4. Infectious stomatitis (herpetic, aphthous, erosive, ulcerative). Etiology, clinic picture, diagnostics, differential diagnostics and treatment.
Herpes simplex virus
Oral infection with herpes simplex virus occurs in three clinical forms. The most common type consists of recurrent small blisters on the lips commonly referred to as fever blisters or secondary herpes labialis. The second type is a generalized oral infection called primary herpetic stomatitis. The third and least common form of oral herpes infection consist of small ulcers usually localized on palatal mucosa (see picture below).
Fig. Herpes simplex virus, blisters on the soft palate
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Herpes labialis. This lesion is well known and unlikely to be a diagnostic problem. It tends to be a recurrent disease in teenagers and adults. Elapsed time between recurrences varies from person to person. Recurrences are thought to be triggered by exposure to sunlight, febrile diseases, physical and psychogenic trauma, and other irritants.
Generalized involvement of the oral mucous membrane is called primary herpetic stomatitis and represents the initial exposure to the virus. This is a one time infection, but the patient remains susceptible to recurrent or secondary oral herpes infections. It is more commonly seen in children, but teenagers and adults are also affected. Patients initially have gingivitis with swollen and red gingiva, then small blisters may appear on other mucosal surfaces. The blisters break quickly and are seldom seen by the dentist or physician. After they break, the lesions appear as small ulcers that resemble small aphthous lesions. The primary, generalized infection is accompanied by fever, cervical lymphadenitis, and inability to eat or drink without considerable pain.
Patients who suffer recurrent intraoral herpes are few. Recurrent intraoral herpes infections tend to occur as vesicles followed by small ulcers, mainly on the hard palate mucosa and often follow trauma to the area, such as palatal injections or periodontal therapy.
Herpes simplex virus (HSV) types 1 and 2 cause infections of the skin and mucous membranes and can affect several organs, resulting in a variety of clinical manifestations, some of which can be very serious. HSV-1 and HSV-2 are closely related and share common genetic material, but generally differ in their epidemiology. Transmission of viral DNA can be the result of active virus being released by the host, often from infected lesions. Close contact is required for infection, because viral particles rarely survive outside the human body for long. HSV infection is a global, year-round problem. Most oral lesions are caused by Type I virus but approximately 10% are thought to be caused by Type II.
1. Etiology and pathogenesis
Primary infection usually resolves in 10-14 days. HSV can enter the body via damaged skin or through mucosa. The virus may be acquired by neuronal tissue, which enhances its ability to spread, as well as via local invasion and blood-borne routes. After the initial infection has subsided, viral material may remain ‘hidden’ in nerve cells near the original infection site. Infection can be reactivated from this dormant state, which explains why some infections recur. Reactivation can be associated with immunosuppression, a high temperature or stress, and many episodes and states of shedding active virus can remain unknown to the host. This has implications for the rate of transmission and of course has significant meaning when dealing with HSV-2 (genital herpes).
2. Clinical features
Generally, HSV-1 is associated with oral and facial infections while HSV-2 is associated with genital lesions, although both virus types can result in infections in both areas.
When skin and mucosa are affected, the eyes, mouth or genitalia are also common sites of infection. In a first time infection, children and young adults are commonly affected. Owing to the intra-oral lesions (gingivostomatitis) caused by HSV, especially in a primary infection in children, there is a risk of reduced oral intake, potentially leading to dehydration.
A primary oral infection may cause no symptoms or it may lead to small blisters that can rupture and result in ulcers. Sometimes there are symptoms of infection – high temperature, swollen lymph nodes and general lethargy. Pharyngitis caused by HSV may be impossible to distinguish clinically from bacterial pharyngitis. In patients with reduced immunity, herpetic lesions can be more invasive and longer lasting, and may spread more easily to other organs.
Herpes labialis (cold sores) is usually a reactivation of dormant HSV and is associated with typical lip lesions (see below).
Herpetic whitlow is an infection of the finger end, as virus is transmitted directly where the skin barrier has been breached. In the healing phase, lesions eventually form crusts. Recurrence is relatively common but can be less severe than the original infection.
