Oral Medicine

Bacterial Infections
Dr. Tamar Kartin - Gabbay

The Department of Oral Medicine

The Hebrew University and Hadassah,
School of Dental Medicine and School of medicine
 Bacterial conditions
üTuberculosis
üLeprosy
üActinomycosis
üNoma
üSTD
üSyphilis
üGonorrhea
 Tuberculosis
• Most common cause of infection-related
death worldwide.
• 1993 - WHO declared TB to be a global
public health emergency.
• In Israel – New immigrants from
endemic countries in eastern Europe and
Africa.
 ‫הארעות של שחפת בישראל‪1989-2002 ,‬‬
‫)שיעור ל – ‪(100,000‬‬
‫‪12‬‬

‫‪10‬‬

‫‪8‬‬

‫‪6‬‬

‫‪4‬‬

‫‪2‬‬

‫‪0‬‬
‫‪89‬‬ ‫‪90‬‬ ‫‪91‬‬ ‫‪92‬‬ ‫‪93‬‬ ‫‪94‬‬ ‫‪95‬‬ ‫‪96‬‬ ‫‪97‬‬ ‫‪98‬‬ ‫‪99 2000 2001 2002‬‬
‫*‬
‫שנת דווח‬

‫‪Dept. of TB & AIDS, MOH, Jerusalem‬‬ ‫* שיעור זמני‬

 Pathophysiology

• M tuberculosis
• aerobic bacillus
• non–spore-forming
• slow-growing
• survives under adverse
environmental conditions.
• Humans are the only known
reservoirs for M. tuberculosis
 Pathophysiology
• Aerosol - infective droplet nucleus
– 5µm.
• Contain approximately 1-10 bacilli.
• 5-200 inhaled bacilli are necessary
for infection.
• Droplets are inhaled.
 Pathophysiology
• Bacilli are deposited into the
distal respiratory bronchiole
or alveoli, (subpleural).
• Alveolar macrophages
phagocytose the inhaled
bacilli.
• But macrophages are unable
to kill the mycobacteria,
• Bacilli continue to multiply
unimpeded.
 Pathophysiology
• Transportation of the
infected macrophages
to regional lymph
nodes.
• Lymphohematogenous
dissemination of the
mycobacteria to
other lymph nodes
and organs.
 Pathophysiology
• Cell mediated
immune response
• Elimination of
bacteria with
macrophages
• Formation of
granulomas
Histopathology
 Miliary TB
• Spread of
Mycobacterium
tuberculosis, to
other organs and
lymphatic system.

• Single/multiple
organ spread.
 Signs and symptoms

• Primary TB :
• Absence of any signs
on clinical evaluation.
• Positive Tuberculin
hypersensitivity
 Signs and symptoms
• Pulmonary
– endobronchial TB with focal
lymphadenopathy
– progressive pulmonary disease
– pleural involvement
– reactivated pulmonary disease
 Signs and symptoms
• Extrapulmonary TB
– peripheral lymphadenopathy
– tubercular meningitis
– miliary TB
– skeletal TB
– Other organ involvement.
 Scrofulosis
• Lymphadenopathy:
– anterior or posterior
cervical supraclavicular
nodes
– submandibular,
– submental,
– axillary,
– inguinal

• Nodes are firm and

nontender
• Nonerythematous overlying
skin.
• Nonfluctuant.
• Suppuration and spontaneous
drainage of the lymph nodes
• Caseation and the
development of necrosis
Scrofulas
 Bone Tuberculosis
• Large weight bearing
bones or joints:
– vertebrae (50%),
– hip (15%),
– knee (15%).
• Destruction of the
bones with
deformity
 Oral manifestations
• Following of
implantation of
bacteria on mucosal
surface.
– Tongue
– Palate
• Indurated chronic
non healing ulcer
• Usually painful.
 Oral TB
• Organism is present
in the base of the
ulcer.
• Thus contagious to
dental staff.
• Jaw involvement
after hematological
dissemination
– TB osteomyelitis
 Differential Diagnosis
• Syphilis
• Deep fungal infection
• Squamous cell carcinoma
• Traumatic ulcer
 Treatment
• Isoniazide
• Rifampin
• Streptomycin
• Ethambutol

• Prolonged treatment
Leprosy
 Leprosy
• Hansen’s Disease 1873
• First bacterium to be
identified as causing
disease in man
• Mycobacterium Leprae
• Acid fast bacillus
• Disease affects:
– Skin
– Peripheral nerves
– Mucosa of the upper
respiratory tract
– Eyes
Hosts
 Contagious?

