Oral infections Flashcards
What are the global figures from WHO 2018 on HIV?
- People living with HIV 37.9 million - about 0.8-0.9% of 15-49 year olds
- Newly infected with HIV is 1.7 million
- AIDs mortality is 770000
- Since the beginning of the epidemic 75 million people have been infected and 32 million people have died
- Most cases are seen in Africa
What is the HIV virus and how does it work?
HIV is a retrovirus. It is a single stranded RNA virus with a reverse transcriptase gene. It is spread by body fluids, mainly by unprotected sex or IV drug use. HIV damages the immune and nervous system. The cellular receptor for HIV is the CD4 molecule. It is found on T helper cells, monocytes and dendritic cells. Cells most affected are CD4 ‘helper’ T cells. Damage causes severe immunodeficiency. There is a broad spectrum of illnesses related to level of immunodeficiency. AIDs occurs with CD4 cell counts <200/UL (normal is >600/UL).
What are the symptoms when you are first exposed to HIV virus and how do they change as it progresses to AIDS?
When exposed to the virus we may get something called acute seroconversion illness. It may not be noticed as it may feel like a normal cold/flu. There may be rash, temperature, lymph nodes – non-specific. You can be asymptomatic for many years and only when CD4 count starts dropping do symptoms develop. This is why early testing is very important. There will be persistent generalised lymphadenopathy PGL, then AIDs related complex ARC which is when symptoms are mild: pyrexia, diarrhoea, weight loss, fatigue/malaise. Then there will be progression to AIDS: opportunistic infections, Kaposi’s sarcoma and CD4 T cells <200/UL.
After how much time are you positive for the HIV antibody and progress to AIDS?
You get infected and CD4 count is normal. You will be positive to HIV antibody after about 3 months. You are well for 8-10 years and then the count starts dropping and you become unwell (AIDs).
What is the diagnosis of HIV based on?
- History and clinical features
- General lab investigations - lymphopenia, CD4 count reduced, CD4/8 ratio reduced
- HIV testing (after counselling) - HIV antibodies, HIV antigens
What are the HIV oral manifestations?
- Group 1 lesions (strongly associated with HIV infection)
- Group 2 lesions (less commonly associated with HIV)
- Group 3 lesions (possibly associated with HIV infection)
What are the group 1 lesions in HIV?
- Candidosis - erythematous/pseudomembraneous
- Hairy leukoplakia
- HIV associated periodontal disease
- Kaposi’s sarcoma
- Non-Hodgkin’s lymphoma
What is erythematous and pseudomembranous candidosis?
Erythematous candidosis will be painful on the roof of mouth and tongue. It is seen with dentures. Pseudomembranous candidosis is white patches.
What is the treatment of candida infections?
Topical: - Miconazole - oral gel - Nystatin - suspension Systemic: - Fluconazole - Itraconazole - Voriconazole
What is hairy leukoplakia and the treatment?
Lesions are bilateral but can start as unilateral and corrugated. It is not premalignant. The cause is EBV. It generally does not require treatment, it may regress with acyclovir but it usually returns on stopping therapy.
What are the types of HIV associated periodontal disease?
- Linear gingival erythema ( red line around teeth - gingival margin)
- Necrotising ulcerative gingivitis NUG
- Necrotising ulcerative periodontitis NUP
- Necrotising ulcerative stomatitis NUS
What are the causes of HIV associated periodontal disease?
- Spirochaetes
- Fusiform bacteria
- Anaerobic rods (similar to ANUG and cancrum oris)
- In linear gingival erytema candida may also play a role
What is the management of HIV associated periodontal disease?
Immediate management: - Removal of necrotic bone and severely involved teeth - Debridement of necrotis tissue - 6% hydrogen peroxide irrigation of pockets/mouthwash - Antibiotics - metronidazole - Oral hygiene instruction Long term: - Periodontal management
What is kaposi’s sarcoma?
It is caused by HHV8. It can be in the mouth or on the skin. Red lumps/spots are seen and black spots on the roof of the mouth.
What is the management of Kaposi’s sarcoma?
May include:
- Radiotherapy
- Systemic chemotherapy
- Intra-lesional chemotherapy
- Surgical excision
What is non-hodgkin’s lymphoma and the management?
