Bacterial infections of mouth

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Clinical Microbiology
Fifth Year

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Bacterial infections of mouth

  1. 1. Bacterial infections of mouth • • • • • Staphylococcal mucositis Streptococci - Pharyngitis Gonorrhea - Pharyngitis Syphilis – Chancre Tuberculosis – Chronic non healing granulomatous lesions
  2. 2. Staphylococcal mucositis • Causes severe mucositis of mouth in IC patients • In conjunction with Candida albicans it can cause Angular cheilitis. • Systemic diseases – Crohn’s disease, Comatose, Dehydrated, Elderly, patients on Intra Venous Fluids. • Oral discomfort, mucosal erythema, crusting and bleeding, sometimes aspiration pneumonia • Responds to regular oral lavage, Flucloxacillin.
  3. 3. Streptococci • • • • • Gram positive spherical bacteria Arranged in chains or pairs Part of normal flora of mouth Catalase negative. Important species - S. pyogenes, S. viridans (viridans group), S. agalactiae, S. equisimilis S.mutans (dental caries)
  4. 4. Virulence factors • • • • • Pyrogenic Exotoxin Hemolysins Streptokinase (Fibrinolysin) Hyaluronidase Deoxyribonucleases (Streptodornase)
  5. 5. Pathogenicity - S. pyogenes • Primary site of invasion is throat • Sore throat is the most common disease. • It may be localized as tonsillitis or diffused as Pharyngitis • Tonsillitis is more common in older children and adults, Pharyngitis is common in children • Lesions – painful, erythmatous, inflammed.
  6. 6. Viridans group (S.viridans) • Normal residents of mouth and upper RT • May species S. mitis, mutans, salivarius, sanguis. • Usually non pathogenic but can on occasions. • Endocarditis - Following dental extraction or other dental procedures transient bacteremia and implanted in damaged or prosthetic heart valves, form vegetations. • Prophylactic antibiotic coverage is mandatory
  7. 7. Scarlet Fever by S. pyogenes • Can affect the tongue or cheeks. • A typically strawberry or raspberry colored tongue is seen at an early stage. • S. pyogenes produces scarlatinal toxin or Pyrogenic exotoxin(super antigen) • The rest of the mouth and throat are also affected.
  8. 8. Dental caries by S. mutans • Mutans – assumes bacillary forms in acidic Ph • Breaks down dietary sucrose, producing acid and a tough adhesive dextran. • Acid damages dentine, dextrans bind together food debris, epithelial cells, mucus and bacteria to form plaques then leading to caries
  9. 9. Diagnosis and Management • DIAGNOSIS - Throat swab - Gram stain(cocci in chains but not confirmative) • Culture – blood agar(hemolysis α or β no hemolysis) • Blood culture in endocarditis, many samples • Antibody titer estimation. • TREATMENT – Antibiotic sensitivity testing, Penicillin G, Cephalosporins.
  10. 10. Gonococci - Microbiology • Family - Neisseriaceae, Genus – Neisseria • Gram negative oval or spherical cocci • Diplococcus with adjacent sides concave, typically Kidney shaped. • Oxidase positive. • Aerobic, non motile, non spore forming. • Found predominantly within PMN’s in smears • Selective medium – Thayer-Martin medium
  11. 11. Oral gonorrhea- Gonococcal pharyngitis • • • • Gonorrohea = flow of seeds Primary site of infection - genitalia Commonest site in oral cavity – Pharynx C/F – Oral lesions are variable, Ulceration, Pain, Edema, Vesiculation, Inflammation, Submandibular lymphadenopathy,
  12. 12. Contd,,,, • Can resemble Acute Necrotizing Gingivitis exhibiting a necrotic Pseudomembrane covering ulcerations OR A severe Erythematous inflammatory response of oral mucosa. • When seen as ulcers can be mistaken for Streptococcal infections or Multiple aphthous stomatitis
  13. 13. • DIAGNOSIS -- GRAM TAIN (G-ve intracellular diplococci) -- Culture (selective medium) Thayer-Martin medium --Positive oxidase test • TREATMENT -- Penicillin or Tetracycline -- Ceftazidime or Ceftriaxone 2grams single dose
  14. 14. Syphilis • Sexually-transmitted disease (STD) produced by Treponema pallidum, a microaerophilic spirochete which mainly infects humans and is able to invade practically any organ in the body. • 3 stages in syphils – Primary, - Secondary - Tertiary and - Congenital
  15. 15. Primary syphilis • Usually the consequence of orogenital or oroanal contact with an infectious lesion. • Incubation period is between one and four weeks and range is 9- 90 days. • Oral syphilis manifests as a SOLITARY ULCER. • Following contact, T. pallidum penetrates the genital or oral mucosa, multiplies at the site of entry, and systemically spreads via the lymphatics and blood.
  16. 16. • Chancre (ulcer )– The earliest lesion is painless • • • • deep, erosive, indurated, red or purple or brown base and an irregular raised border. Always accompanied by regional lymph node enlargement, multiple, rubbery and discrete. Chancres contain many viable Treponemes, and are highly infectious. Because it is transient and painless in nature, the initial lesion is asymptomatic. Genital in 85% of cases, anal in 10%, and oropharyngeal in 4%.