• Only moderately
• Requires repeated
frequent direct
contact with
infected person for
a long period of
time.
 Clinical features
• Clinical spectrum:
– Tuberculoid leprosy – limited form
– Lepromatous leprae – generalized form
• Skin – erytematous plaques/ nodules
• Mucosa – lesion resemble skin lesions.
• PNS – anesthesia.
• Severe maxillofacial deformities
 Diagnosis
• Biopsy:
– Granulonatous inflammatory response
– Macrophages
– Multinucleated cells with bacilli
• No laboratory tests

Treatment:
Prolonged multi-drug approach:
Dapson, Rifampin, Thalidomide
Case presentation
• 78 years old male
• Pain in the left upper jaw
• Localized to the left upper 2nd PM.
• No Medical Records
• Treated in the hematology out patient
clinic of another institution, not able to
give further information
 Phone conversation with
treating physician:
•Pt. Suffers from Multiple Myeloma
•Treated with courses of:
–Prednisone 60mg
–Melphalan (alkylating agents)
•4 consecutive days each month.
Other drugs:
• Aredia – (bisphosphonate, inhibits bone resorption)

• Tramadex – (opiate analogue)

• Controloc – (proton pump inhibitor)

• Motilium – (antidopaminergic)

• Losec - (proton pump inhibitor)

 Labs
• WBC 3.9 k/ul
• RBC 2.85 MU/L
• HGB 8.69 g/dL
• HCT 24.78 %
• PLA 163.0 k/ul
 Clinical examination
• Left submandibular lymph node palpated –
mobile, not tender.
 i
o
n

Note:Tooth #25 V
– 2nd degree mobility. i
- Tender upon percussion t
- Vitality tests negative a
Alveolar ridge, distal to #25 –l
sinus tract i
t
y
periodontitis, attrition of occlusal surfaces.
t
e
s
t
s

n
e
g
Radiographic examination
sequestrum
Tooth #25 – Drill Test (-)
Necrotic pulp
Distal Area – sequestrum and susp.
osteomyelitis

Pt. Referred to surgery for extraction

of #25 & exploration of distal alveolar
ridge.
 Differential diagnosis
• Draining sinus tract from #25
• Osteomyelitis (fungal/bacterial)
• Plasmacytoma
Drill test
• Swabs were sent for microbiological
analysis.
• Bone samples and sinus mucosa samples
were sent for pathological analysis.
 Microbiology
• Strep viridans species
• Sensitive to all antibiotic agents.
 Pathology
Oral mucosa
acute and chronic
inflammation in the
sub-mucosa
necrotic bone.
bone marrow replaced
by actinomyces
colonies.
• In Brown & Brenn (B&B) staining and silver
staining delicate branching filaments are
seen.
Sample from sinus:
• respiratory mucosa
• Submucosa with severe acute and
chronic inflammation
• Staining of antibody
light chains were
polytypic.

κ λ
• Patient hospitalized for IV antibiotic
treatment – Augmentin 1mg*3 for 10d
– continued with P.O Augmentin 875mg*2 for
14 days.
• Post op complications:
– Hemorrhage
– Swelling
10 weeks post op
 Actinomycosis
• Gram positive
• Anaerobic microaerophilic bacteria
• Appear as hyphae or filaments
microscopically.
• Habitants of the normal oral flora.
• Become pathogens when introduced into
soft tissue.
 Pathogenic species
• Actinomyces israelii
• Actinomyces viscosus
• Actinomyces naeslundii
• Actinomyces odontolyticus
• Actinomyces meyeri
• Propionobacterium propionicus

• Actinomyces radicidentis
 Actinomycosis
• Cervicofacial (55%)
• Abdominal-pelvic (25%)
• Pulmonary (15%)
• Subcutaneous and others (5%)
 Characteristics

• Chronic disease
• Suppuration
• Draining sinuses and fistulas
• “Sulfur granules” – granular aggregates
of actinomyces.
• Surrounding hard fibrous tissue
 Cervicofacial actinomycosis

• indurated swelling in the

mandible and neck region.
• fibrosis
• Abscess in adjacent soft
tissue.
• Pain
• Pyrexia
• Sinus tracts in long
standing disease.
 Actinomycosis DD
• Osteomyelitis (bacterial/fungul)
• Scrofula
• Staphylococcal infection.
 Diagnosis
• Clinical presentation
• Positive culturing of the organism
• Observation of sulfur granules in
exudate or tissue sections
• Histopathological appearance.
 Treatment
• Surgical excision and debridment
• IV Crystalline Penicilline 3*106 IU * 3-4
dly for 6-12 weeks.
 In Our Case
• Maxillary actinomycosis of the
edentulous alveolar ridge.
• Osteomyelitis
• Positive pathologic results, negative
microbiology analysis.
• Immunocompromised/ medically
compromised patient.
 Microorganism with similar
clinical features
• Nocardia asteroides
 Noma
• Cancrum Oris
• Gangrenous stomatitis

