Oral Infections: Viral, Bacterial & Fungal PDF

11/26/2024 Oral Infections Viral, Bacterial & Fungal Dr. Eman Alsheikh 1 Bacterial Infections 2 1  11/2...

11/26/2024 Oral Infections Viral, Bacterial & Fungal Dr. Eman Alsheikh 1 Bacterial Infections 2 1  11/26/2024 Bacterial infections of the mouth can range from mild conditions to severe infections that may affect oral and systemic health. 3 Clinical manifestations of bacterial infections in oral mucosa vary from small, localized lesions to diffuse ones, which may lead to destruction of the local tissues, up to systemic life threatening infections. Examples of widespread oral lesions are stomatitis, glossitis, gingivitis and pharyngitis. 4 2  11/26/2024 Common Bacterial Infections 5 1. Dental Caries Causative Streptococcus mutans, Lactobacillus species, Bacteria: Actinomyces. These bacteria metabolize dietary sugars, producing acid Pathogenesis: that demineralizes tooth enamel. Symptoms: Tooth sensitivity, pain, visible cavities. Prevention/Treat Good oral hygiene, fluoride use, and fillings for advanced ment: decay. 6 3  11/26/2024 2. Periodontal Diseases 7 a. Gingivitis Porphyromonas gingivalis, Pathogens Fusobacterium nucleatum, Prevotella intermedia Red, swollen gums that bleed on Clinical Features probing. Management Scaling and root planing, oral hygiene. 8 4  11/26/2024 b. Periodontitis Similar to gingivitis but with higher Pathogens involvement of Aggregatibacter actinomycetemcomitans. Pocket formation, bone loss, tooth Clinical Features mobility. Deep cleaning, possible surgery, Management antimicrobial therapy. 9 c. Periapical Abscess Mixed anaerobic bacteria Pathogens (Fusobacterium, Prevotella, Peptostreptococcus). Infection of the root canal system Pathogenesis spreading to periapical tissues. Pain, swelling, systemic symptoms if Clinical Features severe. Management Root canal therapy or extraction. 10 5  11/26/2024 3. Specific Oral Infections 11 a. Acute Necrotizing Ulcerative Gingivitis (ANUG) Pathogens Treponema spp., Fusobacterium spp. Predisposing Factors: Poor oral hygiene, stress, smoking, Pathogenesis immunosuppression. Ulcerated, painful gums with gray pseudomembrane, Clinical Features halitosis. Management Debridement, antimicrobial therapy (e.g., metronidazole). 12 6  11/26/2024 b. Osteomyelitis of the Jaw Mixed anaerobic bacteria Pathogens (Fusobacterium, Prevotella, Peptostreptococcus). Infection of the root canal system Pathogenesis spreading to periapical tissues. Pain, swelling, systemic symptoms if Clinical Features severe. Management Root canal therapy or extraction. 13 c. Ludwig’s Angina Polymicrobial, including Streptococcus, Staphylococcus, Pathogens and anaerobes. Submandibular space infection often secondary to dental Pathogenesis infections. Clinical Features Swelling, airway compromise. Management Airway management, IV antibiotics, surgical drainage. 14 7  11/26/2024 Diagnosis 15 Clinical examination Radiographic imaging (e.g., periapical, panoramic X-rays) Microbial culture and sensitivity testing in severe cases. 16 8  11/26/2024 Prevention and Control 17 Regular oral hygiene practices Routine dental check-ups Prophylactic antibiotics in high-risk patients (e.g., those with heart valve replacements undergoing dental procedures). 18 9  11/26/2024 Systemic Implications 19 Bacteremia from oral infections Oral bacterial infections are not confined to the oral cavity; they can have significant systemic consequences due to the spread of bacteria and their toxins through the bloodstream or lymphatic system. Links to systemic diseases: Cardiovascular diseases, diabetes, adverse pregnancy outcomes. 20 10  11/26/2024 21 1. Cardiovascular Diseases Link: Chronic periodontal diseases, especially periodontitis, have been associated with an increased risk of cardiovascular conditions such as atherosclerosis, myocardial infarction, and stroke. Mechanisms: ▪ Dissemination of bacteria (Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans) into the bloodstream can contribute to endothelial dysfunction. ▪ Bacterial byproducts and inflammatory mediators (e.g., C-reactive protein) promote plaque formation in arteries. Evidence: Studies show elevated systemic markers of inflammation (e.g., interleukin-6) in individuals with severe periodontal disease. 