1. Applied Oral Pathology through Interactive Learning
Infectious Diseases
Rachel S. Ennis
MDH707 Spring 2011

2. Infectious Diseases Chapter 4 Objectives
Inflammatory and immune response
Causes of opportunistic infection
Organisms involved in specific infectious diseases
Oral candidiasis; five forms
Herpes labialis; clinical features
Recurrent intraoral herpes simplex infection; clinical features
Minor aphthous ulcers; clinical features
You will have patients throughout your career, that come to you with some pathological condition that you will need to recognize, and learn how to treat. These pathological conditions include benign “variations of normal”, as well as infectious diseases.
Our focus for today's lecture will concentrate on infectious diseases of the oral cavity.
We will be discussing the following objectives for this chapter.

3. Objectives continued:
Herpes Zoster; clinical characteristics
Epstein-Barr Virus; four associated diseases
Coxsackie virus and oral manifestations
Oral manifestations of HIV infection; clinical appearance
Review objectives.

4. Any ideas?
? ? ?
Suppose a patient of record comes in to your office. You’ve seen him before, but today he doesn’t’ greet you with his typical smile and “happy to see you” face. Instead he appears to be in obvious discomfort. He is a nineteen year old male, college freshman. With concern, you ask how he is doing and he responds: “Not so well…my whole mouth is killing me...and I have exams all next week”
“Oh no”, you reply, “When did you start to notice all this?”
“Well, a couple of days ago, my gums started to feel funny, and when I looked at them, it kind of looks like they are peeling away, and they are really sore and bleeding. I also have a really bad taste in my mouth, and my breath STINKS!!”
You start thinking about the things that might be involved with the cause of your patient’s discomfort. Stress, lack of sleep, exams, and mentally note that all these things may be contributing to this acute condition.
You tell the patient that you are going to examine his mouth. You put the patient bib on and immediately notice a horrible odor emanating from his mouth. This is your first indicator that something is definitely not healthy, as this patient usually has no obvious problems with his mouth and oral hygiene.
You lay the patient back and examine his mouth. His gums appear grayish at the gingival margin, they are erythematous, and there is necrosis and cratering of the interdental papilla, causing a foul odor.
What are your thoughts here? Does anyone have any idea of what this may be?
How will you treat him?

5. Acute Necrotizing Ulcerative Gingivitis
Edematous and erythematous gingiva
Cratered or “punched out”
interdental papillae
Painful
Foul odor
Metallic Taste
Associated with decreased resistance
Caused by Fusiform bacilli,
and spirochetes
This is a bacterial infection called ANUG, or trench mouth.
The treatment for Anug includes:
Amoxicillin (oral antibiotics) to treat infection
Chlorhexidine or Betadine rinse to aid in treating infection
Hydrogen peroxide rinse and/or warm salt water rinse
Short term pain medication as needed
Dental cleaning when patient is comfortable
Often associated with decreased resistance, so a college student during exams would be prone to this infection.

6. Inflammatory and Immune Response
Inflammatory response: body’s first line of defense against tissue injury and disease-producing microorganisms
Immune response: defends body against injury, remembers past instances of injury
What happens when the body is compromised? First, we see an inflammatory response. The inflammatory response may be acute or chronic. The five classic signs of inflammation include redness, heat, swelling, pain, and loss of normal tissue function.
Systemic signs of inflammation include fever, increase of white blood cell production, increase in protein produced by liver (c-reactive protein) and lymphadenopathy.
The immune response occurs after the inflammatory response, and is necessary for complete recovery. The immune response can remember past instances of injury and respond more quickly to foreign substance when encountered again. At this point, there is an accumulation of white blood cells, and antibodies begin to form.
An opportunistic infection may be setting in..so,
what is an opportunistic infection?

7. Opportunistic Infection
Alteration in the oral micro flora
Organisms that are normally nonpathogenic are able to cause disease
An opportunistic infection occurs when there are changes in the oral micro flora, such as a decrease in salivary flow, antibiotic use, or a change in the immune system. The oral microflora is affected so organisms that would usually not be considered pathogenic are able to cause disease.
Can you think of two opportunistic infections we commonly see in the oral cavity?

8. Opportunistic infections of the oral cavity
Dental caries
Periodontal disease
These are both examples of opportunistic infections in the oral cavity?
They are both infections caused by bacteria.

