2 lecture BY

nd

DR. IMAN METWALY

3. Infective lesions
A-Candidiasis
Etiology &pathogenesis Candida Albican is the most common oral fungal infection It is normally presenting in oral mucosa in symbiosis {30-50 %of people carry it} Considered to be opportunistic infection as it may be pathogenic in certain situations May attack oral mucosa ranging from mild superficial mucosal involvement to fatal disseminated disease in severely immunocompromized patients

Predisposing factors 1. Local factors i. Mucosal trauma ii. Denture wearing iii. Denture hygiene iv. Tobacco smoking 2. Age {extremes of age : neonates , infants & old age} 3. Drugs :broad spectrum antibiotics ,corticosteroids , immunosuppressant therapy 4. Xerostomia : drugs , radiotherapy 5. Systemic diseases: iron deficiency,diabetes mellitus, acute leukaemia , HIVinfection & AIDs 6. Other immunodeficiency states

Classification of oral candidiasis

Exhibits a variety of clinical patterns

1-Candidiasis confined to the mucosa

A-Acute
1. Pseudomembranous candidiasis {Thrush } 2. Erythematous candidiasis {antibiotic sore mouth or acute atrophic }

B-Chronic
1. Chronic hyperplastic {candidal leukoplakia }

{Erythematous Candidiasis] 2. Chronic atrophic candidiasis {denture sore mouth=denture stomatitis } 3. Chronic central papillary atrophy of the tongue {median rhomboid glossitis} 4. Chronic multifocal candidiasis in addition to the dorsal tongue it includes the junction of the hard & soft palate resulting in what is called kissing lesions 5. Angular cheilitis either a component of chronic multifocal candidiasis or occurs alone or associated with denture stomatitis

2-Oral manifestations of generalized candidiasis

-Mucocutaneous candidiasis

A-{acute candidiasis}
1.Pseudomembranous Candidiasis {Thrush}
Appearance & symptoms : 1. Adherent white plaque that resembles curled milk 2. White plaques are composed of tangled masses of hyphae , yeast desquamated epithelial cells & debris 3. Scraping them with dry gauze sponge can remove these plaques. The underlying mucosa appear normal or erythematous 4. Mild burning sensation or unpleasant taste Common sites: buccal mucosa , palate , tongue , palate Initiating factors : 1. Exposure to broad-spectrum antibiotics 2. In infant due to immature immune system 3. Old age due to systemic illness or debilitating condition 4. Impairment of immune system {leukemic patients, HIV patients}

Diagnosis :by scraping

A-{acute candidiasis} 2. Atrophic {Erythematous} Candidiasis {antibiotic sore mouth}

Appearance & symptoms : 1. Burning sensation of the oral mucosa 2. Diffuse loss of the filliform papillae {reddened" bald" tongue} 3. White flakes are not a prominent feature Initiating factor Follows a course of broad-spectrum antibiotic

B- 1.Chronic Hyperplastic Candidiasis { Candidal leukoplakia }

Clinical features 1. White patch that cannot be removed by scraping 2. Common on the anterior buccal mucosa 3. Often has intermingling of red & white areas resulting in speckled leukoplakia

Initiating factors 1. Occurs in adults with no apparent predisposition to infection by candida Albican 2. It has not been known whether candidal leukoplakia is a candidal infection on top of leukoplakia or the candidal organism capable of inducing a hyperkeratotic lesion

B-2. Chronic Atrophic Candidiasis {denture sore mouth}

Appearance & symptoms 1. Symptomless condition 2. Bright red somewhat velvety to pebbly surface , with little keratinization 3. Found mostly in denture wearers 4. Occurs commonly on the hard palate 5. Associated with angular cheilitis due to loss of the vertical dimension Initiating factors 1. Wide contact surface area between the palatal mucosa &the acryl 2. Chronic low grade trauma resulting poor prosthesis fit 3. Improper occlusal relationthip 4. Failure of removal of the appliance at night{long term use} 5. Absence of hygienic instructions 6. Denture that firmly adhere to the palate , with no saliva create a good media for the growth chronic atrophic candidiasis Differential diagnosis : Allergic stomatitis which is an allergy to denture acryl

B-3.Chronic central papillary atrophy of the tongue {median rhomboid glossitis}

It was thought to be a developmental defect Clinically a well demarkated erythematous zone that affect the midline ,posterior dorsal tongue The erythema is due to loss of filiform papillae It resolves with antifungal therapy

B-4.Chronic multifocal candidiasis {in addition to the dorsal

tongue it includes the junction of the hard & soft palate resulting in what is called kissing lesions

B-5.Angular cheilitis either a component of multifocal candidiasis

or occurs alone or associated with denture stomatitis Characterized by fissuring erythema, scaling of the skin at the corners of the mouth It occurs due to reduced vertical dimension of occlusion & folds at the corner .Saliva tend to pool in such areas keeping them moist, favoring a yeast infection

C-Mucocutaneous candiiasis It is a component of a rare group of immunologic disorders The severity of the candidal infection correlates with the severity of the immunologic defect It is a persistent superficial candidal infection of the mucosae , nails & skin Oral mucosa is involved in almost all cases Oral lesions resemble those seen in chronic hyperplastic candidiasis { thick white plaque that do not rub }

