It is teeming with spirochetes. * Lues maligana occurs in immunocompromised cases. There are necrotic ulcerations on the face and scalp. The oral cavity is affected in up to 30% of cases.

Answer 58

* Mucosa appears grey-white due to intense exocytosis and spongiosis. * Necrosis of this epithelium produces an ulceration which is irregular in outline. * It is surrounded by erythema. * May be multiple and sometimes painful * "Snail-track" ulcers are confluent mucous patches.

Answer 59

* Papules which enlarge to become red-brown, broad based elevations * Flat top and lobulated or warty surface. * Up to 3 cm in diameter. * Surface exhibits papillary epithelial hyperplasia. * Connective tissue shows endarteritis obliterans and perivascular cuffing with plasma cells. * Teeming with spirochetes

Answer 60

* Occurs in immunocompromised cases * Necrotic ulcerations on the face and scalp * Oral cavity is affected in up to 30% of cases

Answer 61

* 1 to 30 years | * The tertiary stage occurs in 1/3 of patients

Answer 62

* Surface ulceration with peripheral pseudoepitheliomatous hyperplasia * Underlying necrotizing granulomas * Organisms very difficult to identify

Answer 63

* Oral gummas start as small, firm, painless nodules, most in the palate or tongue. * Lesions are rubbery due to a semi-firm type of necrosis. This results in ulceration which may heal after several months. * Interstitial glossitis is thought to be result of contracture of lingual musculature after healing of gummas. Lobulated and irregular lesions may reach several cms in diameter. * Sometimes, the necrotic tissue in the ulcer base sloughs away leaving a punched-out defect. In the palate, this may produce an oro-nasal fistula. * Syphilitic (luetic) glossitis presents as a smooth, bald (depapillated) on the dorsum of the tongue with areas of leukoplakia. Microscopically, there is diffuse epithelial atrophy, loss of lingual papillae and hyperkeratosis. Surface epithelial premalignant and malignant changes are far less common than in the past due to the decline in late stage syphilis. (Arsenical agents and heavy metals used to treat syphilis before antibiotics may have caused some of the earlier cancers)

Answer 64

* Small, firm, painless nodules, most in the palate or tongue. * Lesions are rubbery due to a semi-firm type of necrosis. Ulceration may heal after several months.

Answer 65

* Thought to be result of contracture of lingual musculature after healing of gummas. * Lobulated and irregular lesions may reach several cms in diameter. * Sometimes, the necrotic tissue in the ulcer base sloughs away leaving a punched out defect. * In the palate, this may produce an oro-nasal fistula. * Microscopically, there is surface ulceration with peripheral pseudoepitheliomatous hyperplasia and underlying necrotizing granulomas. Organisms are very difficult to identify.

Answer 66

* Smooth, bald (depapillated) on the dorsum of the tongue with areas of leukoplakia * Microscopically, there is diffuse epithelial atrophy, loss of lingual papillae, and hyperkeratosis. * Surface epithelial premalignant changes are far less common than in the past due to the decline in late stage syphilis. (Arsenical agents and heavy metals used to treat syphilis before antibiotics may have caused some of the earlier cancers.)

Answer 67

* Hutchinsonian teeth * Abnormal facies: frontal bossing, saddle nose, small maxilla, rhagades (linear scars or furrows at corners of mouth and nose due to secondary bacterial infections of early facial skin lesions). * Nerve deafness * Optic atrophy * Corneal opacities (due to past interstitial keratitis) * TRIAD: eyes, ears, and teeth

Answer 68

* Enamel hypoplasia of permanent teeth which start to calcify during first year. * Hutchinson's incisors: small, barrel-shaped, tapered towards incisal edge which is notched. * Moon molars: dome-shaped crown * Mulberry molars: narrow crown with multiple small nodules ("cusps")

Answer 69

* Extrapulmonary lesions are more likely to occur in AIDS patients than in others. * Usually 2nd to pulmonary disease. * Dissemination via infected sputum. * Occasionally lymphohematogenous (exogenous is exceedingly uncommon). * Oral mucosal lesions: irregular, indurated erythematous or ulcerated nodules which are often painful. * Osteomyelitis: hematogenous or due to entry, via a tooth, into periapical tissues, and then into bone. * Cervical lymph nodes are the most common site in the head and neck.

