FUNGI BACTERIA

DISEASE The oral focal theory

• A concept generally negleted for several decades, is controversial yet has gained renewed interest with progress in clasification and identification of oral microorganisms.

• Additionally, recent evidence associating dental with artherosclerosis and other chronic disease has also helped resurrect the focal infection theory Pathways of infection arising from oral bacteria The three pathway that may link oral bacteria to secondary disease distant from the oral nidus are : 1. Metastatic infection attributable to transient bacteria in the blood 2. Metastatic immunologic injury 3. Metastatic toxic injury

The scientific evidence weak a it is best supports of first pathway of transient bacteriemias of oral origin Mechanical prosthetic valve (arrow)

Odontogenic infection

Caries dental Necrosis of the pulp pulp polyp

Periapical abscess Periodontal infection

Periodontal abscess

Gingivitis ANUG Salivary infection Mucositis

Recurent Apthous Minor

RAS Mayor Fungal infection

• Are oral fungal common ? • No, most are associated with an underlying systemic condition immunosuppression

imunodeficiency syndrome cancer therapy anemia diabetes uremia leukemia • Patients who have conditions that modify the normal oral environment are at increased risk of fungal infection

Among these individuals are patients with _ xerostomia _ have taken broad spectrum antibiotics Diagnosis of oral fungal infection based on :

• History • Clinical appearance • Culture • Potassium hydroxide preparation • Biopsy

• What is the most common fungal infection to affect the ? • caused by Candida Albicans What is the typical clinical presentation of oral candidiasis ?

• Pseudomembranous candidiasis • Hyperplastic candidiasis • Erythematous candidiasis • Angular Pseudomembranous candidiasis ( Thrush )

• Most typical clinical presentation of the infection • White, cottage cheesy-looking raised lesions • Most often of tongue or • Can be scrapped off, leaving a painful, raw bleeding base

Hyperplastic Candidiasis

• Less common • As area at corners of the mouth or the cheeks • Unlike pseudomembranous forms, these lesions cannot be scraped off

Erythematous Candidiasis

• Most often present on the dorsal surface or edges tongue and palate • The degree of mucosal erythema may be variable • Patients with this form of candidiasis often complain of a burning mouth Viral infection

• Are viral infections of the mouth common or rare ?

Viral infections are among the most common causes of oral lesions Symptoms of acute viral infections that affects the mouth

• Vesicles or rupture small ulcers • History suggesting viremia : fever, malaise, myalgia, upper respiratory symptoms, anorexia • Pain associated lesions Group of for most oral infections:

• HS type 1,2 • Varicella-zoster virus • The epstein-barr virus • • Herpes virus 6,7,8 ( infectious in immunocompromisefd patient HIV HAS BEEN ISOLATED FROM BODY FLUIDS :  HUMAN BLOOD.  SEMEN  VAGINAL SECRETIONS.  BREAST MILK.  TEARS.  URINE.  SALIVA.  CEREBROSPINAL FLUID.  AMNIOTIC FLUID. SAN FRANSISCO, AUG. 17, 1990 :

I. CANDIDIASIS. A. Pseudomembranous candidiasis. B. Erythematous candidiasis. C. Angular cheilitis.

II. / PERIODONTITIS. A. HIV – associated gingivitis. B. HIV – associated periodontitis. III. NECROTIZING STOMATITIS.

IV. . A. Intra oral form. B. Perioral form.

V. CYTOMEGALOVIRUS. VI. VARICELLA – ZOSTER VIRUS

VII. APHTHOUS ULCERATION. A. Minor. B. Mayor. C. Herpetiform.

VIII. . IX. HIV .

X. ORAL KAPOSI SARCOMA.

XI. ORAL / PAPILOMA. A. Papilloma. B. Focal epithelial hyperplasia. TREATMENT OF THE ORAL LESIONS ASSOCIATED WITH HIV INFECTION.

CONDITION THERAPY

I. Candidiasis Antifungal (topical and / or systemic).

II. HIV- associated Plaque removal, debri- gingivitis dement, chlorhexidine, povidone iodine. CONDITION THERAPY HIV- associted Plaque removal, debri- periodontitis dement, chlorhexidine, metronidazole.

Necrotizing sto- Debridement, chlorhe- matitis xidine, metronidazole.

