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Oral infections 1. Dr Bródy Andrea Semmelweis Egyetem Orális Diagnosztikai Tanszék The significance of infectious diseases Same pathogenic – different consequences • In the 1960s we were convinced that the final victory over infectious diseases was only a matter of time - antibacterial, antifungal, anti-parasite medicines - vaccinations The significance of infectious diseases Fought diseases rise again – causes • Most people die of infectious diseases in the world • More relations are discovered between infectious and other diseases (Chlamydias – atherosclerosis, Helycobacter pylori – ulcus, etc.) • New and altered pathogenics appear (Zika virus, Lyme disease, Legionellosis, TBC, malaria, HIV, heartworm) • Anti-vaccination movements, wars – the danger of endemics is increasing again • Appearence of the pathogenics in new places • Change of sexual habits The significance of infectious diseases causes Fought diseases rise again • Fast and cheap travel opportunities – importing new diseases Not diagnosed properly Wrong treatment • Not enough responsible drug therapy • Agressive therapy for severe diseases Survival rate increases Nosocomialis infections Therapeutical side effects • Average age rise • Environmental changes Factors determining the formation of infections Same pathogenic – different consequences Virulence of the microorganism Size of inoculum infection Immunity of the host body Grouping of pathogenics Three main groups • Obligate Causes infection in responsive person • Facultative Causes disease under only certain circumstances • Opportunistic Causes infection only in case of altered immunity • • nosocomialis infections sexually transmitted infections Nosocomialis infections • Growing proportion among all infectious diseases • Patients from infectious departments are out to the general departments • Pathogenics are different from the „street” versions - resistance • Treatment is becoming more challenging Pathogenics and the host body • In the body, special microflora is found in each place • Substances produced by microbes: Making it possible to bond to the tissue (adhesion) Blocking the adhesion of other microbes, so the colonised microflores create a defensive ring towards the outside (colonisation resistance, immunity) Unnecessary antibiotic use destroys this defensive function!!! Infection or colonisation? • Microorganisms settle in the tissues in both If there’s no response: colonisation In case of response: infection (may be with or without symptoms) • An important question is whether the isolated microbe is a part of the flora or is an infectious agent? (e.g. Candida detection) Factors determining the outcome of the infection • The virulence, quantity, drug sensitivity of the the pathogenic • Place of infection • Immunity • Quality of the applied treatment Systematic relations of oral cavity infections Systematic infections often cause symptoms in the oral cavity Primary oral cavity infections also cause systematic consequences every time. Oral cavity viral infections Dicovery of the viruses BEIJERINCK Infected healthy plants with the filtrate of mosaic viruses (1898) „contagium vivum fluidum” It occured in 1903 already that viruses may cause tumors. The viruses • They consist of genetic substances (DNA, RNA) and protein • Their size range is between 20 nm to 300 nm • They multiple by getting into and using living cells – they reprogram the host cells infectious genetic information • The virus out of the cells is the virion • The virion consists of the DNA (or RNA) and a protein shell (capsid). In some cases an additional lipoprotein shell, the peplon is found. • Special viruses: • Bacteriophages • Retroviruses • Viral infections cause symptoms in the oral cavity in a significant number of the infections, furthermore, often they appear only there or they appear there for the first time. However, infection always a systematic problem. • Detection is important for the following reasons: • Early treatment, • To prevent further spreading • Diagnosis: clinical symptoms, serology, DNA (RNA) examination • Most viral infections are spread by saliva or other body fluids. They are found in big numbers mostly where close body or body fluid contact occurs. Children are particularly sensitive. • In developed countries childhood infections are frequently skipped, therefore adult primer infections are more often detected. The effect of viruses on the human body • Immediate, possibly life threatening disease (Grippe, Ebola) • Slowly developing disease, e.g. tumor (HPV, hepatitis B,C, TBC), slow viruses (sclerosis multiplex, kuru) • Destruction of the immune system (HIV) • Stimulation of the immune