22 11  11/26/2024 2. Diabetes Mellitus Bidirectional Relationship: Poorly controlled diabetes exacerbates periodontal disease due to impaired immune response and altered healing. Severe periodontitis can worsen glycemic control by increasing systemic inflammation. Mechanisms: Advanced glycation end-products (AGEs) in diabetes promote tissue destruction and bacterial proliferation. Periodontal inflammation releases cytokines (e.g., TNF-α), contributing to insulin resistance. 23 3. Adverse Pregnancy Outcomes Complications Linked: Preterm birth/ Low birth weight/ Preeclampsia Mechanism: Oral bacteria (e.g., Fusobacterium nucleatum) can translocate to the placenta via the bloodstream. Inflammatory mediators from periodontitis may trigger premature uterine contractions. Evidence: Pregnant individuals with untreated periodontal disease are at higher risk for complications. 24 12  11/26/2024 4. Respiratory Infections Association: Aspiration of oral pathogens into the respiratory tract can lead to pneumonia, particularly in elderly or immunocompromised individuals. Mechanism: Oral bacteria such as Streptococcus pneumoniae and Haemophilus influenzae colonize the respiratory tract. Dental plaque acts as a reservoir for pathogens contributing to ventilator-associated pneumonia in hospitalized patients. Prevention: Good oral hygiene and professional cleanings reduce respiratory infection risks. 25 5. Rheumatoid Arthritis Link: Chronic periodontitis has been associated with the onset and progression of rheumatoid arthritis (RA). Mechanism: Shared inflammatory pathways, such as elevated levels of pro-inflammatory cytokines (e.g., IL-1, IL-6). P. gingivalis produces an enzyme (peptidylarginine deiminase) that may induce autoantibody formation against citrullinated proteins, a hallmark of RA. Clinical Implication: Managing periodontal disease can potentially alleviate RA symptoms. 26 13  11/26/2024 6. Endocarditis Cause: Bacterial endocarditis can result from bacteremia originating from oral infections. Pathogens: Streptococcus viridans group is most commonly involved. Mechanism: Bacteria enter the bloodstream during dental procedures or severe oral infections. They adhere to damaged heart valves or endothelial surfaces, forming infective endocardial lesions. Prevention: Antibiotic prophylaxis is recommended for high-risk patients undergoing invasive dental procedures. 27 7. Chronic Kidney Disease (CKD) Link: Periodontal inflammation has been implicated as a contributing factor to CKD progression. Mechanism: Chronic inflammation from oral infections exacerbates systemic oxidative stress, contributing to renal damage. Elevated levels of inflammatory markers from periodontitis are correlated with worsening kidney function. 28 14  11/26/2024 8. Alzheimer’s Disease Emerging Research: Studies suggest a potential link between chronic oral infections & neurodegenerative diseases like Alzheimer’s. Mechanism: P. gingivalis has been detected in the brains of Alzheimer’s patients. Oral bacteria may exacerbate neuroinflammation, promoting amyloid-beta plaque formation. Implication: Treating periodontal disease may reduce neuroinflammation risk. 29 9. Osteoporosis Connection: Periodontitis and osteoporosis share common inflammatory pathways and risk factors. Mechanism: Bone resorption in periodontitis may be exacerbated by systemic factors linked to osteoporosis. Management: Collaborative care with endocrinologists and dentists can optimize treatment outcomes. 30 15  11/26/2024 10. Compromised Immune Systems At Risk Groups: Patients with HIV/AIDS or undergoing chemotherapy are particularly vulnerable to systemic complications from oral infections. Mechanism: Weakened immune defenses allow oral pathogens to disseminate more easily, causing systemic infections. 31 Preventive Measures to Mitigate Systemic Risks Regular oral hygiene and professional cleanings. Early detection and treatment of periodontal disease. Multidisciplinary management in high-risk patients (e.g., diabetics, cardiac patients). Prophylactic antibiotics in patients with prosthetic heart valves or immunosuppression. 32 16  11/26/2024 Systemic Bacterial infections with oral involvement 33 Scarlet fever Scarlet fever is a bacterial infection caused by Streptococcus pyogenes (Group A Streptococcus, GAS). It primarily affects children aged 4–8 years and is characterized by a distinctive rash, fever, General malaise, and sore throat. The pathophysiology involves the interaction of streptococcal erythrogenic toxin with the host immune system. 