III. Herpes simplex If not self limiting, if prolonged, if frequen- tly recurrent  acyclo- vir.

IV. Herpes zoster Oral Acyclovir. CONDITION THERAPY

V. Aphthous ulcer Topically steroid

VI. Hairy leukoplakia Usually no treatment, severe  acyclovir

VII. Kaposi sarcoma Excision, laser, radia- tion, chemotherapy

VIII. Oral Excisison, laser

IX. Xerostomia Salivary stimulation, artificial saliva.

HIV

• The main targets for the virus are cells expressing the CD4 membrane reseptor, such as T4 helper lymphocyte, macrophages and monocyte

• Viral replication occures within the CD4 cel, leading to its destruction and loss of function. As a result the number of CD4 cell declines, and the patient become at high risk for opportunistic infections. Many medication used to treat HIV have side effect

• Abacavir oral ulceration • Flycotsine myelosuppression • Foscarnet ou &m • Ganciclovir m • Hydroxyurea ou • Interferon xerostomis,metallic taste & m • Lopinavir u & x • Pentamidine mt • Rifampin salivary discoloration • Ritonavir perioral paresthesia • Saquinavir p, neutropenia, thrombocytopenia • TMP/SMZP myelosup,ou, glositis • Dideoxycytidine my & ou Zidovudine Neutropenia

VIRUS

Viral infection causing, or associated with diseases of the :

VIRUS PENYAKIT Herpes Simpleks 1 & Primary Gingivostomatitis 2 Herpetica Recurrent Herpes Intra Oral Recurrent Varicella - Zoster Herpes Zoster

Coxsakie A Herpangina Hand, foot and mouth disease Viral infection causing, or associated with diseases of the oral mucosa : VIRUS PENYAKIT

Cytomegalovirus Salivary gland disease

Epstein Barr Hairy leukoplakia Virus Paramyxovirus

Papilomavirus Viral warts

H I V Manifestasi oral HIV INFECTION

Family

∗ Herpes simplex virus ––– 111 ∗ Herpes simplex virus –––222 ∗ Cytomegalovirus ∗ VaricellaVaricella----zosterzoster virus ∗ Epstein Barr virus ∗ Human herpes virusvirus----6666 ∗ Human herpes virusvirus----7777 ∗ Human herpes virusvirus----8888 Herpes Simplex virus –––111 ⇒⇒⇒ perioral, eyes

Herpes Simplex virus –––222 ⇒⇒⇒ genitals

TRANSMISSION : 1. Airbone droplets 2. Intimate contact HERPES SIMPLEX VIRUS INFECTION

PRIMARY RECURRENT INFECTION INFECTION PRIMARY HSV-1 INFECTION :

---Seronegative for HSV ---Children, young adult --- Does not imply clinical signs & symptoms ⇒⇒⇒ subclinical ---Incubation periode : several days ––– 2 weeks --- ⇒⇒⇒ Primary Gingivostomatitis Herpetica ⇒⇒⇒ Herpetic Whitlow PRIMARY GINGIVOSTOMATITIS HERPETICA.

CLINICAL APPEARANCES : ---Prodromal symptoms : fever, malaise, nausea, headache, lymphadenopathy. ---Vesicle →→→ rupture →→→ round/oval ulcers, shallow, greygrey----whitewhite pseudomembrane, surrounded by erythema area. ---Ulcers can coalescent →→→ large ulcers. ---Pain, disorders of swallowing, eating, secondarily infected. ---Location: any intra oral. ---Acute gingivitis marginalis →→→ gingiva are swollen with red edges that bleed easily. ---Heal : 10 –––12 days →→→ self limiting disease, without scar.

Treatment :

Goals : 1. To shorten the current attack. 2. To prevent recurrences.

Medications : ♥♥♥ Analgesics. ♥♥♥ Vitamin. ♥♥♥ Anaesthetic topical. ♥♥♥ Antivirus. RECURRENT HSV INFECTION :

---Affect 20 40% 0f adult population. ---Antibody for HSV was present. ---Reactivation of latent virus by trigger factors. --- ⇒⇒⇒ Recurrent Herpes Labialis ⇒⇒⇒ Recurent Herpes Intra Oral ⇒⇒⇒ Herpetic Whitlow. RECURRENT HERPES LABIALIS.

CLINICAL APPEARANCES : ---Prodromal symptoms : mild fever, tingling, burning or pain in which lesions will appear. --- Vesicles on the vermillion border of →→→ rupture →→→ shallow ulcer. ---Yellow crust formation. ---Problems : pain, cosmetic disfigurement, psychosocial effect. ---Heal : 1 –––2 weeks without scar. ---Recurrences is variable.

RECURRENT HERPES INTRAORAL.

CLINICAL APPEARANCES : ---Prodromal symptoms →→→ mild. ---Vesicles →→→ rupture →→→ ulcers. --- Intraorally.

Recurrent Herpes Labialis maybe seen concurently with the intraoral lesions or they occur alone.