system Enteroviruses (Picornaviruses) • They spread enterally in the mucosa of the intestines mostly causing a mild infection faecal-oral way • They leave life-long immunity behind • Frequent diseases: Herpangina, Poliomyelitis, Hand, foot, and mouth diseases 18 Herpangina • In the back region of the oral cavity – only on the soft palate and the uvula – small ulcers develop. • Diagnosis: based on clinical symptoms (especially children) • Treatment: symptomatic 19 Hand, foot, and mouth disease • Mostly caused by Coxsackie A or B virus • Beyond vesicular skin symptoms it may cause enchephalomyelitis as well • Mostly mild disease, it heals by itself within approximately a week • Slight fever, red throat • Vesiculas surrounded by inflamed frame Differential diagnosis: varicella, impetigo, aphta, Kawasaki disease, herpangina Herpes viruses They belong to the DNA viruses. Their typical attribute is that they are capable of hiding for a long time in the human body by evading the immune system and cause diseases that flare up from time to time. Type Name 1 Herpes simplex 1 (HSV-1) 2 Herpes simplex 2 (HSV-2) 3 Herpes varicella-zoster (VZV) 4 Epstein-Barr (EBV) 5 Cytomegalovirus (CMV) 6 Human herpes virus 6 7 Human herpes virus 7 8 Human herpes virus 8 (Kaposi sarcoma) • Herpes simplex viruses 1. HSV-1 Primarily causes oral cavity infections however it tends to play a role more and more often in anogenital infections. • It multiplies in the skin or mucosa and then reaches the sensing ganglions, where it’s persisted • Upon the first encounter, especially in children it usually causes acute gingivostomatitis herpetica Unpleasent breath, fever, bad general feeling, vesiculas and ulcers, plaque, pain • Treatment: accurate mouth hygiene, painkillers, antiseptic rinsing, spice free diet, fluids, antiviral drugs (e.g. Aciclovir) Differential diagnosis: Herpangina, aphta, Hand, foot and mouth disease Herpes simplex 1 Herpes labialis, herpes intraoralis • The persisting virus is activated by different stimuli or the declining of the immune system. • Primarily lip, face and oral cavity Differential diagnosis: Herpangina, aphtas, Hand, foot and mouth disease, impetigo Herpes simplex viruses 2. HSV-2 • One fifth of the American adult population is infected with HSV-2 • Primarily causes anogenital infection • Infection during pregnancy may lead to the death of the foetus Differential diagnosis: Herpangina, aphta, Hand, foot and mouth disease 3. Varicella • First encounter – chickenpox • Mostly mild disease, extraordinarily contagious Spreads by droplet infection • Infection during pregnancy may lead to the death of both the foetus and the mother • • • • • Foetus: severe malformations Mother: fulminans varicella pneumonia Endangered as well: Smokers! People with weakened immune system Small vesiculas may appear in the mouth as well – e.g. on the hard palate After the elapse of the disease the virus may persist in the ganglions Reactivated - herpes zoster Treatment: symptomatic. (Reye!) Using antiviral drugs may be effective. Prevention: vaccination within 3 days upon exposion 25 3. Herpes Zoster • The extraordinarily painful and itchy vesiculas appear by the nerve paths – in case of trigeminus affection e.g. on the face and cornea – urgent consultation with an oculist is advised • The vesiculas appear on only one side of the oral cavity too and they follow the path of the nerves – may imitate tooth pain or may cause facialis paresis • It is life threatening for immune deficient people • Treatment: antiviral drugs orally or IV • Postherpeticus pain 26 4. Epstein-Barr Mononucleosis infectiosa, Burkitt lymphoma, B cell lymphomas, nasopharyngealis carcinoma, inflammation of the salivary glands, hairy leukoplakia in immune deficient people In a significant number of people the virus persists without symptoms during their whole lifetime. The decline of the immune system may lead to the activation of the virus and the development of different tumors (e.g. Non-Hodgkin lymphomas, nasopharynx- and stomach carcinoma). 