34 17  11/26/2024 Clinical Features of Scarlet Fever 1. Prodromal Symptoms: Fever, chills, sore throat, and headache. Nausea and vomiting in some cases. 2. Rash (Key Feature): Appears 12–48 hours after the fever onset. Diffuse, finely papular, "sandpaper-like" texture. Begins on the neck and chest, spreading to the trunk and extremities. The rash is accentuated in skin folds (Pastia’s lines). 35 Clinical Features of Scarlet Fever 3. Tongue Changes: Initially coated with a white layer and red papillae ("white strawberry tongue"). Later progresses to a bright red appearance ("red strawberry tongue"). 4. Desquamation: After the rash subsides (around the 7–10th day), peeling occurs, particularly on the fingertips, palms, and soles. 5. Other Features: Pharyngeal erythema, tonsillar exudates, and cervical lymphadenopathy. 36 18  11/26/2024 Scarlet fever The oral mucosa is reddened The ‘strawberry tongue’ of scarlet fever: The tongue undergoes pathognomonic changes; the dorsum develops a white coating through which white edematous fungiform papillae project. The ‘raspberry tongue’ of scarlet fever: Later the white coating is shed, and the dorsum becomes smooth and red with enlarged fungiform papillae 37 38 19  11/26/2024 Treatment of Scarlet fever Antibiotics: Penicillin V or amoxicillin is the first-line treatment. Alternatives: Macrolides (e.g., erythromycin) for penicillin-allergic patients. Symptomatic Relief: Antipyretics (e.g., acetaminophen) for fever and discomfort. Hydration and soft foods for sore throat. 39 Complications (If Untreated): Acute rheumatic fever (ARF) due to immune cross-reactivity. Post-streptococcal glomerulonephritis (PSGN). Otitis media, pneumonia, or abscess formation. 40 20  11/26/2024 Tuberculosis (TB) TB is a re-emerging infectious disease caused by Mycobacterium tuberculosis. It is commonly seen in immunocompromised patients, including elderly persons. TB is rare in Western countries; however, it is being reported more frequently in recent years. This has been attributed to increased migration and spread of HIV. Although one-third of the global population is affected by TB, oral involvement is rare. When it does occur, it is usually due to open pulmonary infection or coexisting HIV. 41 Tuberculosis (TB) The oral lesion presents as a deep, painful ulcer with raised borders, gradually increased in size. Any part of the oral mucosa may be involved, although the posterior aspect of the dorsum of the tongue is the commonest site. PCR may facilitate definitive diagnosis, especially in cases with an unusual presentation. 42 21  11/26/2024 43 Tuberculosis (TB) Histopathology shows necrotizing granuloma with Langhan’s giant cells and epithelioid cells and a Ziehl–Nielsen stain reveals mycobacteria. Previous infection can sometimes be seen on facial views as radio-opacities due to calcifications within lymph nodes. Refer to a chest physician for management as combination chemotherapy is required. Often in children a lymph node excision may be required. 44 22  11/26/2024 45 Syphilis Syphilis is a sexually transmitted disease cause by Treponema pallidum. 46 23  11/26/2024 Syphilis ‘1° lesion’ A chancre (a firm, painless ulcerated nodule) develops at the site of inoculation. Genitalia and anus are the most common infectious, however, it can present on the lips or tongue. This lesion is highly infectious, and T. pallidum can easily be isolated. There is usually marked cervical lymphadenopathy which resolves spontaneously in 1–2 months. 47 Syphilis ‘2° lesion’ Develops 2–4 months after the 1° with a cutaneous rash, condylomata, and systemic features such as malaise, fever, headache, & weight loss. The oral lesions include sensitive sloughy mucous patches known as snail-track ulcers (serpiginous ulceration). These are also, highly contagious & T. pallidum can be easily isolated. Syphilis serology is positive at this stage. The ulcers generally clear up by 12 weeks, although there may be recurrences up to 1yr. 48 24  11/26/2024 Syphilis ‘3° lesion’ Develops several years later in 30% of patients & is marked by gumma formation. This is a necrotic granulomatous reaction usually affecting the palate or tongue, which enlarges & ulcerates and may lead to perforation of the palate. Lesions are non-infectious. Tertiary syphilis is a multisystem disorder causing CNS involvement and vasculitis. 