3. Investigations
HSV can be diagnosed by a combination of clinical and laboratory features. Where there are typical lesions, it is reasonable to make the diagnosis clinically; however, if lesions are non-specific or if the patient is immunosuppressed, this may not be possible. Viral culture, looking for viral elements such as DNA or antigen, can be taken from sampling lesions
4. Differential diagnosis:
Primary herpetic stomatitis may resemble oral lesions of erythema multiform, but herpes can be diagnosed by exfoliative cytology. A characteristic multinucleated cell appears in the smear of herpes infections. Culture of the virus is possible if a viral laboratory is available. Lesions of herpangina and hand, foot and mouth disease, both caused by Coxsackievirus, may clinically resemble oral herpes virus infections. Recurrent intraoral herpes may be confused with herpes zoster. Aphthous can be differentiated since it usually does not occur over bone, does not form vesicles and is not accompanied by fever or gingivitis.
5. Treatment
Management will depend on the site affected. Simple mouthwashes may soothe irritation of oral mucosa. Persistent or severe symptoms may require oral antivirals. Those unable to tolerate oral intake may need admission for IV fluids.
The antivirals acyclovir, famciclovir and valaciclovir may be used; all shorten lesion duration on skin and mucosa as well as reducing symptom length. Penciclovir and Abreva are available in a topical ointment. They can also be used to reduce risk of relapse in oral or genital disease. If used, these agents should be initiated as early as possible. Patients with widespread herpetic stomatitis should drink liquids to prevent dehydration. A broad-spectrum antibiotic is commonly given to control secondary bacterial infection, but does not shorten the viral infection. Antiviral drugs may shorten the duration of the disease if they are started early. Clinicians should be aware that the herpesvirus may cause disseminated infection including encephalitis in which case the prognosis is extremely grave.
Shingles
This disease often causes a painful, blistering rash. Anyone who has had chickenpox can get shingles. After the chickenpox clears, the virus stays in the body. If the virus reactivates (wakes up), the result is shingles — a painful, blistering rash. Shingles is most common in older adults. A vaccine, which can prevent shingles, is available to people ages 60 and older. Dermatologists recommend this vaccine for everyone 60 and older.
Shingles tends to cause more pain and less itching than chickenpox.
Common signs and symptoms are:
The warning: An area of skin may burn, itch, tingle, or feel very sensitive. This usually occurs in a small area on 1 side of the body. These symptoms can come and go or be constant. Most people experience this for 1 to 3 days. It can last longer.
· Rash: A rash then appears in the same area.
· Blisters: The rash soon turns into groups of clear blisters. The blisters turn yellow or bloody before they crust over (scab) and heal. The blisters tend to last 2 to 3 weeks.
· Pain: It is uncommon to have blisters without pain. Often the pain is bad enough for a doctor to prescribe painkillers. Once the blisters heal, the pain tends to lessen. The pain can last for months after the blisters clear.
· Flu-like symptoms: The person may get a fever or headache with the rash.
Fig. Shingles. The rash can be very painful and widespread.
Fig. Shingles. This patch of skin was very painful before the shingles appeared.
Shingles is a painful skin rash. It is caused by the varicella zoster virus. Shingles usually appears in a band, a strip, or a small area on one side of the face or body. It is also called herpes zoster.
Fig. Shingles. Skin lesion on the skin.
Shingles is most common in older adults and people who have weak immune systems because of stress, injury, certain medicines, or other reasons. Most people who get shingles will get better and will not get it again.
Shingles occurs when the virus that causes chickenpox starts up again in your body. After getting better from chickenpox, the virus “sleeps” (is dormant) ierve roots. In some people, it stays dormant forever. In others, the virus “wakes up” when disease, stress, or aging weakens the immune system. Some medicines may trigger the virus to wake up and cause a shingles rash. It is not clear why this happens. But after the virus becomes active again, it can only cause shingles, not chickenpox.
There is a small chance that a person with a shingles rash can spread the virus to another person who hasn’t had chickenpox and who hasn’t gotten the chickenpox vaccine.
Shingles symptoms happen in stages. At first there is a headaches or sensitive to light, flu symptoms but not a fever.
Later, may feel itching, tingling, or pain in a certain area. That’s where a band, strip, or small area of rash may occur a few days later. The rash turns into clusters of blisters. The blisters fill with fluid and then crust over. It takes 2 to 4 weeks for the blisters to heal, and they may leave scars. Some people only get a mild rash, and some do not get a rash at all.