9. Infectious Diseases and the organisms involved
Impetigo: Staph Aureus, Staph pyogenes.
Tonsillitis and Pharyngitis: Streptococci, Adenoviruses, Influenza, and Epstein-Barr virus
Tuberculosis: Mycobacterium tuberculosis
Actinomycosis: Actinomyces israelii
Syphilis: Treponima pallidum
Veruca vulgaris: Human papilloma virus
Condyloma acuminatum: Human papilloma virus
Primary herpetic gingivostomatitis: Herpes simplex virus
Acute Necrotizing Ulcerative Gingivitis: Borrelia vincentii fusiform bacillus, and spirochete
Let’s look at some infectious diseases, and the organisms that cause them:
Impetigo is a bacterial skin infection involving the skin of the face or extremities, and is usually seen in young children. Treat with antibiotics
Tonsillitis and pharyngitis are inflammatory conditions of the tonsils and pharyngeal mucosa. Treat with antibiotics
Tuberculosis is an infectious chronic disease and primarily affects the lung. Oral lesions associated with TB are rare. Anti- TB agents
Actinomycosis presents as skin lesions or abscesses that tend to drain, often seen on mandible. Long term antibiotics
Syphilis presents as chancre in oral cavity. Treat with antibiotics
Veruca vulgaris, mouth wart-most commonly seen on lips, surgical excision, may recur
Condyloma acuminatum any location, may be multiple, Suggestive of sexual abuse when seen in a child, needs surgical excision, may recur. Report as child abuse!
Primary herpetic gingivostomatitis, herpes simplex virus, antiviral drugs/ magic swizzle
ANUG: caused by fusiform bacilli, spirochetes,Treat with antibiotics, oral rinse

10. Impetigo Adult male with impetigo Child with impetigo on chin on chin
Impetigo is a common bacterial infection, usually seen in children, but may be seen in adults. The adult male above contracted the infection from a razor cut.
Typically the sores will appear around the mouth or nose if the face is infected. The sores may be painful and itch.
Treatment for impetigo includes both topical and oral antibiotics in more severe cases.

11. Syphilis chancre Dorsal surface of tongue
Primary syphilis lesion; Painless sore on tongue that is not healing
Clinical appearance:
A discrete, round ulcer with raised borders is located on the anterior third of the dorsal tongue.
This picture is of a 32 year old male patient with a history of chronic alcoholism and a previous episode of a sexually transmitted disease, accompanied by regional lymphadenopathy
Caused by spirochete Treponema Pallidum
Sexual contact, blood transfusion

12. Actinomycosis Left mandible
This picture is of a 22 year old male patient, experiencing pain, swelling and throbbing on the left side of his face (over the mandible) related to a cut after shaving.
No significant medical findings
Clinical Appearance: an approximately 6mm, round, slightly raised, erythematous “pimple” is located on the facial skin slightly above the lower left mandible on the face.
The incision and draining site is seen below the lesion
An incision and drainage procedure was required of the facial skin lesion
Sulfur granules present in the purulent exudate.

13. Condyloma acuminatum Lower lip Age 7 Male
Father bought this child to the dentist to examine a “growth” located on the labial mucosa of the lower lip
Clinical appearance: approx 7x9 mm, irregularly shaped , pink, papillary lesion is located on the right side of the labial mucosa of the lower lip.
Biopsy of the lesion is performed and determined to be C.A.
Benign lesion, if found in mouth, suggestive of oral genital contact.
If found in child, need to report child abuse!

14. Oral Candidiasis (thrush)
Pseudomembranous
Erythematous
Denture stomatitis (chronic atrophic candidiasis)
Chronic hyperplastic candidiasis
Angular cheilitis
There are five different forms of Candidiasis. They include:
Pseudomembranous: underlying mucosa is erythematous, burning sensations, and metallic taste.
Erythematous: painful, generalized or localized
Denture Stomatitis: most common, on palate and maxillary alveolar ridge, asymptomatic
Chronic hyperplastic: white lesion that does not wipe off.
Angular cheilitis: fissuring at labial commissures

15. Angular cheilitis Commissure of lips
This is typically seen in edentulous patients, although you often see this in the general population. It is easily treated with Mycalog II Creme.
This is caused by candida infection. (yeast)

16. Pseudomembranous candidiasis
Hard palate
This is a picture of a 30 year old male. He complained of a sore palate, a burning sensation and metallic taste.
Patient infected with HIV for more than eight years
Currently taking Highly active antiretroviral therapy (HAART)
Clinical Appearance: Diffuse white curd like material on hard palate that wipes off
Treatment:-- Nystatin tablets, Chlorhexidine rinse

17. Herpes Labialis Caused by herpes simplex virus
Also called “cold sore or fever blister”
Vermillion of lips
Herpes Labialis is a secondary herpes infection that typically occurs on the lips, but may occur intraorally.
Antiviral drugs, Denavir, Zovirax,(topical) Valtrex-systemic (oral)

18. Herpes Labialis Vesicles on lips and vermillion boarder
Vesicles have formed but not blistered yet.
Patient generally feels “tingling”, or burning sensation prior to vesicle appearance. Use of antiviral drugs, or topical antiviral ointment is most effective as soon as the patient feels the signs of a cold sore appearing.