49 Congenital syphilis Due to T. pallidum crossing the placental barrier leading to the classical appearance of saddle nose, frontal bossing, sensorineural deafness, Hutchinson incisors (peg-shaped with notch), and mulberry (Moon) molars. 50 25  11/26/2024 Gonorrhoea Gonorrhoea is 15 times more common than syphilis. It results from oro-genital contact with an infected partner and presents as a non-specific stomatitis or pharyngitis with frequent persisting superficial ulcers & purulent gingivitis caused by Neisseria gonorrhoeae. Swabs may reveal Gram –ve intracellular diplococci. Rx is with high-dose penicillin; sexually transmitted infections should be referred to a genitourinary medicine specialist. 51 Condition caused by BACTERIA and other causes 52 26  11/26/2024 Glossitis Glossitis refers to the inflammation of the tongue, characterized by changes in color, texture, and size. It can be acute or chronic and is often associated with other systemic or local conditions. 53 54 27  11/26/2024 1. Nutritional Deficiencies: Iron deficiency: Leads to atrophic glossitis (smooth, shiny tongue). Vitamin B12 deficiency: Associated with megaloblastic anemia and neurological symptoms. Folate deficiency. 2. Infections: Causes Bacterial: Syphilis (tertiary stage - glossitis with leukoplakia). Fungal: Candidiasis (seen in immunocompromised individuals). Viral: Herpes simplex virus or Epstein-Barr virus. 3. Trauma or Irritation: Sharp teeth or dental appliances. Excessive hot or spicy foods. Alcohol and tobacco use. 55 4. Allergic Reactions: Food allergies. Reactions to toothpaste, mouthwash, or medications. 5. Autoimmune Disorders: Causes Sjögren’s syndrome. Lichen planus. Pemphigus vulgaris. 6. Systemic Diseases: Anemias (e.g., pernicious anemia, iron-deficiency anemia). Celiac disease. 56 Kawasaki disease. 28  11/26/2024 7. Drug-Induced: Chemotherapy drugs. Causes Certain antibiotics (e.g., penicillin). 8. Idiopathic Causes: Geographic tongue (benign migratory glossitis). Median rhomboid glossitis (developmental) 57 58 29  11/26/2024 Pathogenesis The pathogenesis depends on the underlying cause: 1. Inflammation: Trauma, irritants, or infection triggers inflammatory cell infiltration leading to redness and swelling. 2. Atrophy: Deficiency of nutrients like iron or B12 causes epithelial thinning and papillae loss, resulting in a smooth tongue. 3. Immune Mechanisms: Autoimmune conditions can attack the mucosa, resulting in chronic changes like erosions or ulcers. 4. Microbial Growth: Fungal infections lead to overgrowth of Candida species, particularly in immunosuppressed individuals. 59 Clinical Features General Features: Pain: Burning sensation or tenderness of the tongue. Swelling: Enlarged tongue (macroglossia in chronic cases). Color Changes: Red (erythematous glossitis) or pale (anemia-related glossitis). Texture Changes: Smooth tongue due to atrophy of papillae (atrophic glossitis). Functional Issues: Difficulty eating, swallowing, or speaking. 60 30  11/26/2024 Clinical Features Specific Conditions: Iron Deficiency: Smooth, shiny tongue with pallor. B12 Deficiency: Beefy red tongue, often associated with neurological symptoms. Candidiasis: White plaques that can be scraped off, leaving erythematous areas. Geographic Tongue: Migratory, irregular, erythematous patches with white borders. Median Rhomboid Glossitis: Well-demarcated, red, rhomboid area on the dorsal tongue. 61 1. Address Underlying Cause: Nutritional deficiencies: Management Iron supplements for iron deficiency. Vitamin B12 injections for pernicious anemia. Folic acid supplementation for folate deficiency. Infections: Antifungal medications (e.g., nystatin, clotrimazole) for candidiasis. Antibiotics for bacterial infections. Antiviral drugs for HSV infections. Autoimmune disorders: Corticosteroids (topical or systemic) for lichen planus or pemphigus vulgaris. 62 31  11/26/2024 2. Symptomatic Relief: Topical treatments: Lidocaine gels for pain relief. Antiseptic mouth rinses. Dietary modifications: Avoid irritants (spicy foods, alcohol, tobacco). 63 3. General Measures: Maintain good oral hygiene. Use soft toothbrushes to prevent trauma. Regular dental check-ups. 4. Treatment of Chronic Glossitis: Biopsy may be required to rule out malignancy or precancerous conditions. 