Answer 70

• Mycobacterial lymphadenopathy of oropharyngeal and cervical nodes. • Nodes may caseate with sinus tracts • Nontuberculous mycobacterial infection - Usually from contaminated milk

Answer 71

* Mycobacteria leprae which is tropic for histiocytes and Schwann cells. It was believed to localize in cool sites, but that concept has been challenged. * Involvement of Schwann cells leads to sensory loss. * Exposure to Mycobacteria leprae rarely causes disease because the organism has low infectivity.

Answer 72

* Paucibacillary (tuberculoid): hypersensitivity to the organism. Occurs in patients able to mount a strong immune response. It is much more localized than the lepromatous form. This is a granulomatous inflammatory response. Limited number of well-circumscribed nodules. * Multibacillary (lepromatous): this occurs when there is reduced cell-mediated immune response. Organisms proliferate in huge foamy histiocytes (Lepra cells). Clinically, there are many poorly-demarcated macules, plaques, and nodules.

Answer 73

* Face: Leonine appearance due to sagging skin (caused by coalescence of nodules). Also loss of eyebrows and pendulous earlobes. * Nose: collapse of nasal bridge and perforation of palate. * Oral: nodules (lepromas) which are red or yellow, hard or soft, sessile, often ulcerated. They heal by scarring, which results in microstomia. There is destruction of the premaxilla, odontodysplasia leprosa (in children), loose teeth, and gingival hyperplasia.

Answer 74

• Demonstration of acid-fast organisms in smear or tissue sections.

Answer 75

Cure can be achieved by a 3-drug combination (rifampin, dapsone, and clofazimine) for 2 years. There are now fewer than one million cases world wide.

Answer 76

* This is a clinical syndrome caused by a group of anaerobic, gram positive, filamentous, branching higher bacteria. * Actinomyces israeli is the most common cause in humans. * Sulfur granules are 1 to 4 mm, firm yellow granules which represent bacterial colonies. They drain in pus from multiple sinuses in infected sites but are also found in healthy mouths in tonsillar crypts, plaque, calculus, necrotic pulps. * The disease occurs when the bacteria penetrate deeper tissues.

Answer 77

* Culture (positive in only 50% of cases) or by finding typical colonies in inflammatory lesions. * Each actinomycosis species is identified by fluorescein-isothiocyanate species specific conjugate antisera. * Histology: acute suppurative inflammation with colonies which consist of central basophilic mycelium with peripheral radiating eosinophilic filaments ("ray fungus") * Colonies are surrounded by suppurative necrosis, numerous white blood cells including pmn's, foamy macrophages, occasional giant cells, granulation tissue and fibrosis.

Answer 78

* 60% of all cases are cervicofacial. * Portals of entry are deep soft tissue trauma, caries/P.A.P., and tooth extractions. * Classical presentation: several woody (fibrotic) circumscribed swellings which eventually break down, forming a central softer abscess and discharging yellow fluid with sulfur granules via sinus tracts. * Initially, soft tissue is involved more often than bone, but osteomyelitis may develop. Radiographs may show ill-defined areas of radiolucency (sometimes with a reactive opaque component). * Necrotic pulp --> periapical infection --> alveolar abscess --> skeletal muscle --> draining sinuses on the surface of the skin or mucosa * When soft tissue overlying the infected mandible is involved, it is known as "lumpy jaw" * An acute (non-fibrotic) form of the disease sometimes occurs as localized abscesses

Answer 79

Surgical drainage and antibiotics (primarily penicillin) for long periods.

Answer 80

• Candida is the genus. C. albicans is the species which most often causes oral disease. • It is an oral commensal. • C. albicans is a yeast-like fungus which invades epithelium in hyphae or pseudohyphae form, inducing proliferative reaction and plaque. • Local predisposing factors: smoking, dentures, xerostomia, broad spectrum antibiotics. • Systemic predisposing factors: cell mediated immune deficiency, HIV, other debilitating diseases, iron deficiency, steroids, extremes of age. • When organisms become pathogenic, they become intracellular parasites and (some authorities claim) cause epithelial dysplasia.