19. Herpes Labialis Lower lip
This Herpetic lesion has blistered, and is very contagious in this state.
Patients need to be made aware of the importance of proper hygiene-(no mouth contact or sharing saliva with other individuals, including sexual contact). This cold sore can be transmitted through oral/genital contact.

20. Recurrent intraoral herpes simplex infection
Herpes simplex virus
Keratinized mucosa (hard palate, and gingiva
May be caused by sunlight,
menstruation,fatigue,fever,stress
Painful, focal crops of vesicles
Prodromal symptoms: pain,burning,tingling
Lesions may last one to two weeks, episodes of recurrence vary from once a month to once a year.
Transmitted by direct contact with infected person, most amount of virus is in vesicle stage.
Antiviral drugs: Valtrex
Magic swizzle for intraoral relief

21. Primary Herpes Simplex Infection
Dorsal surface of tongue
6 year old child with low grade fever for past three days. Child can’t eat due to sores in mouth and on his tongue, gums hurt.
Clinical appearance, Multiple tiny vesicles and ulcers present on child’s labial mucosa, palate, and tongue
Vesicles and ulcers are accompanied by generalized, painful, erythematous swollen gingiva
Child also has painful bilateral cervical lymphadenopathy.
Viral disease, most often found in young children. Resolves in 1-2 weeks. Treatment includes Xylocaine, Valtrex,
Fluids, and liquid food supplements.

22. Minor aphthous ulcers Nonkeratinized mucosa
One to several ulcers present
No vesicle preceding ulcer
Pain
<1cm
Round to oval
Can recur
Most of us have experienced this nuisance in our mouths.
Although they can be small, they can also be quite painful.
Many patients refer to these ulcers (incorrectly) as cold sores.

23. Minor aphthous ulcer Floor of mouth
Ulcers heal within 7-10 days. Burning sensation prior to ulcer.
Clinical Appearance: single, round ulceration, yellowish to white fibrin center surrounded by an erythematous halo, approximately 8mm in size, located on the right side of the floor of the mouth.
Use of corticosteroid cream for palliative treatment. Kenalog in Orabase
RX Magic Swizzle-(kaopectate,benedryl,lidocaine)
Prevention:
Avoid triggering foods: nuts, chocolate, acidic fruits
Avoid trauma: toothbrush trauma, cheek bite, etc.
Avoid sodium lauryl sulfate: a soap found in most toothpaste and mouthwashes. Consider Biotene toothpaste or Rembrandt for canker sore sufferers.
Consider antimicrobial rinse: chlorhexidine or listerine for prevention only.

24. Major Aphthous Ulcer Soft palate
Patient complains that he has a large painful ulcer in the back of his mouth. He states that he is never without an ulcer and each one takes several weeks to heal.
This appears as a deep oval ulceration with a yellowish to white fibrin center surrounded by an erythematous halo, approximately 1 1/2 cm in diameter. Located in the left side of the soft palate.
Accompanied by pain.
Same treatment for major aphthous ulcer.
Biopsy should be performed to rule out other ulcerations from other causes

25. Herpes Zoster Shingles
Unilateral, painful eruption of vesicles along sensory nerve
May affect three branches of trigeminal nerve
Prodromal symptoms: pain, burning,paresthesia
May last several weeks
Oral lesions are painful, begin as vesicles that progress to ulcers. Some patients may have neuralgia which may take months to resolve.
Vaccine for patients over 60.
Antiviral drugs.

26. Herpes Zoster Shingles
This female patient has a history of breast cancer that has been treated with surgery and a recent course of cancer chemotherapy.
She has lesions unilaterally on the left side of her face, and within the intraoral cavity.
These are painful vesicles and ulcers.
Pain, burning or paresthesia often precedes the development of vesicles
Next picture: intraoral infection.

27. Varicella Zoster Lips and palate
These unilateral vesicles in the oral cavity and on the patient’s face and lips are caused by the varicella-zoster virus.
Antiviral drugs, and magic swizzle for treatment.

