Specific Infections of the Oral Mucosa
Plan :
Introduction
Definition
Tuberculosis
Syphilis
Conclusion
INTRODUCTION:
Cutaneous and mucosal infections of the cervicofacial region are frequent and it is important to distinguish among them infections specific to a specific germ which can be part of a general infection, this is the case of specific infections such as tuberculosis, syphilis and oral mycoses.
DEFINITION:
A specific infection is defined as an infection caused by a single germ, which presents clinical manifestations (oral or otherwise) specific to the causative agent and which is sensitive to the same treatment.
TUBERCULOSIS:
Definition: It is an infectious disease that can become widespread, it is either:
- from primary tuberculosis of oral inoculation (rare)
- or a secondary localization of the disease in the oral cavity; the oral cavity can be affected by Koch’s bacillus (BK) expelled from the lungs and which grafts onto an already injured mucosa.
Etiopathogenesis: The causative agent is Koch’s bacillus (BK). The entry point is often respiratory (direct contamination by inhalation of micro droplets of infected saliva), sometimes digestive. Oral contamination can occur by ascending route from a pulmonary tuberculosis focus. BK begins by reaching the lymphatic tract and later it will penetrate the bloodstream.
Clinical study:
Primary tuberculosis infection:
Primary tuberculosis infection is most often pulmonary and clinically silent, confirmed by intradermal reaction (IDR) to tuberculin and the presence of BK in gastric tubing.
The oral localization gives a clinical picture dominated by the triad:
- inoculation canker,
- satellite adenopathy
- and general signs of inoculation.
Specific Infections of the Oral Mucosa
Oral inoculation chancre: after an incubation period of a few days to 2 months, a lesion appears which is initially unremarkable and develops into an ulceration:
- At the vestibular seat of the lower arch, particularly at the level of the posterior gingivojugal groove, either on the mucous caps of an erupting tooth, or at the necks of the teeth, or on the lips or the lateral edges of the tongue.
- The shape is oval, semi-lunar or book-shaped, with a diameter of 1 to 2 cm, it is extensive and indolent (not indurated).
- The outline is regular, raised, with a uniform base, soft yellowish and without a reddish peripheral halo as for aphtha. In the absence of treatment, the ulceration becomes sphaceous, leading to exposure of the maxillary bone.
Adenopathy motivates the consultation and should lead to the search for a sometimes discreet chancre, it can precede the chancre, it is made up of several lymph nodes of variable volume:
- Homolateral or bilateral (submandibular, high jugular)
- Little mobile, frequently fixed by a certain periadenitis
- Able to undergo all stages of caseification (rawness, softening, fistulization), the suppuration lasts 1 to 1 and a half years, producing a yellow and lumpy pus.
General signs: The primary infection is low-level and the general condition is not altered, later the signs of tuberculosis infection will appear: asthenia, weight loss, anorexia, night sweats; they are then accompanied by biological signs.
Chronic progressive tuberculosis:
BK is carried in bronchial secretions, it inoculates the mucosa from a pre-existing erosion, most often lingual, jugal or gingival, leading to the formation of an extremely painful ulcer in the oral cavity, with thin, detached edges and a vegetative and slightly hollow surface, generally covered with a yellowish gray exudate. The surrounding tissues are inflamed but not indurated.
Tuberculous gum :
Seen in malnourished children and in immunocompromised conditions. It results from hematogenous dissemination of BK from a pre-existing tuberculous focus and produces well-defined, painless, firm dermo-hypodermic nodules that eventually soften and fistulate in the skin or mucosa. BK can be detected in tuberculoid granulomas that have significant caseation (caseous necrosis characterized by the transformation of cells located in the center of the tubercles into a yellowish, compact material that looks like a piece of cheese).
Paraclinical examinations:
- The tuberculin IDR (intradermal reaction) uses a protein derived and purified from BK, an erythematous reaction greater than 02 mm with induration after 48 hours indicates that the patient is exposed to the tubercle bacillus and develops hypersensitivity to the antigen.
- Chest X-rays show calcifications
- Histological diagnosis after biopsy may reveal a giant cell epithelioid granuloma with caseous necrosis.
Differential diagnosis:
In the face of oral tuberculosis, it is necessary to eliminate:
- In front of a cold gum and abscess: a dermoid cyst of the tongue, fibroma and lipoma, actinomycosis and syphilitic gumma;
- In front of ulceration: traumatic ulceration and carcinoma;
- In the presence of tuberculous parotitis: common germ parotitis, glandular syphilis, salivary actinomycosis, glandular lithiasis
Treatment :
Tuberculosis is a notifiable disease.