Answer 81

• White removable plaques (pseudomembranous) • chronic white adherent plaques (hyperplastic) - Candidal leukoplakia - Chronic mucocutaneous candidiasis • Red macules ("erythematous/atrophic") - Multiple acute red macules - Multiple chronic red macules with or without removable white plaques ("Chronic multifocal") - Denture stomatitis • Other distinctive clinical presentations - Median rhomboid glossitis (central papillary atrophy of tongue) - Angular cheilitis/cheilosis/stomatitis (Perleche)

Answer 82

* Removable, soft, creamy, slightly raised, white or blue-white flecks or confluent plaques. Underlying mucosa may appear normal, red, or ulcerated, and may bleed slightly * Usually asymptomatic, but sometimes there is mild burning sensation and a bad taste * It is seen in association with other forms of candidiasis * Acute onset when induced by broad-spectrum antibotics * Chronic (slow onset, long standing) in debilitating conditions

Answer 83

White, tough, adherent plaques seen in candidal leukoplakia and in chronic mucocutaneous candidiasis

Answer 84

* In candidal leukoplakia, the adherent white plaques are surrounded by erythema and/or are speckled. * This form occurs most at the commissures, dorsal surface of the tongue, and palate. * Such lesions may have increased frequency of dysplasia. * It is not known whether the organism produces dysplasia or secondarily infects previously altered epithelium.

Answer 85

* Oral chronic white adherent plaques (chronic hyperplastic candidiasis) are accompanied by candidiasis of nails, skin, and other mucosae. * There are several types some of which are inherited. * Oral candidiasis is prominent in Familial CMC (AR), Diffuse CMC, and APECS.

Answer 86

``` • Transmitted on an autosomal recessive basis • Autoimmune endocrinopathies include: - Thyroiditis - Hypoparathyroidism - Addison's disease - Diabetes mellitis - Ovarian pathology • There is chronic mucocutaneous candidiasis of the mucosae, skin, and nails. • Other stigmata include: - Enamel hypoplasia - Pernicious anemia - Achlorhydria - Malabsorption - Eye lesions ```

Answer 87

* Antibiotic sore mouth is due to broad spectrum antibiotics * Similar lesions occur following loss of the removable white plaques (seen in thrush) * Mucosa is red, edematous, and may be sore (burning) * When the tongue is affected, there is loss of lingual papillae.

Answer 88

* May present with or without removable white plaques * Red lesions on the dorsal tongue (central papillary atrophy), palate and angles of the mouth * Burning sensation * This occurs in HIV and may occur in xerostomia, other debilitating conditions such as diabetes mellitus and with immunosuppressive agents including steroids.

Answer 89

* "Denture sore mouth" is usually classified as another example of "erythematous or atrophic" candidiasis. * Fiery red palate is sharply outlined by the shape of the denture. Pain or burning sensation is noted at times. * The tight-fitting denture blocks access of saliva to that area. Organisms may produce enzymes which provoke inflammation and/or cause hypersensitivity. Other possible factors include denture trauma, poor oral hygiene, and systemic factors. * Usually smears from the denture fitting surface are positive for hyphae, but those from mucosa are not. * This condition is often seen with thrush flecks, angular cheilosis, or palatal hyperplasia. * It may be treated with Nystatin cream applied to the mucosa and the fitting surface of the denture

Answer 90

* Clinically, there is a smooth area in the midline of the dorsal surface of the tongue, immediately anterior to the sulcus terminalis. The area may be red or pink and slightly sore. It is depapillated but in some (hyperplastic) cases there is a lobulated elevation. * Historically, it was believed to be a developmental defect (failure of tuberculum impar to fuse with lateral processes of the tongue). * It occurs alone, or as part of chronic multifocal candidiasis. * Histologically, there is loss of lingual papillae but there is also extensive acanthosis with long anastomosing rete ridges. * Hyphae are usually seen in the superficial layers of the epithelium.

Answer 91

• Also known as cheilosis/stomatitis (Perleche) • Erythema & fissures at corners of mouth which appear wrinkled and macerated; they do not extend onto the mucosa. They ulcerate and crust. The area feels dry and burning • Seen with all other forms of candidiasis, particularly chronic multifocal candidiasis, but often occurs alone. • Other etiologic factors include: - Other microorganisms (Staphylococcus aureus, etc.) - Overclosure - Dietary deficiencies, e.g. riboflavin - Debilitating diseases

Answer 92

Circumoral fissuring and discoloration occur in people with severe lip-sucking habits.

Answer 93

* White removable (Pseudomembranous) * Multiple chronic red macules (chronic multifocal) * Chronic white adherent (Chronic hyperplastic) * Angular cheilitis

Answer 94

* Compared with non-HIV cases, HIV candidiasis is more often multifocal, chronic, and resistant to treatment. * Histology shows that hyphae evoke only a weak inflammatory cell reaction.

Answer 95

* Nystatin and clotrimazole are topical agents. * Peridex (chlorhexidine) mouthrinse. * Fluconazole and itraconazole are used systemically as tablets and/or intravenously * Treat underlying cause

Answer 96

* Exfoliative cytology * Tissue sections * Culture

Answer 97