64 32  11/26/2024 65 Mucositis Mucositis refers to the inflammation of the mucous membranes lining the mouth and gastrointestinal (GI) tract. It is a common side effect of cancer treatments such as chemotherapy and radiotherapy, though it may also arise from infections, trauma, or other systemic conditions. 66 33  11/26/2024 Causes: 1. Cancer Treatments: Chemotherapy: Particularly drugs like methotrexate, fluorouracil, and doxorubicin. Radiotherapy: Especially when targeting the head and neck region. Hematopoietic stem cell transplantation (HSCT): Associated with severe oral mucositis. 2. Infections: Viral: Herpes simplex virus, cytomegalovirus. Fungal: Candida species. Bacterial: Opportunistic infections in immunosuppressed patients. 67 Causes: 3. Trauma: Ill-fitting dental appliances. Sharp edges of teeth or accidental biting of the mucosa. 4. Systemic Conditions: Nutritional deficiencies (iron, folate, or B12). Autoimmune diseases (e.g., pemphigus vulgaris, lichen planus). 5. Other Causes: Allergic reactions to medications or foods. Smoking, alcohol consumption, and dehydration. 68 34  11/26/2024 1. Epithelial Damage: Pathogenesis Cancer treatments or other insults damage the rapidly dividing basal epithelial cells, leading to thinning or ulceration of the mucosa. 2. Inflammation: Cytokines like interleukin-1 (IL-1) & tumor necrosis factor-alpha (TNF-α) are released, triggering inflammation and tissue injury. 69 3. Immunosuppression: The immune system's weakened state due to chemotherapy or radiotherapy allows opportunistic infections to flourish. Pathogenesis 4. Secondary Infections: Ulcers created by epithelial damage become portals for bacterial, viral, or fungal invasion, exacerbating the condition. 5. Healing Impairment: Reduced cellular turnover in the mucosa delays healing & worsens the inflammatory response. 70 35  11/26/2024 Oral Mucositis: Clinical Features Erythema: Redness of the oral mucosa, often the first sign. Ulcerations: Painful ulcers covered with a yellow or white fibrinous membrane. Burning Sensation: Pain or sensitivity to food, drinks, or oral hygiene products. Dry Mouth (Xerostomia): Often associated with head and neck radiation. Bleeding: Mucosal tissues may bleed easily with minor trauma. Difficulty Eating, Swallowing, or Speaking: Severe discomfort can lead to malnutrition and dehydration. 71 Clinical Features Gastrointestinal Mucositis: Nausea, vomiting, and diarrhea. Abdominal pain and cramping. Intestinal bleeding in severe cases. 72 36  11/26/2024 1. Preventive Measures: Oral Hygiene: Use of soft toothbrushes, fluoride toothpaste, and antiseptic mouth rinses. Management Cryotherapy (Cold Therapy): Sucking on ice chips during chemotherapy to reduce blood flow to oral tissues. Prophylactic Medications: o Palifermin (keratinocyte growth factor) to promote mucosal healing. o Antiviral, antifungal, or antibacterial agents in high-risk patients. Dietary Adjustments: Avoid spicy, acidic, or abrasive foods. 73 2. Treatment of Established Mucositis: Pain Management: Topical anesthetics (e.g., lidocaine, benzocaine mouthwash). Systemic analgesics (e.g., acetaminophen or opioids for severe pain). Anti-Inflammatory Agents: Corticosteroid mouth rinses to reduce inflammation. Sucralfate to form a protective barrier over ulcers. 74 37  11/26/2024 Infection Control: 2. Treatment of Established Mucositis: Antifungals (e.g., nystatin, fluconazole) for candidiasis. Antivirals (e.g., acyclovir) for herpes simplex virus. Antibiotics for bacterial superinfections. Mucosal Protectants: Coating agents like Gelclair or Orabase to protect damaged tissues. Use of artificial saliva for xerostomia. 75 3. Management During Cancer Treatment: Dose modification or interruption of chemotherapy or radiotherapy in severe cases. Management Low-level laser therapy (LLLT) to promote healing and reduce pain. 4. Nutritional Support: Use of liquid or soft diets. Parenteral nutrition if oral intake is severely limited. 76 38  11/26/2024 Prognosis The prognosis depends on the severity of the mucositis and the underlying cause. With appropriate management, symptoms typically resolve within a few weeks after the discontinuation of the causative agent. Chronic cases may require ongoing care to prevent complications such as secondary infections or nutritional deficiencies. 77 Thanks 78 39