  17. 17. • Lip is common site in oral syphilis. • Oral chancres are common on upper lip in men, lower lip in women. • The tongue, palate and nostrils are occasional sites of chancre development. • Diagnosis of primary syphilis - Monoclonal antibody immuno peroxidase staining techniques from biopsy material. - Molecular methods in situ and tissue PCR. - Detecting IgM antibodies to T. pallidum may detect early infection.
  18. 18. Secondary syphilis • Oral lesions arise in at least 30% of patients with secondary syphilis. • Hard palate, Buccal mucosa or Commissures. • Occurs about 2 to 10 weeks after infection. • Hematogenous dissemination of Treponema pallidum from primary lesions. • ‘Rubbery’ cervical or generalized lymphadenopathy • 2 principal oral features are mucous patches and maculo-papular rashes.
  19. 19. Secondary syphilis • Muco-cutaneous lesions (papular, macular, annular or follicular) eruption usually confined to the palate. • Mucous patches coalesce to form ‘snail-track ulcers’ • ULCERONODULAR DISEASE (LUES MALIGNA) explosive generalized form, fever, headache, myalgia, papulo pustular eruption ,sharply demarcated ulcers with hemorrhagic brown crusts, commonly on the face and scalp (‘Moth-eaten alopecia’ Syphilitic leukoderma-patches of hypo pigmentation) • Condylomata lata
  20. 20. Secondary oral syphilis with lesions on the soft palate. Secondary oral syphilis: mucous patches covered by grayish, white pseudome mbranes of the lower vestibular mucosa
  21. 21. Tertiary Syphilis • After a variable period of latency, tertiary or late stage disease develops in about one third of untreated secondary syphilis patients. • Manifestations may take up to 10 years to appear and then present themselves as benign tertiary (gummatous lesions), Cardiovascular syphilis, or Neurosyphilis
  22. 22. Tertiary syphilis • Gumma (manifests initially as 1 or more painless swelling, ulceration, breakdown and healing, eventual bone destruction, palatal perforation and oro-nasal fistula formation) • Most commonly found on the hard palate or tongue, may be on soft palate, lower alveolus, and parotid gland • Osteomyelitis • Atrophic and interstitial glossitis • Syphilitic leukoplakia • Syphilitic sialadenitis • Trigeminal neuropathy (Hitzig’s syndrome) • Argyll-Robertson pupil
  23. 23. Congenital syphilis • • • • • • • • • Moon’s/Mulberry molars. Hutchinson’s incisors. Facial deformity High arched or ‘gothic’ palate Maxillary hypoplasia ‘Bulldog’ jaw Saddle shaped deformity of nose Frontal bossing. Mucous patches. Rhagades (scars radiating from lips) Cranial neuropathies(facial nerve paralysis)
  24. 24. Perioral fissuring (rhagades) in a 3 yearold patient with congenital syphilis
  25. 25. Diagnosis • Dark field microscopy - Direct observation. • Serology – 1. Non treponemal tests,–VDRL or RPR 2. Treponemal specific tests FTA-ABS, TPHA (Hem Agglutination), MHA-TP (Microhemagglutination) • Molecular methods – tissue PCR for all types of syphilis.
  26. 26. Treatment Condition Treatment Alternative if allergy Primary, secondary and early latent syphilis 2.4 million U IM benzathine penicillin G Doxycycline 100 mg po bds for 14 days or tetracycline 500 mg po qds for 14 days Late latent and tetiary syphilis 7.2 million U IM benzathine penicillin G as three doses of 2.4 million units at 1 week intervals Doxycycline 100 mg po bds for 28 days or tetracycline 500 mg po qds for 28 days Retreatment (unless CSF indicates neurosyphilis) 7.2 million U IM benzathine penicillin G as three doses of 2.4 million units at 1 week intervals
  27. 27. Oral Tuberculosis • Primary infection in lungs • Oral cavity - Primary lesions manifest as single, painful, non healing chronic ulcers. • Ulcer has an indurated, irregular, undermined margin, and a necrotic base. • Oral lesions variable –ulcerations, nodules, fissures, plaques, granulomas. • Most commonly the tongue, followed by the palate, the lips, the buccal mucosa, and the gingiva • Cervical and submandiular lymphadenopathy • Other features of Tuberculosis mat be present.
  28. 28. Ulcer on the ventrum of the tip of the tongue, with slightly elevated margins and a wide zone of surrounding erythema. Dorsum of anterior one-third of the tongue with erythematous, lobulated appearance.
  29. 29. Ziehl-Neelsen stain showing two acid-fast bacilli (arrows) The chronic granulomatous lesion in the submucosa of the lip
  30. 30. Diagnosis • Biopsy-histological examination (caseating granuloma), Z-N stain – AFB seen, Fluorescent stains • Culture : Lowenstein-Jensen medium • Skin testing (Mantoux test) • Molecular methods - PCR.
  31. 31. Treatment – • Combination chemotherapy with Anti T drugs • Anti Tubercular Treatment – Rifampicin, Isoniazid, Streptomycin, Ethambutol, Pyrazinamide. • Course of Six months treatment • 4 drug combination for first 2 months (isoniazid rifampicin, pyrazinamide, ethambutol) – Initiation phase -followed by 4 months of two drug combination (rifampicin, isoniazid) – continuation phase

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