It’s possible to feel dizzy or weak, or have long-term pain or a rash on the face, changes in vision, or a rash that spreads.
Shingles is treated with medicines. These medicines include antiviral medicines and medicines for pain. . The medicine may even prevent long-lasting nerve pain. Anti-viral medicine is most effective when started within 3 days of seeing the rash.
Starting antiviral medicine right away can help rash heal faster and be less painful. Good home care also can help feel better faster. Take care of any skin sores, and keep them clean
Recurrent aphthous stomatitis
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Today the local and systemic conditions and genetic, immunological and microbial factors all have been identified as potential causes.
Differential diagnosis
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The classic forms of RAS are minor, major, and herpetiform. Minor RAS appears as recurrent, round, closely defined, small painful ulcers with shallow necrotic centers, raised margins and erythematous halos in the labial, buccal and floor of the mouth mucosa. Major RAS is similar to the minor but is larger, deeper, often scars and can last for weeks to months. Herpetiform RAS are the least common and appears as small and numerous ulcers.
Clinical pictures
Fig.• Herpetiform aphthous ulcer in the floor of the mouth •
Fig • Typical aphthous ulcer in the upper sulcus (between upper lip & cheek)
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Fig.• Aphthous ulcer in the lower labial gingiva (lower front gum) •
Fig.• Aphthous ulcer in the buccal mucosa (cheek) •
Fig.• Large aphthous ulcer in the lower labial mucosa (lower lip) •
Fig.• Herpetiform aphthous ulcer in the floor of the mouth •
Thrush
Thrush is a common infection that affects many newborns and younger children. It is caused by the Candida albicans yeast or fungus, which can also cause vaginal infections and diaper rashes. When it infects a child’s mouth, it is called oropharyngeal Candidiasis, or more simply – thrush.
Symptoms of Thrush
Thrush is one of those infections that looks and sounds much worse than it is. Although sometimes painful, the most common symptom is for an infant to have white patches coating the inside his mouth. You may see these patches on the insides of his cheeks, on his tongue, on the roof of his mouth, and on his lips and gums as it spreads.
White, cream-colored, or yellow spots in the mouth. The spots are slightly raised. There is normally no pain in the area underneath the spots. After scraping off these spots, they leave small wounds that bleed slightly. In adults, thrush can cause an uncomfortable burning sensation in the mouth and throat.
Diagnosis
Oral thrush is an infection of yeast fungus, Candida albicans, in the mucous membranes of the mouth. Strictly speaking, thrush is only a temporary candida infection in the oral cavity of babies. But we have, for this purpose, expanded the term to include candida infections occurring in the mouth and throat of adults, also known as candidiasis. Candida is present in the oral cavity of almost half of the population. Everyone who wears dentures will have candida, without necessarily suffering any ill effects. Candida doesn’t become a problem until there’s a change in the chemistry of the oral cavity that favours candida over the other micro-organisms that are present. These changes can occur as a side-effect of taking antibiotics or drug treatment, such as chemotherapy.
These changes can also be caused by certain conditions – such as diabetes, drug abuse, and malnutrition – and as a consequence of immune deficiencies relating to old age or infection – such as AIDS. Furthermore, people whose dentures don’t fit well can sustain breaks in the mucous membranes in their mouth, which can act as a gateway for candida. People who suffer from this problem often have moist, pale pink spots on their lips, known as angular cheilitis, which is an indication of a candida infection.
Who is at special risk?
· Newborn babies.
· Denture users.
· Adults with diabetes or other metabolic disturbance.
· People with a dry mouth relating to side-effects of their medication (eg anti-psychotics) or medical conditions (eg Sjőgren’s Syndrome).
· People undergoing antibiotic or chemotherapy treatment.
· People prescribed oral steroid medication or steroid metered dose inhalers.
· Drug users.
· People with poor nutrition.
· People with an immune deficiency.
Diagnosis
In babies, thrush is usually diagnosed on the basis of the clinical picture. Occasionally, in order to make a diagnosis, the doctor will scrape the baby’s tongue and send the sample for analysis. In adults, many other diseases and illnesses, including very early stages of cancer, can have similar symptoms. Therefore it’s important to consult your doctor and get a thorough check-up. In cases where thrush occurs as the result of disease or illness in other organs or systems, like AIDS, sudden and very intense thrush can be a sign of a general aggravation of the main illness. This makes it all the more important to pay attention to this and similar changes, so you can get help in time.
