ICP Infections of the Oral Mucosa

Infections of the Oral Mucosa by Andrea Richards

• Consultant in Oral Medicine, Birmingham Dental Hospital

Causes of Oral Mucosal Infections

• Viral infections

• Fungal infections

• Bacterial infections

Signs and Symptoms

• Prodrome

  • Typical of viral infections: malaise, fever, pain preceding skin lesions.

• Oral Mucosa Symptoms

  • Vesicles, ulcers, swellings, white/red patches, purulent discharge.

  • Sore throat.

• Extra-Oral Symptoms

  • Facial swelling, erythema, skin lesions (blisters, ulcers, rashes).

  • Angular cheilitis, papillomatous lesions, ocular lesions, lymphadenopathy.

• Systemic Symptoms

  • Fever, malaise, loss of appetite, weight loss.

Viral Infections

• Types of Viral Infections Affecting the Oral Mucosa

  • Herpes simplex (HSV)

  • Varicella Zoster

  • Herpangina

  • Hand, foot and mouth disease

  • Human Papilloma Virus (HPV)

  • Infectious mononucleosis

  • Measles

  • Cytomegalovirus

  • Oral infections associated with HIV infection.

Herpes Simplex Virus (HSV)

Primary Herpetic Gingivostomatitis

• Description

  • Primary infection with HSV, usually HSV-1.

  • Common in children; increasing cases in older patients.

  • Close contact predisposes to infection; may be subclinical.

• Symptoms

  • Oral vesicles that break down into ulcers; may be widespread.

  • Enlarged cervical nodes.

• Management

  • Adequate fluids, analgesia/antipyretics, soft, bland diet.

  • Use of CHX mouthwash.

  • Antivirals like aciclovir mainly for immunocompromised patients.

Recurrent HSV Infections

• Description

  • Remains latent in trigeminal nerve ganglion; about 15% of adults have recurrent infections.

  • Primarily occurs as Herpes labialis; can also affect the oral cavity (less common).

• Reactivating Factors

  • Fever, sunlight, trauma, immunosuppression.

• Symptoms

  • Starts as a macule, then a pustule, and eventually scabs over within 3-4 days.

• Management

  • Aciclovir or penciclovir cream helpful if used during prodrome.

Erythema Multiforme

• Description

  • Acute, often recurrent hypersensitivity reaction.

  • Causes may be difficult to establish; frequently associated with herpes simplex and certain drugs.

• Symptoms

  • Serosanguineous exudates on lips, widespread oral ulceration.

  • Target lesions may develop on other mucosae or skin.

• Demographics

  • Mainly affects younger adults; varies in severity.

  • Severe forms like Steven-Johnson syndrome can be fatal.

Varicella-Zoster Virus Infections

Chickenpox (Varicella)

• Description

  • Primary infection common in children;

• Symptoms

  • Itchy skin rash, fever, oral ulcers resembling HSV, but do not affect the gingiva; cervical lymphadenopathy.

Shingles (Zoster)

• Description

  • Recurrent VZV infection, mainly in adults (especially elderly and immunocompromised).

• Symptoms

  • Unilateral rash, vesicles that scab over; oral ulcers if maxillary/mandibular nerve affected.

  • Possible ocular lesions in ophthalmic shingles.

Coxsackie Viruses

• Description

  • Many types causing transient infections of oral mucosa.

• Conditions

  • Herpangina: Fever, sore throat, ulcers on soft palate, cervical lymphadenopathy.

  • Hand, foot and mouth disease: Rash, oral ulceration (usually mild), malaise.

• Management

  • Fluids, analgesia, antipyretics, and CHX mouthwash.

Epstein-Barr Virus (EBV)

• Description

  • Causes glandular fever (infectious mononucleosis).

• Symptoms

  • Fever, sore throat, oral ulceration, general lymphadenopathy, petechiae in palate.

• Associations

  • Implicated in hairy leukoplakia in immunocompromised patients.

Influenza-like Illnesses and Other Associated Symptoms

• Management

  • Fluids, analgesia, antipyretics, CHX mouthwash.

Human Papilloma Virus (HPV)

• Description

• Uncommon viral papillomas found primarily in the fauces, soft palate, tongue.

• Transmission

  • Verrucae vulgaris usually transmitted from skin to lips.

• Cancer Associations

  • Certain HPV types (mainly HPV 16) associated with oropharyngeal and cervical cancers.

Fungal Infections

Oral Candidal Infections

• Types

  • Acute pseudomembranous candidiasis (thrush)

  • Acute atrophic (often associated with antibiotics)

  • Chronic atrophic (often associated with dentures)

  • Angular cheilitis

  • Median rhomboid glossitis

  • Chronic hyperplastic

  • Chronic mucocutaneous

Thrush (Acute Pseudomembranous Candidiasis)

• Characteristics

  • Mainly caused by Candida albicans; common in immunocompromised patients and neonates.

  • White papules or confluent plaques on oral mucosa that can be wiped off.

• Management

  • Remove predisposing factors, topical antifungals (nystatin), systemic antifungals (miconazole, fluconazole).

Denture Stomatitis

• Description

  • Chronic atrophic candidiasis characterized by mild inflammation under denture.

• Management

  • Remove/treat underlying factors, denture hygiene, antifungals (nystatin, miconazole, fluconazole).

Angular Cheilitis

• Description

  • Inflammation at commissures, mainly in adults, especially the elderly.

• Predisposing Factors

  • Denture-wearing, xerostomia, smoking, deficiency states, immune defects.

• Management

  • May require mixed infection treatment; advise to stop smoking; topical cream or gel treatment.

Median Rhomboid Glossitis

• Description

  • Depapillated patch in midline of dorsum of tongue.

• Management

  • Stop smoking, improve denture hygiene, antifungal treatment.

Chronic Hyperplastic Candidiasis

• Description

  • Persistent white patch unable to be removed, typically on buccal mucosa.

• Risk

  • Malignant risk up to 40%; may require systemic antifungals.

Bacterial Infections

Overview

• Bacterial infections include: AUG/ANUG/NUG, Actinomycosis, Syphilis, Tuberculosis, Gonorrhea, Cancrum oris, Leprosy.

• Emerging concern for increasing incidence of syphilis, TB, and gonorrhea.

Syphilis

• Description

  • Increasing incidence in the UK; oral lesions may occur:

    • Primary: Large painless indurated ulcer (chancre).

    • Secondary: Mucous patches, ulcers, rashes, lymphadenopathy.

    • Tertiary: Leukoplakia on the tongue, gumma in palate or tongue.