• Disease of childhood
• Destructive process of orofacial tissue
• Tissue necrosis:
– Fusiform bacilli
– Vincent’s spirochetes

• Compromised systemic health (malnutrition,

HIV, others).
 Clinical features
• Painful ulceration
(gingiva/oral mucosa)
• Fast spreading.
• Fetid necrosis
• Bone denudation
• Teeth exfoliation
 Treatment
• Treatment of predisposing conditions.
• Fluids
• Electrolytes
• Penicillin
• Debridment of necrotic areas
Not only in Africa
 Syphilis
• Syphilis is a sexually transmitted
disease caused by the bacterium
Treponema pallidum.
• “The great imitator” - many of the signs
and symptoms are indistinguishable
from those of other diseases.
• Contact with syphilis sores.
• Occur mainly on the external genitals,
vagina, anus, or in the rectum.
• Sores also can occur on the lips and in
the mouth.
• Mother can pass it to fetus
 Primary Stage
•
Appearance of a single sore (called a
chancre)
• May be multiple sores.

• Incubation - 10 to 90 days (average

21 days).

• The chancre
– Firm, Round, small, and painless.
– Appears at the spot where syphilis
entered the body.
– Lasts 3 to 6 weeks
– Heals without treatment.

– If adequate treatment is not

administered, the infection
progresses to the secondary stage.
 Secondary stage
• Skin rash and mucous membrane lesions

• Non itching rash

• May appear as the chancre is healing or several weeks after the chancre has
healed.
• Rough, red, or reddish brown spots both on the palms of the hands and the
bottoms of the feet.

• Fever
• Swollen lymph glands
• Sore throat
• Patchy hair loss,
• Headache
• Weight loss
• Muscle aches
• Fatigue.

• Resolve with or without treatment, but without treatment, the infection will
progress to the latent and late stages of disease.
Skin rash
 Mucus patches

• In mucus membranes -
ulcers covered by
mucoid exudate
– (Called mucus patches).
Mucus patches
 Tertiary Stage
• The latent stage of syphilis begins when secondary symptoms
disappear.

• May continue for years.

• Damage of internal organs, including the brain, nerves, eyes,

heart, blood vessels, liver, bones, and joints.

• Signs and symptoms:

– Difficulty coordinating muscle movements
– Paralysis,
– Numbness,
– Gradual blindness,
– Dementia.
– Death.
 Gumma

• Granulomatous
destructive lesion.
• Palate is the most
common oral
location.
 Syphilitic glossitis
• Generalized glossitis
– Mucosal atrophy
– Pre-malignant lesion
(predisposing for
squamous cell
carcinoma).
 Diagnosis
• Dark field microscopy.
• VDRL - Venereal Disease Research
Laboratory slide test.
• This screening test for syphilis
measures reaginic antibody.
 Hutchinson’s triad – congenital
syphilis
• Late stigmata of
congenital syphilis.
– Interstitial keratitis
– Eights nerve
deafness
– Notched screw-
driver shapaed
incisors.
 Saddle nose
• Syphilitic
involvement of the
vomer.
 Differential diagnosis
• Chancre
– Squamous cell carcinoma
– Chronic traumatic lesion
– Tuberculosis
– Histoplasmosis
• Mucus patches
– Infections and non infectious conditions.
• Gumma
– Midline granuloma
 Treatment
• Penicillin

• Erythromycin
• Tetracycline
 Gonorrhea
Causative agent:
• Neisseria gonorrhoeae
• Gram negative diplococcus
• Short incubation period less then 7 days

• Transmission
– Direct sexual contact with infected partner.
– Break in skin or Mucosa for infection.
 Sites of infection
• Genitelia >
Esophagus > Oral
mucosa

• In the head and neck

region manifest as
pharyngitis
 Clinical features

• No specific clinical
signs.
• Ulceration
• Generalized
erythema.
 Differential Diagnosis
• Aphtous ulcers
• Herpetic ulcers
• Erythema multiforme
• Pemphigus
• Pemphigoid
• Drug eruptions
• Streptocoocal infections
 Diagnosis

• Gram stain
• Thayer Martin
medium cultures
• Imuunofluorescent
antibodies.
 Treatment
• Penicillin G (rising resistance)

• Cephalosporins spectinomycin.
‫תודות לדר איילון על חלקה במצגת זו •‬