4. Epstein-Barr • Mononucleosis infectiosa: It may be detected during the disease and for a few months afterwards from the saliva – it is spread by saliva but its infectious capacity is low • Symptoms: Throat pain, swollen lymphatic nodes, low fever, general bad feeling, swollen upper eyelid • Angina type – ulcers in the pharynx and the tonsils, possibly oedema too, sore throat • Glandular type (Pfeiffer glandular fever) – enlarged lymphatic nodes and swollen liver and splenes • Differential diagnosis – serology • Atypical mononuclear cells • Treatment: Symptomic 28 4. Epstein-Barr Burkitt lymphoma • Non-Hodgkin lymphoma • The endemic form appears in malaria infected territories in young children. • The sporadic form worldwide – mostly abdominal Bcell origin lymphoma • Not too malignant – 3 year survive is around 80% 4. Epstein-Barr Hairy leukoplakia • In people with immunodeficiency– often in HIV infected people • No malignant • In the background some immundeficiency is existing 4. Epstein-Barr Malignus tumors • Carcinoma: EBV transformer effect + weak immune system + enviromental factors • Malignus lymphomas – in transplanteted person and patients with AIDS – polyclonal B lymphocyta proliferation– the weakened cellular immunity system cannot react properly In 95% of the people the virus persists without any symptoms through their whole lifetime. 5. Cytomegalovirus • Only the human cytomegalovirus causes human infection • 50-80% of people go through it by the time of reaching adulthood, and the virus may persist • Symptoms only develop in 1% of the cases, they resemble mononucleosis. • Infection in the uterus causes serious malformations • Swollen saliva glands • Often causes the death of AIDS patients cytomegalic inclusion disease Exanthema subitum – Herpes virus 6, 7 • • • • Mild rash disease May activate the HIV virus By the age of 2-3 practically everybody gets over it There are no typical oral symptoms Kaposi sarcoma - herpes virus 8 (KSHV) • This virus plays a role in the development of more than one type of tumors • The Kaposi sarcoma is an endotelial, vascular originated tumor – angiogenetic tumor • It is transmitted sexually, nosocomial infection is not known • Often occurs in AIDS patients Mumps virus Parotitis epidemica • Childhood disease. One or two side swelling of the parotis appears (other big salivary glands may be affected too) • May be spread by droplet infection • Diagnosis: clinical symptoms – swelling, erythema and oedema of the ductus Stenon, pain (eating, opening) • Complications often occur Differential diagnosis: stone, other salivary gland inflammation, enlarging lymphatic nodes, tooth originated inflammation Morbilli • Dangerous childhood disease. Main characteristics are maculo-papulosus rash, fever, respiratory symptoms and often severe complications (pneumonia, enchephalitis, stomatitis gangraenosa) • It is spread by droplet infection • Differential diagnosis: herpes, herpangina • The virus has an immunstimulate effect Morbilli - Koplik spot • Simultaneously with the appearance of the catarrhal symptoms, first erythematosus then red sided white spots show up and disappear within 1-2 days. Papilloma (HPV) virus • The human papilloma virus infects the cells of the epithelium and the mucosa • HPV 1-4 – warts appear on the skin, but occasionally on the gingiva and the hard palate as well. • Condyloma acuminatum: HPV6, HPV 11 • Infection: with close contact, in dressing rooms, passing newborn through the vagina, sexual transmission • Certain strains are oncogens – e.g. cervix carcinoma, pharinx carcinoma (HPV 16,18,33) • Prevention: vaccination, sexual habits Pox viruses – molluscum contagiosum • Large viruses that may be seen with light microscop too • Wart-like, beningnant deformations in the skin and/or the mucosa • Transmission via direct contact • Spontaneously heals after a few months • Treatment: removal or freezing or waiting HIV, AIDS Due to the suppression of the immune system a wide range of diseases threaten the patient • • • • • • Candidiasis Linearis gingiva erythema Herpes simplex infections Kaposi sarcoma, hairy leukoplakia, lymphoma Necrotising gingivitis Necrotising parodontitis Tumor viruses • • • • • More strains of the human papilloma Epstein-Barr Human herpes virus 8 Molluscum contagiosum Hepatitis B, C Other viral infections with dental significance • Hepatitis B, C • Influenza • And the latest threat: Ebola Treatment of infectious patients • In case of an acute infection, if possible, the treatment has to be delayed or a conservative solution is advised to be chosen Exception: pulpitis, periapicalis abcessus • In case of a chronical infection, providing treatment may not be denied! • In most cases, exposion with the blood or body fluid of a HBV, HCV or HIV infected person does not lead to infection. • For HIV, probability of infection after exposion is 0,3% • For HBV and sensitive persons is 6-30%, for HCV it is 1,8%, • Contact of small quantity of blood with intact skin does not hold any risk. Prevention of the spread of infection • Should be called in to consultation as the last patient • Mouth hygiene has emphasized significance, chlorine hexidine rinsing • Wearing protective gear is especially important - mask, glasses, plexiglass, gloves • The use of turbine and depurator should be avoided • Sterilization must be carried out as normally!! Thank you for your attention!