Prophylactic treatment is based on sterilization of milk, control of bovine tuberculosis, BCG vaccination (mandatory) and isolation of infected subjects.
Curative treatment: infected patients are referred to specialized centers (anti-tuberculosis division or DAT) for:
- Anti-tuberculosis medical treatment (Isoniazid, Ethambutol, Streptomycin and Rifampicin) in a 6-month course;
- Surgical treatment: excision of infectious foci (adenectomy, excision of gums and cold abscesses, sequestrectomy, curettage of foci and elimination of fistulas)
SYPHILIS:
Definition: It is an infectious, contagious disease, which can be acquired or congenital, and can have revealing oral manifestations at all stages of its development.
Etiopathogenesis: the responsible agent is Treponema pallidum, the contamination is:
- Either venereal in 95% of cases (sexual contact)
- Either congenital through the placental membrane (mother-child)
- Either during a blood transfusion (transvascular route)
Clinical study:
Primary syphilis (highly contagious): soft chancroid + satellite adenopathy
The syphilitic oral chancre is typical : it is first of all a red excoriation at the point of inoculation (lip, tongue, tonsil or vestibular gum incisor canine region crimping the dental necks in a quarter moon shape), it represents 8% of extra-genital chancres, it becomes typical around the 8th day :
- An erosion and not a painless ulceration (or painful only in the event of superinfection) rounded or oval (0.5 to 2 cm in diameter),
- Muscle flesh-colored varnished plate , non-inflammatory,
- The edges are clean, flat and not protruding,
- It secretes a serosity but does not suppurate,
- Cardboard induration is characteristic and is limited to the chancre,
- It heals spontaneously in 4 to 6 weeks.
The chancre is very contagious, it contains a large number of treponemes which are easily detected by microscopic examination.
Specific Infections of the Oral Mucosa
Satellite adenopathy (treponemal reservoir):
- It follows the canker as the shadow follows the body (according to Fournier),
- appears around the 6th day after the chancre in the corresponding territory (under the chin or under the mandible) and persists for several months after its healing,
- hard, mobile, painless polyadenopathy , without periadenitis,
- one of the lymph nodes is larger.
Secondary syphilis: begins 1 to 3 months after the appearance of the chancre and corresponds to the phase of dissemination of the bacteria. Its clinical expression is very varied, leading to the name of the disease (great simulator). Oral lesions are very contagious, we have 2 efflorescences spread over 2 and a half to 4 years, in the form of cutaneous-mucosal blooms and a poly micro adenopathy:
- On the skin : syphilitic roseola (pale pink round macule 5 to 10 mm in diameter);
- On the mucosal level : secondary flat syphilides (erosive lesions and mucous plaques).
- Possibility of parotid and maxillary localizations.
Tertiary syphilis: this is a silent phase where there is an absence of general signs and adenopathies . Little or no contagiousness, characterized by the installation of ulcerative mutilating syphilitic gummas of the palate or tongue resembling carcinomatous lesions; remember that a gumma is a painless and mobile hypodermic nodule, softening, ulcerating and emptying leaving scars, which can be located on the face, lips and palate.
Congenital syphilis : transmitted to the fetus by transplacental route from the 4th month of pregnancy or during childbirth. It can be early with multiple visceral lesions or late with malformative lesions; oral anomalies include an ogival and very deep palate, Hutchinson teeth (small central incisor, the free edge of which has a semi-lunar notch) and Moon or muriform molars.
Specific Infections of the Oral Mucosa
Paraclinical examinations:
Serology confirms the diagnosis: BW (BORDET-WASSERMAN) and VDRL (hemolysis reaction around the 25th day ). TPHA (hemagglutination test, becomes positive 10 to 20 days after the chancre).
Treatment: This is a notifiable disease. The patient is referred to specialized services (dermatology and infectious diseases), the treatment is based on slow-release penicillin. In case of allergy, oxytetracycline, erythromycin or cephalosporins are used. Prosthetic rehabilitation should be considered in case of buccosinusal or bucconasal communication.
CONCLUSION:
It is essential to know how to recognize these infections when the oral location is obvious, and to know how to make the diagnosis in order to refer the patient to the specialized service and treat the pathology as a whole because other organs can be affected, and especially to know how to detect at the early stage to avoid complications which can be serious, without forgetting the nature of contagion and transmission which must be declared and measures taken during the clinical examination to avoid it.
Specific Infections of the Oral Mucosa
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An annual checkup helps monitor oral health.