28. Epstein-Barr Virus Infectious Mononucleosis Palatal petichiae
kissing disease
Nasopharyngeal carcinoma
Burkitt lympoma
Hairy Leukoplakia
usually on lateral border of tongue
EB virus is associated with these diseases that occur in the oral region.
Naso pharyngeal carcinoma and Burkitt lymphoma are rare malignant neoplasms. Mono, and hairy leukoplakia are more common.
Mono: sore throat, fever, lympadenopathy enlarged spleen, malaise, fatigue.
Mono may last 4-6 weeks
Saliva is route of transmission
Hairy leukoplakia often seen immunocompromised patients, or HIV patients

29. Hairy Leukoplakia Lateral boarder of tongue
28 year old male noticed white lesion on his tongue.
Tested positive for HIV infection 2 years ago, but has not had any opportunistic infections.
Presently taking several antiretroviral agents
Clinical appearance: An irregular white lesion is located on the lateral and dorsal surfaces of the tongue.
The surface appears corrugated.
The lesion does not wipe off.
Caused by the EB virus
Usually asymptomatic
May respond to antiviral medication but recur when treatment is discontinued.

30. Coxsackievirus Discovered in Coxsackie, NY
Transmission by fecal-oral contamination, saliva, respiratory droplets
May cause:
Herpangina
Hand-Foot-and Mouth Disease
Acute Lymphonodular Pharyngitis
Herpangina-vesicles on soft palate, fever, malaise, sore throat, difficulty swallowing. Resolves in one week with out treatment.
Hand Foot and mouth: usually occurs in epidemics in children younger than 5 years old. Oral lesions are painful vesicles and ulcers, anywhere in mouth. Multiple macules or papules occur on skin, typically on feet, toes, hands, and fingers. Lesions resolve within 2 weeks.
ALP- fever, sore throat, mild headache. Lymphoid tissue of soft palate or tonsillar pillars appears as yellowish or dark pink nodules. Lasts up to 2 weeks, no treatment.

31. Sores on dorsal surface of tongue and palate
Coxsackie virus
Sores on dorsal surface of tongue and palate
This is very common in children and very contagious.
Lesions may appear on face, in mouth, or on hands and feet.
Viral in nature, so no antibiotics. Magic swizzle for discomfort.

32. HIV and Oral Lesions Candidiasis Herpes simplex infection
Herpes Zoster
Hairy Leukoplakia
Human papilloma virus lesions
Atypical gingivitis and periodontitis
Kaposi sarcoma
Non-Hodgkin lymphoma
Aphthous ulcers
Mucosal pigmentation
Bacterial salivary gland enlargement and xerostomia
Spontaneous gingival bleeding resulting from thrombocytopenia
Because the immune system is compromised, HIV patients are prone to many oral lesions.
Not all patients that present with these oral lesions are infected with the HIV virus.

33. HIV associated thrush Soft palate
The infection appears thick and white, and can be wiped off.
Both of these pictures are in HIV infected males, involving the palate and tongue.

34. Papilloma Papilloma on soft palate
58 year old male patient complains of a rough area on the roof of his mouth.
Clinical Appearance: Oval, white exophytic, sessile lesion with a cauliflower-like surface is located at the junction of the hard and soft palate and measures approximately 8x6 mm.
Benign tumor of squamous epithelium. My have sessile or pedunculated base.
May be white or color of mucosa, often appearing “cauliflower like”.
Excision to remove lesion, may recur.

35. Papilloma Lateral boarder of tongue
This is a cauliflower like white projection on the lateral boarder of the tongue. It has a sessile base, (as opposed to peduncuated or “stalk like”).
Excision to remove lesion, may recur.

36. Papilloma Buccal Mucosa
This is located on the buccal mucosa, again, with a sessile base.
Excision to remove lesion, may recur.

37. Kaposi sarcoma HIV infection
Kaposi sarcoma in HIV infected male on dorsal surface of tongue.
These reddish purple lesions can be anywhere on the body.

38. !
Today you have seen just a few examples of various infectious diseases.
It is important to become familiar with oral pathology, including causes, symptoms, clinical appearance and recommended treatment for these diseases, as you will be using this information on a regular basis throughout your dental hygiene career.

39. References
Ibsen, O., Phelan, J.A. (2009). Oral pathology for the dental hygienist, 5thed. St. Louis, MO: Saunders Elsevier. Langlais, R. P. , Miller, C.S. , Nield-Gehrig, J. S. (2009) Color atlas of common oral diseases, 4thed. Philadelphia, PA: Lippincott Williams and Wilkins.