It appears as an abnormal growth in the oral cavity. You may not see any specific features. The management is radiotherapy and chemotherapy.
What are the group 2 lesions associated with HIV?
- Atypical orophrayngeal ulceration - usually severe with atypical presentation
- Idiopathic thrombocytopenia purpura - low platelet count, can result in purpuric patches on the oral mucosa, if platelet count very low (<60000/ml) risk of post extraction bleeding
- Salivary gland disorder - dry mouth, decreased salivary flow rate, swelling of major salivary glands, treatment with salivary stimulants and oral lubricants
- Viral infections other than EBV - cytomegalovirus (severe or atypical oral ulcers), herpes simples (severe secondary herpes), human papillomavirus (multiple warts), herpes (varicella) zoster (severe shingles)
What are the group 3 lesions associated with HIV?
- Oral bacterial infections other than periodontal disease
- Fungal infections other than candidosis
- Melanotic hyperpigmentation
- Neurological disturbances - trigeminal neuralgia, facial palsy
How is HIV prevented?
- Male and female condom use - male condoms have >85% protective effect
- Testing and counselling for HIV (also STI and TB) - TB is responsible for nearly 1 in3 HIV associated deaths
- Voluntary medical male circumcision - reduces risk of heterosexually acquired HIV in men by about 60%
- Use of ARVs for prevention - HIV positive person adhering t ART reduces risk of transmission by 96%, pre-exposure prophylaxis PrEP and post-exposure prophylaxis PEP within 72 hours
What is the HIV management?
- Systemic treatment with anti-retroviral therapy
- Dental care and oral hygiene provided by GDP
- Oral manifestations - treat as per lesion requirements
What is the systemic treatment of HIV?
Modern combination anti-retroviral therapy. It is often called HAART (highly active anti-retroviral therapy). It is very effective at preventing progression to AIDs. It reduces immunosuppression and associated opportunistic infections and tumours. There can be prophylactic treatment for opportunistic infections. It is provided by HIV clinics, GUM clinics, GMP etc.
What should you do if there is a needle stick/occupational exposure?
First aid:
- Encourage bleeding under running water
- Apply or scrub with antiseptic then cover wound
- Irrigate exposed eyes, nasal or oral mucosa
- Record details in accident book
Management:
- Report exposure to occupational health, GUM clinic or GMP. They will arrange counselling re post-exposure prophylaxis with AZT and confidential HBV and possible HIV testing
They will also organise a risk assessment, so identification of source patient and clinical and serological evaluation of HIV/HBV status with patients permission
- Follow up - hep B testing, vaccination and treatment, HIV testing, HCV testing.
What are the classical signs of acute inflammation?
They are diagnostic: - Swelling - Redness - Loss of function - Heat - Pain or tenderness There may also be systemic signs such as pyrexia or malaise as well as regional lymphdenopathy.
What is an abscess and how is it detected clinically?
An abscess if a pus filled pathological cavity, which can form as part of the inflammatory response to acute infection. Acute exacerbations of chronic inflammation can also occur followed by periods of quiescence. Every abscess should be drained. Clinically, abscess formation can be determined by the presence of fluctuance to gentle palpation. Pressure exerted by 1 finger should be detected by another finger as ‘bounce’. If there is no fluctuance then cellulitis is present which does not need drainage. Two fingers on abscess and palpate between the fingers.
How is an abscess diagnosed?
Diagnosis of an acute dentoalveolar abscess is usually solely by clinical means. Radiographs do not typically show any change in the periapical tissues. This is because it takes approximately 10 days for sufficient bone loss to occur to be detectable on an intra-oral film. The earliest radiological sign is widening of the periodontal ligament space.
Where does the pus from an abscess track?
Pus from an acute dentoalveolar abscess takes the track of least resistance through the cancellous bone and points on the nearest epithelial surface. This is usually on the buccal aspect of the maxillary or mandibular alveolus where the overlying bone is thinnest, but can be palatally/lingually.
What are the general measures for an acute infection?