VARICELLA –––ZOSTER VIRUS

⇒ DNA untai ganda ⇒ Neurotropic ⇒ Penularan : kontak langsung, infeksi droplet. ⇒⇒⇒ Infeksi primer dan rekuren ⇒⇒⇒ bersifat laten Varicella – zoster virus

PRIMARY INFECTION RECURRENT INFECTION

CHICKENPOX / HERPES ZOSTER / VARISELA HERPES ZOSTER :

Clinical appearancess : - Gejala prodromal : parastesi, gatal, rasa terbakar, nyeri di daerah dermatom yg terlibat. - Dermatom yg terlibat : T5, C3, L1, L2, s. trigeminal ---Ruam makulopapular →→→ vesikel →→→ ulser dengan dasar eritematus →→→ krusta. - Distribusi unilateral. - Intra oral : vesikel →→→ ruptur →→→ ulkus. ∗∗∗ Cab. Maksilaris : palatum lunak, mukosa bibir atas, uvula mukosa pipi. ∗∗∗ Cab. Mandibularis : lidah, gimngiva, mukosa bibir bawah.

TREATMENT :

---Bed rest. ---Local applications of heat. --- Topical anesthetic. ---Antiviral. ---Analgesics. ---tranquilizers.

ORAL CANDIDIASIS

A SUPERFICIAL INFECTION OF ORAL MUCOUS CAUSED BY THE YEASTLIKE FUNGUS CANDIDA ALBICANS FACTORS PREDISPOSING TO ORAL CANDIDIASIS : LOCAL FACTORS SYSTEMIC FACTORS Denture wearing Physiological Old age, infancy, pregnancy

Saliva Endocrine disorders Xerostomia, low pH Diabetes Melitus

Commensal flora Nutritional deficiencies Iron, folate, vit.B 12

HighHigh----carbohydratecarbohydrate diet Malignancies Leukemia

Smoking tobacco Immune defects HIV / AIDS

Drugs / medication Broad spectrum antibiotics Corticosteroids Cytotoxic drugs CLASSIFICATION OF ORAL CANDIDIASIS : T Y P E CLINICAL

ACUTE : Creamy / white patches on the surface of ACUTE oral mucous; forming confluent; curdcurd----likelike PSEUDOMEMBRANOUS pseudomembranes. Pseudomembranes CANDIDIASIS can be scraped off to reveal raw, = ORAL TRUSH erythematous base.

ACUTE ATROPHIC Small lesions, usually on the tongue, with CANDIDIASIS reddening / inflammation of surrounding = ANTIBIOTIC SORE TONGUE tissue T Y P E CLINICAL

CHRONIC : Chronic erythema and edema of Chronic Atrophic Candidiasis upper palate localized to occluded / = Denture Stomatitis traumatized tissue

Chronic hyperplastic White patch adherent to mucous on Candidiasis an erythematous base which is not = Candida Leukoplakia removable by digital pressure. Usually on the anterior buccak mucous

Angular cheilitis Erythema, fissure and encrustations =Perleche at corners of mouth.

DIAGNOSIS :

CLINICAL APPEARANCES +++ LABORATORIUM EXAMINATIONS : * Culture * Cytologic * Serology TREATMENT :

⇒⇒⇒ To correct predisposing factors ⇒ To correct sources of infection ⇒ Antifungal drugs ANTIFUNGAL DRUGS

POLYENE AZOLES

A. AMFOTERICIN B A. IMIDIAZOLE : - Clotrimazole B. NYSTATIN - Ketoconazole - Miconazole

B. TRIAZOLE : - Fluconazole - Itraconazole Viral Infections of the Oral mucosa

Systemic signs - Malaise - Anorexia - Fever -Myalgia

Oral signs - Croppy vesicle - Coated tongue - Ulceration becaused of ruptured vesicle pain I Herpes Simplex

1. Primary Herpetic Gingivostomatitis 2. Recurrent Herpes Simplex

II. Herpes Zozter Primary Herpetic Ginggivostomatitis

Clinical signs 1. Classic viral prodrome - malaise - arthralgia - anorexia - fever and chills 2. Triad of lesion ( after 24-48 hours ) - Vesicle rupture large, painful ulcerated area - Acute ginggivitis swelling, redness and bleeding - Tongue white coating

3. Submandibular and cervical lymphadenopathy

Diagnosis Based on history and appearance of the lesion

Treatment - Self limiting in healthy patient - Acute phase rarely lasts more than 1 week - Secondary infection Antibiotic - Bed rest - Aspirin to control fever and pain - Large fluid intake - Paliative mouth rinses Labialis ) Reactivation of the herpes virus previously

Proposed to : seasonal and related to cold, sunlight, stress immunosuppression, trauma, fever.

