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7/30/2019 Infections of the Oral Mucosa 2 (Slide 12 +13)
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Infections of the Oral Mucosa
2
Dr. Rima Safadi
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Fungal Infections
Candida albicans
Dimorphic
Multiply by budding
Commensal
Others like C.
glabrata, tropicalis,parapsilosis, C. kruseiare also pathogenic
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Fungal InfectionsCandida albicans
Variable carriagerates around 40%...
Mainly on the tongue Candidal counts
overlap betweenpatients (infection)
and carriers Presence of hyphae in
smears is importantfor diagnosis
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Candidosis Opportunistic pathogen
Disturbance of balance between host and
organism (homeostatic balance)
Factors: local and systemic
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Candidosis
Factors predisposing to candidal infection
Local factors: trauma, denture hygiene,
tobacco smoking, carbohydrate-rich dietAge
Drugs: broad spectrum AB, steroids, cytotoxic
drugs Xerostomia
Systemic diseases
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Candidosis
Protection against candidal infection
Non specific factors: shedding ofepithelium, salivary flow, commensalbacteria
Specific:
Serum antibodies: less important
Secretory immunity is more important (itdecreases adherence of candida)
Cell mediated
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Candidosis
Pathogenesis of Candidal infection
Adherence
Secretion of enzymes: proteineases
Invasion of epithelium by hyphae
Secretion of nitrosamine compounds ? Type 4 hypersensitivity to candidal
pathogens
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PAS stain
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Classification of Oral Candidosis
Classifications: acute or chronic, oral or extraoral
Acute:
Psuedomembranous
Erythematous (atrophic)
Chronic
Psuedomembranous
Erythematous (atrophic) Hyperplastic (candidal leukoplakia)
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Classification of Oral Candidosis
Candida associated lesions:
Denture stomatitisAngular cheilitis
Median Rhomboid glossitis
Secondary oral candidosis:
Systemic mucocutanous candidosis
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Acute Pseudomembranous
Candidosis (Thrush) Pain or burning Predisposing:
xerostomia, antibiotics
decreased hostresistance
5 % of infants, 10%of elderly
White plaques and red base
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Acute Pseudomembranous
Candidosis (Thrush)
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Acute Erythematous (Atrophic)
Candidosis (antibiotic sore
tongue)
Generalized pain,burning, erythema
Prolongedcorticosteroids or
antibiotics Red and painful
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Chronic Atrophic Candidosis (Candida-
associated denture stomatitis) Secondary infection by Candida intissues modified by continualwearing of dentures
Poor denture hygiene High carbohydrate diet
May be asymptomatic
Candida colonize the denture
surface Minimal or no candidal invasion of
mucosa
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3 patterns ofinflammation (Newtonsclassification):
1. Pinpointed erythema
2. Diffuse erythema
3. Granular or multinodular(chronic inflammatorypapillary hyperplasia)
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Chronic Hyperplastic Candidosis
(Candidal Leukoplakia) Persistent white patch Speckled/nodular
Most frequent location:buccal mucosa atcommissures
Triangular Bilateral
Associated with angularcheilities?
Strong association withsmoking Local factors?
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Chronic Hyperplastic Candidosis
(Candidal Leukoplakia) Can be multifocal
Chronic multifocal oralcandidosis
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Chronic Hyperplastic Candidosis
(Candidal Leukoplakia)
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Chronic Hyperplastic Candidosis
(Candidal Leukoplakia)
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PAS Stain
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Chronic Hyperplastic Candidosis(Candidal Leukoplakia)
Premalignant?????
50% associated with
epithelial dysplasia
15% progress to true dysplasia
Most of candidal leukoplakias are non homogenous
Candidacan generate carcinogenes like nitrosamine
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Angular Cheilitis
Fungal or bacterial orcombined
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Angular Cheilitis Multifactorial disease of
infectious origin
Candida or Staph aureus orStreptoccocci
Mainly in denture wearers
30% of patient with
denture stomatitis haveanguar cheilitis
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Angular Cheilitis Cracks, fissures, crusts,
pain in commissure area
Loss of vertical
dimension Deep folds of skin at
angles of mouth
Continual wetting by
saliva Nutritional deficiencies
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PAS stain modified for fungi
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Median Rhomboid Glossitis
Just anterior to foramen
cecum
Red depapillated smooth or
fissured asymptomatic
Etiologic debate Developmental or chronic candidal
infection Opposing lesion on the palate
may be seen Multifocal candidosis
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Chronic mucocutanous candidosis
Persistent superficial infection of: skin,mucosa, nails
Oral mucosa involved in most cases
Orally: similar to candidal leukoplakia
May be multifocal
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Deep fungal infections
Non specificulceration
Or Granulomatous areas
Blastomycosis
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Histoplasmosis
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Zycomycosis
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HIV infection and AIDS
Sero-conversion: detection of HIV antibodies in blood in 3 months May have also acute symptoms
Sero-postitive for many yearslater on Persistent generalized lymphadenopathy AIDS related complex:persisitent pyrexia, lymphadenopathy, diarrhea, weight
loss, fatigue and malaiseFinal Stage: Fully developed AIDS: opportunistic infections,
Kaposi sarcoma, non Hodgekins lymphoma.