Thrush Treatments
In Babies, oral thrush may clear spontaneously without treatment and may be prevented by sterilising all feeding equipment and mouth toys.Thrush is usually treated with a prescription medicine called Nystatin which is given four times a day. The dosage is 0.5ml to each side of the child’s mouth if they are under 30 days old, and 1 ml to each side of their mouth for older infants and toddlers. Treatment is continued for about 7 to 10 days and at least 3 days after you no longer see any signs of thrush. If your child’s infection isn’t quickly improving after a few days, you may want to use a gauze to directly rub the medication on the white patches. Although your child will likely swallow the dose of Nystatin, since it isn’t absorbed, it is the direct contact with the yeast that combats the infection. Fluconazole (Diflucan) is another prescription medication that can be used as an alternative to Nystatin. It has the benefit of once a day dosing, but it is more expensive than Nystatin and is usually used as a second line treatment, when Nystatin doesn’t work. Keep in mind that in one small study, Comparison of fluconazole and nystatin oral suspensions for treatment of oral candidiasis in infants, “fluconazole was shown to be superior to nystatin suspension for the treatment of oral thrush in otherwise healthy infants.”1
It’s been suggested that by giving the child sterilized water immediately following a milk feed, residual milk in the mouth is rinsed away, reducing the population of candida within the oral cavity.
In other circumstances, the condition that caused the thrush must be brought under control. This might involve investing iew and better fitting dentures, or adjusting diabetes treatment. For AIDS patients, it’s not always possible to correct the immune deficiency. A course of oral treatment, using antifungal drugs, has to be used.
Once the condition that caused the oral thrush has been treated, the thrush itself can be cured.
Treatment is with antifungal medicines, in the form of pastilles that are sucked or oral suspensions that are held in the mouth before swallowing. These allow the antifungal agent to act locally in the mouth. Examples include nystatin (eg Nystan oral suspension), amphotericin (eg Fungilin lozenges) or miconazole (eg Daktarin oral gel). In certain complicated cases, or if the infection spreads, systemic treatment will be necessary in the form of antifungal tablets, or perhaps in the form of injections. Thrush can make the mouth so sensitive that it’s impossible to perform regular oral hygiene. Use a very soft toothbrush. It can often help to rinse the mouth with a diluted solution of 3 per cent hydrogen peroxide.
Acute Necrotizing Ulcerative Gingivitis (Anug)/ Vincent’s Stomatitis/ Trench Mouth
Periodontal diseases are often classified according to their severity.Gingivitis is an infection that occurs when bacteria invade soft tissues, bone, and other places. They range from mild gingivitis, to more severe periodontitis, and finally acute necrotizing ulcerative gingivitis, which can be life threatening.Infection begins when the body’s immune system is overwhelmed. It is the interaction between host and bacteria, mostly fusospirochetes.Iecrotizing condition, punchedout gingival margin, pseudomembrane that peels off, leaving row areas. Mariginal gingiva affects, other oral tissue rarely.Acute necrotizing ulcerative gingivitis is a rapidly progressive ulceration typically starting at the tips of the interdental papilla, spreading along the gingival margins and going on to acute destruction of the periodontal tissue.
ANUG is characterized by:
1. Sudden onset
2. Precede and episode of debilitating disease like respiratory tract infection.
As a result, they often developed trench mouth, a severe form of gingivitis that causes painful, infected, bleeding gums and ulcerations.Trench mouth is also known as Vincent’s stomatitis and acute necrotizing ulcerative gingivitis (ANUG). Fortunately, regular brushing and flossing, professional tooth cleaning and antibiotics can usually clear up the infection from trench mouth. And practicing good oral hygiene can help prevent future problems.
Fig. Acute necrotizing ulcerative gingivitis
Oral symptoms:
· Sensitive to touch.
· Constant radiating, gnawing pain, intensified by hot food or mastication.
· Metallic foul taste.
· Excessive Pasty saliva.
· Feeling of ‘wooden pegs’.