``` • Pseudohyphae (elongated yeast cells) or hyphae (2m diam) • Stained smears - Magenta with PAS - Black with silver-based stains • KOH - 10-20% KOH lyses epithelial cells - Yeasts & hyphae more resistant - Disadvantages • No permanent record • Organisms stain less intensely than with PAS ```

Answer 98

* Pseudohyphae (elongated yeast cells) or hyphae (2u diameter) within thick perakeratin * They stain black with silver-based stains or magenta with PAS * Neutrophil microabscesses associated with the organisms * Elongated rete ridges * CIC's in superficial lamina propria

Answer 99

* Colonies grow on Sabouraud's agar in 2-3 days of incubation at room temperature * Immunofluorescent techniques may be needed if colonies fail to grow.

Answer 100

Deep fungal infections of the mouth

Answer 101

* Such as Histoplasmosis capsulatum | * Intense chronic inflammation and granulomas in normal hosts

Answer 102

* Life-threatening invasive infections * Tissue necrosis, hemorrhage, and vascular occlusion with little or no inflammatory response. * Macrophages stuffed with organisms. NO GRANULOMAS (unlike pathogenic fungi)

Answer 103

* Infection by inhalation of soil particles contaminated by bird droppings * It is a pathogenic fungus which occasionally causes isolated pulmonary disease in previously healthy people, especially along the Ohio and Mississippi rivers and in the Caribbean. * Disseminated disease in immunosuppressed individuals. * Oral lesions are secondary to pulmonary or disseminated disease. * Oral lesions are typically ulcerated, often irregular, mucosal enlargements with ill-defined margins.

Answer 104

• Occurs in people with advanced systemic diseases (such as diabetes mellitis) • Inhalation of spores rarely causes disease in healthy people • Opportunistic infection caused by fungi of class Zygomycetes, order Mucorales - Including genera Absidia, Mucor, Rhizomucor, and Rhizopus • In bread molds and decaying vegetation • Hyphae invade walls of blood vessels, causing thrombi and necrosis

Answer 105

* Best diagnosed by culture * Morphology of stained organisms in tissue sections using PAS or silver stains is also useful. * There are serologic tests for antibodies and antigens.

Answer 106

``` Zygomycetes (especially Mucor) Aspergillus & Cryptococcus --> Susceptible host --> Maxillary "sinusitis" --> Vessel blockage or compression --> Black necrotic tissue --> Palatal perforation (often fatal) ```

Answer 107

``` • Malignancies - Salivary gland malignancies - Extranodal T cell lymphoma - Squamous cell carcinoma - Melanoma • Wegener granulomatosis • Infections - Zygomycosis (murcormycosis) - Gummas of tertiary syphilis - Leprosy • Cocaine use • NSM rarely causes perforation ```