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Infection by the virus means: virus binds to:CD4 T lymphocytes, macrophages, CNS cells,
endothelial cells
CD4 cells die leading to decrease number of T
helper
Impaired immunity particularly against: viruses,
fungi and encapsulated bacteria.
Table 11.5 in your text book groups the lesionsassociated with AIDS
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Oral Manifestations of HIV infection
Oral candidosis Most frequent oral manifestation Azole resistant species Psuedomembranous and erythematous are most
frequent types. Chronic, multifocal May involve any part of the oral mucosa
Hyperplastic type involves buccal mucosa rarely
commissures Prevalence:
20% of HIV seropositve positive patients 70% of AIDS have oral candidosis
Prev. decreasing with introductions of HAART
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Viral Infections
HSV, HZV: more severe and extensivethan HIV negative pts
Dissimenated CMV infection
Kaposi sarcoma and HHV8
EBV and Hairy leukoplakia
Oral Warts is increasing.
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Hairy Leukoplakia Common in late stage
HIV infection indicatingAIDS
Vertical white folds onlateral border of thetongue, bilaterally
White patch that can not
be removed May have smooth flat
surface
May have candidal
hyphae but as secondary
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Hairy Leukoplakia
Opportunistic infection oforal epithelium by EBV
After primary infectionshedding from oropharynxor salivary glands persists
Minor trauma to tongue
facilitates infection withvirus
Marked reduction oflangerhans cells
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Hairy leukoplakia
In 20-25% of patients
May indicate the development of AIDS
Can occur in pts receivingimmunosuppressive medications
NOT pre malignant
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Hairy leukoplakia
Acanthosis
Parakeratosis
Finger like surface projectionsof parakeratin
Absence of inflammatory cellsin epithelium and laminapropria
Swollen or balloon cells withprominent cell boundaries in
pricke cell layer belowparakeratin
Perinuclear vaculization, smalldrak nuclei: koilocyte-like cells
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HIV associated periodontal
diseases 1. Linear gingival erythema
2. NUG
3. NUP
HIV Gi i iti
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HIV-Gingivitislinear gingival erythema
Linear band of erythema -free gingival margin
Not responsive to plaquecontrol
Gingival hyperaemia due torelease of vasoactivecytokines rather thaninflammation
Has been associated with C.albicans
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Necrotizing Ulcerative Periodontitis
Severe rapidly destructiveprocess
Necrosis of gingival andperiodontal tissues
Exposure of alveolar boneand sequestration
Due to sever impairmentof local defensivemechanisms likereduction in CD4 cells
Defects usually localized
Not responsive toconventional periodontal
therapy
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ANU periodontitis
Acute Necrotizing Ulcerative
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Acute Necrotizing UlcerativeGingivitis
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Kaposis sarcoma
Clinical features
Commonest tumor associated with AIDS
But with low prevalence especially with medications
Male more than females
Associated with HHV8
Multifocal tumor: skin and mucosa
Mainly palatal lesion, tip of the nose
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Kaposis Sarcoma
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Kaposis sarcoma
Clinical: Kaposis sarcoma can be a surface lesion or a
soft tissue enlargement.
red purple patch
macular
Plaque
Nodular Multiple lesions common
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Kaposi sarcoma
Proliferating endothelialcells
Cleft like vascularchannels
Extravasated RBC Inflammation Occasional atypical cells
Later stages more atypical
cells Early stages difficult to
differentiate it from othervascular lesions
Slit-like vessels
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Oral manifestations of HIV infection
Non Hodgkins lymphoma
Neurological disturbances: HIV is neurotropic may directly involve CNS
Facial nerve palsy Atypical ulceration: resemble aphthous stomatitis may be
associated with CMV
Salivary gland disease: xerostomia
Salivary gland enlargement associated with lymphocytic infiltrate
Lymphoepithelial cysts
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HIV associated HSV infection
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HIV associated HZV infection
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HIV thrombocytopenic purpura,autoimmune response
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HIV oral ulceration
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HIV lymphoma
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