Histopatopathologic features 1. Increased thickness of the parakeratin on the surface of the lesion 2. Elongation of the rete ridges 3. Chronic inflammatory cell infiltrate in the connective tissue immediately subjacent to the infected epithelium 4. Small collections of neutrophils {microabscesses } in the parakeratin layer & the superficial spinous cell layer near the organisms 5. the candidal hyphae are embedded in the parakeratin layer 6. Periodic acid-Schiff {PAS} is used to identify candidal hyphae N.B. Histologic examination of candidal infection is rarely carried out but it is seen by a gram stained smear showing masses of tangled hyphae detached epithelial cells& leucocytes Treatment Local antifungal If there is denture sore mouth rebase the denture N.B. In young adults angular cheilitis is a bad sign, suggesting HIV + ve cases

B-Hairy leukoplakia
An opportunistic infection related to the presence of EpsteinBarr virus,

Found almost exclusively in : 1. Human immunodeficiency virus (HIV) infected individuals {predominantly seen in homosexual males} 2. Patients associated with organ transplantation 3. Patients who are on corticosteroids 4. Patient who are on chemotherapy

Clinical features 1. Found mainly along the lateral margins of the tongue 2. Unilateral or bilateral 3. Painless well demarcated white lesion that varies from a flat plaque-like lesion to papillary, hair- like projections

Differential diagnosis 1. Idiopathic leukoplakia 2. Frictional hyperkeratosis 3. Tobacco associated leukoplakia 4. Chronic hyperplastic candidiasis

4-Dermatologic conditions

Lichen planus Definition : A chronic mucocutaneous diseases of unknown cause Etiology & pathogenesis Although the cause of lichen planus is unknown , it is considered to be an immunologically mediated process It is characterized by an intense T-cell infiltrate { CD4 & specially CD8} cells localized to the epithelium-connective tissue interface The disease mechanism involves several steps that could be described as follows: 1. An initiating factor\ event 2. Focal release & up regulation of cytokines & vascular adhesion molecules 3. Recruitment & retention of T- lymphocytes in the submucosa {lymphocytic band} follows 4. The basal cells undergo apoptosis & liquefaction degeneration

Clinical features Age : <above 40 years {middle age} Sex : females > males { more in menopausal women} Site : the buccal mucosa is involved in the great majority of cases { tongue , gingiva , palate & lips are affected in a descending manner Lesions are bilateral with wide spectrum of clinical presentations {types } Clinical types of lichen planus listed in order of frequency of involvement of the oral mucosa
1-Reticular form : 1. The most common type 2. Characterized by numerous interlacing white keratotic lines or striae {wickham's striae} that produce an annular or lacy pattern 3. It is usually bilateral 4. Site : mostly the posterior buccal mucosa 5. Less painfull {no symptoms } 6. Exacerbation of the lesions{waxing & waning} is characteristic of lichen planus

2-Plaque type : 1. White plaque resemble leukoplakia clinically 2. Has a multifocal distribution 3. Site : primarily the dorsum of the tongue & the buccal mucosa

3-Atrophic type 1. Diffuse red patches { resembling erythroplakia }with fine white striae {i.e. in conjunction with reticular form} 2. Site : the attached gingiva frequently involved, often in four quadrants ,in conjunction with reticular or erosive variants 3. Symptoms : Burning , sensitivity & generalized discomfort

4-Erosive form 1. Erythematous areas with central ulceration 2. A fibrinous plaque or pseudomembrane covers the ulcer 3. The periphery of the lesion is bordered by fine white radiating striae 4. Painful {why is it more significant than the reticular form?} 5. Often involving the four quadrant

N.B. when confined to the gingiva, it mimics ''desquamated gingivitis'' 5-Bullous type 1. Bullae are short lived {rarely seen} 2. On rupturing they leave a painful ulcer

Grinspan's syndrome: lichen planus associated with diabetes mellitus & hypertension

Skin lesions 1. 2. 3. 4. Purple polygonal papules Fine lace like network lines Site : on the flexor surfaces of the extremeties The lesions itch & hurt the patient when he scratches them

Histopathology Characteristic but not specific {seen in other conditions such as lichenoid drug reaction ,lupus erythematosus} 1. Varying degrees of orthokeratosis & parakeratosis on the surface epithelium 2. Variable thickness of the spinous layer { may be atrophic or acanthotic depending on whether the specimen is erosive or reticular lesion} 3. The rete ridges may be absent or hyperplastic{occasionally a saw tooth pattern is seen } 4. Liquefaction degeneration of the basal cell layer
Normal basal cells

5. Civatte bodies : discrete eosinophilic ovoid bodies representing the apoptotic keratinocytes at the basal zone

6. An intense bandlike infiltrate of predominantly T lymphocytes , lying just beneath the epithelium connective tissue junction known as: {subepithelial lymphocytic band}

Differential diagnosis I-Erosive or atrophic lichen planus affecting the attached gingiva must be differentiated from : 1. Desquamative gingivitis , 2. lupus erythematosus, 3. Candidiasis 4. Contact hypersensitivity 2-plaque-like lesion must be differentiated from: 1. Idiopathic leukoplakia 2. Squamous cell carcinoma 3-Other diseases with a multifocal bilateral presentation that should be included in the differential diagnosis are : 1. Lichenoid drug reaction 2. Lupus erythematosus 3. Cheek chewing 4. White spongy nevus 5. Chronic candidiasis Treatment : should be done by dentist ,dermatologist & internal medicine 1. Local steroids : as kenalog in orobase 2. Systemic steroids N.B. Ulcer :is the loss of continuity of the surface epithelium Erosion : is the superficial loss of the surface epithelium Vesicle : is a small fluid filled swelling Bulla : is a large fluid filled swelling A combination of these lesions may be seen in one case