Oral signs:
· Charter shaped or punched out ulcer, that involved primarily tips of interdental papilla, the labial or lingual margin or both, but never across attached gingiva.
· The edge of ulcer is defined by erythema and edema.
· Crater is covered by a gray, pseudomenbranous slough, removal of slough causes bleeding.
· Fetid odor and increased salivation.
· Spontaneous gingival bleeding upon slightest stimuli.
· Involvement may be a single tooth, a group of teeth or throughout the mouth, rare in edentulous patient.
Extra oral signs/symptoms:
Mild to moderate case:
· Local lymphadenopathy.
· Slight increase in temperature,
Severs form:
· Increase fever
· Increase pulse rate,
· Leukocytosis
· Loss of appetite
· Lassitude,
· Insomnia
· Constipation
· Headache
· Mental disease
Very severe from:
· The squeal may be
· Noma or gangrenous stomatitis.
· Fusospiracetal meningitis.
· Peritonitis,
· Toximia
· Pulmonary infection.
· Fatal brain absess.
It’s a mistake to think that a disease of the mouth isn’t serious enough to cause harm to the rest of your health. Acute necrotizing ulcerative gingivitis can become so bad that it is difficult for the patient to eat or swallow.Relatively uncommon in children. It’s pretty obvious as to why that’s a bad idea. Prompt treatment is essential to correct the problem and allow the sufferer relief from this mouth disease.
· You will notice that it is painful to brush your teeth because the bristles will keep rubbing up against the gums which become very sore due to the intense infection
· Serious case of halitosis will either begin or worsen wheecrotizing ulcerative gingivitis is present
· There will be lesions on the gums that are also called canker or mouth sores
Histopathology:
1. Inflammation of marginal gingiva involving both stratified squamus epithelium and underlying connective tissue.
2. Surface epithelium is destroyed and replace by a pseudomembranous meshwork of fibrin, necrotic cells, polymorphonuclear cells and various type of microorganism.
3. The underlying connective tissue is hyperemic with infiltration of PMN’s. Numerus plasma cells may appear the periphery of the infiltration.
4. At the immediate border, the epithelium is edematous and individual cells exhibit degeneration.
Causes:
A. Microorganisms:
a) Fusiform bacilli mainly, e. g. Fusobacterium specis (F. nucleatum)
b) Spirochetes.
c) Filamentus organism, e. g. Borrelia vencenti.
B) Predesposing factors:
-Local factors:
a) Pre existing gingivitis.
bChemical irritants e. g. smoking
C)Systemic factors:
-Nutritional deficiencydue to
· deficient diet.
· debilitating disease.
· vitamine deficiency especially vit ‘B’ complex and vit ‘C
-Debilitating disease:
· Metalic intoxication
· Severe G. I. T. disease eg, ulcerative colitis.
· Cachexia due to chronic disease e. g. Syphilis, Cancer
· Blood dyscaresias e. g. Leukemias.
-)Psychosomatic:
· Anxiety
· Depression
· Stress.
Acute Necrotizing Ulcerative Gingivitis appears with stress. College students can get it during finals and people breaking up can get it. The onset of some medical conditions such as HIV infection can cause it. Regardless of the cause, it should be treated and the cause found. People who smoke, have poor nutrition and who have dental infections are susceptible.
Clinical course of disease:
-May subside spontaneously if history of recurrence
-If untreated may cause
· Progressive destruction of periodontium.
· Denudation of root
· Systemic complications.
Treatment:
Three major aspects of treatment are:
1) Physical (oral hygine) measures:
· Removal of calculus by scaling.
· Home careRegular tooth brushing with appropiate method.
· Poor hygiene that allows plaque buildup is the primary preventable cause of ANUG, but additional factors such as smoking and compromised immune system function caused by other chronic or acute disease. Patients with ANUG typically demonstrate a reduced ability to cope with psychological and emotional stress.
· A gray, bacteriainfested film will form on your teeth and gums which will require advanced gingivitis treatment to effectively remove.
2). Drugs:
Metronidazole (for mixed infection) 200 mg, 3times daily for 3 days, after meal.
3). Use of oxidising agents:
Rinsing with-
· H2O2 directly to the gingiva:
· Chlorhexidine mouth wash.
Advantage of Metronidzole:
i) Rapidly acting
i) Not sensitinzing like penicillin,