- Admission if unwell
- Analgesia
- Control of infection
Patients that are toxic (systemically unwell with malaise, pyrexia, tachycardia or hypotension) should be admitted to hospital. These patients need intravenous antibiotics as well as surgical drainage. NSAIDs will help with pain relief and have an anti-pyrexial effect. Antibiotics are given blindly in the first instance as it is not practical to wait for the results of culture and sensitivity testing. Typically amoxicillin and metronidazole are used in combination and changes made only in the face of microbiological results.
What are the local measures for an acute infection?
- Removal of the cause
- Drainage
- Prevention of spread
- Restoration of function
How do you remove the cause of acute infection?
The most important principle in management of infections, sometimes this is all that needs to be done. However, it can be easier to institute drainage and prevent spread in the acute phase. Examples include extraction of non-vital or hopelessly mobile teeth, removal of sequestrae (dead bone), foreign bodies or salivary calculi.
How is an abscess drained?
Reddening, fluctuance and a point of maximum tenderness indicate pus formation. Pus should be drained and a surgical incision leaves less scarring than spontaneous draining, particularly through the skin. Antibiotics are not a substitute for drainage. There needs to be adequate anaesthesia with 2% lignocaine with adrenaline injected into the overlying mucosa, not into the abscess cavity. Horizontal incision parallel to the occlusal surface of the teeth 1-2cm in length. Consider local anatomy such as the mental nerve. Use a no.11 blade held backwards with an upward sweep. Open the abscess cavity with artery forceps (Hilton’s method). Hot salt water mouthwashes will encourage any remaining pus to drain.
What is done when incising the abscess is not sufficient to drain it?
Incising an abscess cavity to drain it is almost always sufficient for intra-oral abscesses. However, when pus has to pass through several tissue planes in order to escape, for example in deep neck abscesses, a drain can be inserted into the abscess cavity which is exteriorized into the mouth or onto the skin surface (sometimes both: through and through).
How is spread prevented?
This is achieved by drainage, use of antimicrobials and rest. Rest is difficult in the orofacial region but trismus when present achieves this naturally.
How do we restore function?
Review the patient after the acute phase to ensure that things have settled and function has been restored. Sometimes trismus can persist and need treatment e.g. Therabite.
What is the microbial aetiology of dentoalveolar abscesses?
- Black pigmented anaerobes
- Fusobacterium
- Anaerobic cocci (peptostreptococcus, parvimonas)
- Streptococcus
- Non-pigmented anaerobes
- Eubacterium
- Spirochaetes
What are the periodontal abscess symptoms?
- Pain
- Swelling – small localised to diffuse
- Lymphadenopathy and fever may be present
- Facial or neck cellulitis
What are the causes of periodontal abscesses?
The tooth is usually vital.
- Pre-existing periodontal pockets that become occluded - foreign body
- Trauma to the periodontium
- Secondary infection of lateral periodontal cyst
What is seen radiographically for a periodontal abscess and what is the treatment?
There will be radiolucency on the lateral aspect of the root. Multiple periodontal abscesses will be seen in poorly controlled diabetic patients. The microbial aetiology is the same as chronic periodontitis and candida. Treatment is to drain and debride.
What is streptococcal gingivostomatitis?
Streptococcal gingivostomatitis is rare in non-compromised hosts and it most frequently follows tonsillitis. There is severe inflammation of the gingivae with marked pain. It is caused by s.pyogenes. the complications are fasciitis, tissue destruction, rheumatic heart disease, nephritis etc. Differentiate from drug and viral causes. The treatment is prompt treatment with penicillin.
What is acute ulcerative gingivitis?
Acute ulcerative gingivitis is due to poor OH, smoking, stress. It is ulceration and destruction of interdental papilla due to invasion of tissue. There will be halitosis, bad taste, malaise, lymphadenopathy. Treatment is debridement and hygiene.
What is cancrum oris?
Cancrum oris or Noma is usually preceded by ANUG and recent debilitating illness. It is categorised by WHO as a necrotising ulcerative stomatitis. It is a rapid spreading destructive disease where there are gangrenous lesions destroying soft and hard tissues of the face.
What is the cause of cancrum oris?
- Infection - viral e.g. measles, bacterial e.g. TB, scarlet fever or parasitic infection e.g. malaria
- Immune suppressive drugs/disease
- Malnutrition
- F.necrophorum, P.intermedia, T.vincentii, T.denticola, T.forsynthia, alpha-streptococci