Clinical signs - Single or multiple small ( 2 -4 mm in diameter ) vesicle - at the mucocutaneous junction ( vermillion border ) at the corner of the mouth - Vesicle rupture in 36-48 hours ulcer crusted - Uncomportable

Treatment - Healthy patient : application of acyclovir ointment - Keep the lesion lubricated Herpes Zoster

Herpes zoster is a painful viral infection of the posterior root ganglia trigeminal nerve face and oral cavity

Etiology Clinical signs

- Extreme unilateral pain - Approximately 3-5 days later crops of small vesicle linear distribution unilateral - Vesicle rupture ulcerative lesion on the erythematous base - Lesion uncomfortable - Oral lesion : buccal, labial, palatal mucosa, lips - Healing complete in 7-14 days

Complication

- Neuralgia - Facial paralysis - Corneal scarring

Treatment

- Paliative - Self limiting - Severe case : intravenous acyclovir HIVHIV // AIDSAIDS

AIDS : Acquired Immune Deficiency Syndrome Caused by : Human Immunodefiency Virus

Transmission - Sexual contact - Parenterally / Blood Transfusion - Mucous contact with HIV contaminated blood - Perinatally Groups risk patient -Intravenous drug users - Homosexual or heterosexual - Infants - HIV infected mothers - Hemophiliac Virus Lymphocyte

immunologic functions

Opportunistic Infections HIV detection in : - blood - saliva - semen - Vaginal secretion - breast milk - tears - bronchoalveolar secretion - urine - faeces Fungal Infection In the mouth uncommon, often associated with an underlying systemic disorder

Predispose to fungal infection - Diabetes Mellitus - Leukemia - Aplastic anemia - AIDS - Immunosuppression - Inestion of Antibiotic Diagnosis Based on history, clinical appearance, culture or biopsy

Candidiasis Cause : Candida albicans (50%)

Predispose factor - Change in marrow status aplastic anemia - Drugs chemotherapy - Immunosuppressive therapy steroid - Debilitated individual - Prolonged use of Antibiotic - AIDS Clinical signs

1. Pseudomembranous candidiasis 2. Hyperplastic candidiasis 3. Erythematous candidiasis Pseudomembranous candidiasis

-Classic and most common - Raised, white area of palate and tongue - White area : necrotic can be scraped off with a wet tongue blade leaving a raw, bleeding surface

Hyperplastic candidiasis - Less common - Raised, white, non scrapable lesions in the commissures of the mouth - HIV buccal mucosa Erythematous candidiasis

- Most often on the palate, dorsal surface of the tongue - Characterized, red area of oral mucosa - Burning mouth/ often painful - Angular cheilitis - Factors that predispose : systemic Antibiotic therapy inhaled steroid therapy immunosuppression (underlying) HIV infection Tuberculosis

Tuberculosis is a widespread infectious disease caused by Mycobacterium Tuberculosis that affects humans, animal and birds

Predisposing factors - Poor nutrition - General debilitating diseases - Iatrogenic immunosuppression - Overcrowded living conditions - Certain respiratory diseases Symptoms

- Weight loss - Mild cough --- Persistent cough accompanied by bloody sputum - Anorexia - Fatigability - Afternoon rise in temperature - Night sweats - Cavitary pneumonia in chest radiograph Oral Manifestations

Pulmonary Tuberculosis Oral Contact of the oral tissues with infected sputum Sites : - lips, buccal mucosa , tongue, palate, corner of the mouth - Periapikal dental granulomata - Salivary gland - Tuberculosis periostitis Lips : small tubercle ulcer Cheeks : irregular undermined border Tongue : most common lateral margin site of irritant deep central ulcer base thick mucous material Diagnosis - Tuberculin test positive - Chest radiography - Systemic symptom - Smear sputum

Differential Diagnosis - Chancre - Gumma - Carcinoma - Traumatic ulcer - Infection ulcer Medical and Dental management

Patients at high risk are highly contagious Dental procedure should be deferred Patient referred to their physician for further evaluation and management GONORRHEA

Gonorrhea is an almost exclusively sexually transmitted infection caused by a gram negative intracellulary located diplococcus Neisseria gonorrhoeae Clinical Feature

-Most common site is urethra - Incubation period 2-8 day - Most frequently seen in patients 12-15 years old - High risk : military personnel, migrant group, homosexual men, prostitutes - Profuse purulent urethral discharge in male - In female more mild. asymptomatic Oral Findings

• Asymptomatic • Lesions occur within a week of genital contact • Similar to Acute Necritizing Ulcerative Ginggivitis (ANUG) • Gonococcal stomatitis • Diffuse areas of mucosal erythema Medical and Dental management

- Referred to the physician for definitive treatment - Routine dental care should be postponed until treatment is completed