Lecture # 3

Oral medicine

‫بسم الله الرحمن الرحيم‬

Bacterial infections

Today we are going to talk about bacterial infection ,

the details u will find them in the text book ,and in the
essentials of oral medicine ch. 13

Any of these micro organisms can cause a disease only if

they manage to get access and grow in the body , we can
have them normally in the body and not causing any disease
but to be a pathogenic they have to break the immunity
shielder like the tears of the eye , the oral mucosa and the
skin and they need to over come the presence of the normal
flora which is part of the oral cavity , any decrease in the oral
flora will allow the space for these pathogenic bacteria to
grow and increase in number , they have to over come the
inflammatory response , the macrophages the neutrophils
that are present in the connective tissue in the oral
epithelium and finally they have to over come the immune
response the specific t-cells and b – cells producing the
specific antibodies ..

If they manage to over come all these lines of defense then

this pathogen can cause a disease ..

Pathogens can be transformed via air , dust , particles , water

droplets , hands or objects or blood and other body fluids ..
and if u are aware of the term opportunistic pathogens they

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are part of the normal flora that increase in number in
reduction of immunity and they cause a disease ..

Bacterial endocarditis :

One of the topics I thought we need to talk about is the

bacterial endocarditis and we are going to talk about them
briefly , the mouth in general is a host for many pathogens ..
and the presence of an ulcer or trauma or even the tooth it
self can be the access of these pathogens to the blood
stream and then causing the bacterial endocarditis ..

We have high risk patients and moderate risk patients .. the

Dr mentioned only some of the high risk which they are :
prosthetic heart valves , recurrent attack of bacterial
endocarditis (the rest are in the slides ) but any patient can
be infected , any healthy patient can be infected because of
any dental infections .. so these patients we give them
prophylactic antibiotics before we do any dental procedure
we suspect that it might cause a bacteremia (the procedure
that deals with blood like extraction , root planning ,
periodontal treatment ) other procedures like impression or
filling it doesn’t require a prophylaxis antibiotics .. here a
student was discussing with the Dr the antibiotic prophylaxis
and the indication saying that its not indicated any more as
we took in the surgery or perio and the Dr said its
controversial and its up to the dentist who is on the case ..

You need to select the appropriate antimicrobial drug and

there is a certain routine for the antibiotic you give , then u
need to illuminate all sources of periapial and periodontal
lesions .

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Now we will start talking about some of the bacterial
infections that we will see in the oral cavity …

Impetigo :

Is an infection in the skin , its not affecting the oral mucosa

but its very common affecting the paraoral regions it affects
mainly young children coz they are very susceptible for skin
trauma which is a very good environment for the bacterial
accumulation and infection , it will start as a vesicle then
pustules and then it will cause this amber -colored crust , so
usually boys at 6- 7 yrs old have these skin lesions , the
treatment is a course of antibiotics fucidine its very good to
treat these infections and you should insist on the hygiene
habits and the hands and face cleaning .

Tonsillitis and pharyngitis :

They are part of the oral cavity , we need to differentiate

between viral and bacterial infections of the tonsils , you can
see yellow spots they are called follicles this type of tonsillitis
is called follicular tonsillitis , its associated with very high
temperature , enlargement of the uvula (edematous) and
coated tongue , these features are more associated or found
in the bacterial tonsillitis or pharyngitis , you have to
recognize these features so if a patient comes to you with
follicular tonsils u have to refer him to GP (general
practitioner ) to give him a course of antibiotics , other wise
it might progress and cause scarlet fever (‫)الحمى القرمزية‬or
rheumatic heart disease ..

Tuberculosis :

They thought that TB infection has vanished and is not in the

world any more but with the accurance of HIV patients and

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there low immunity it did come back and it affects many
people …

Tb starts as a an acute infection presented with fever chills,

fatigue & malaise weight loss , lymphadenopathy , Enlarged
submandibular & cervical LN after these acute symptoms we
have the chronic phase here there is no respiratory
symptoms yet but the patient can still spread the infection,
so when u take the medical history u ask the pt if he has
fever or noticed weight lose and u examined him and u find
his cervical lymph node are palpable u have to suspect TB …

orally it can be present as painful non-healing ulcer usually

on the dorsum of the tongue & the palate and its caused by
the sputum from the infected lungs and the bacteria in the
mouth will react with the sputum and cause these ulcers, to
diagnose the disease we need to have a biopsy from the ulcer
, so any long standing ulcer u need to suspect TB and take a
biopsy , so the biopsy is part of your diagnosis .. another
diagnostic method is the Purified Protein Derivative (PPD)
where u inject the TB antigen in the patient subcutaneous
tissue and see him after 24 or 48 hrs if u notice any allergic
reaction it means that the patient was infected by these
antigen before and he has the antibodies in his serum or
blood so this confirms that the patient is infected with TB if
there is no allergic reaction then the pt probably is not
infected with TB , the universal precautions for a TB patient
they are the mask, gloves, eye protection are enough if u are
dealing with TB patient , no elective treatment should be
given to an active TB patient , u need to assist the condition
of the pt and in which stage he is , and u need to know these
information from his Dr not the patient him self .. the
treatment of TB was not mentioned by the Dr but we all know
that it is a long course of antibiotics 6-12 months …

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Syphilis :

Is caused by spirochete (Treponema pallidum). It’s a sexually

transmitted disease it can be transmitted by blood or from
the mother to the fetus through the placenta causing the
congenital syphilis .. it has three stages .. the first one is
chancre (primary) it appears as ulcer very red ulcer it can
present at any part of the mouth , tongue or the lip , it lasts
for few weeks then it disappears for a couple of weeks then
it comes back as a secondary syphilis which is presented as
mucous patches on the lip or the tongue or any part of the
oral mucosa , cutaneously u might have the maculae in the
hands or the feet this lesion is very contagious , always
conduct a serological test for an unknown origin ulcer , then
we will have the tertiary stage which again can appear in
different forms like the Gumma here it started as an ulcer
then necrosis of the bone in the palate and causing
perforation it might affect the nasal septum causing a saddle
nose (not sure) , other lesions like syphilitic leukoplakia
which are white lesions that are not frictional lesions or due
to smoking and the only way to diagnose it is to take a biopsy
, or it can appear as a fibrosing glossitis or syphilitic glossitis
all these are confirmed by a biopsy , the syphilitic
leukoplakia and fibrosing glossitis are premalignant lesions
so when doing the biopsy the pathologist will notice the
amount of dysplasia in these two .. the bacteria might spread
to the CNS the patient might develop some behavioral
changes and these problems might be thought to be aging
behavioral while its not and when the patient is given the
antibiotics his mental abilities will improve ..

Congenital syphilis :

Here the child is born with the syphilis because of his infected
mother and they have Hutchinson Triad : deafness ,

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blindness and dental anomalies such as Hutchinson
incisors and mulberry molars .

Diagnosis .. many serological tests are performed to

diagnose it , and treatment is usually penicillin for very long
time …

Gonorrhea :

is another sexually transmitted disease the oral presentation

is very rare , ulcer and Oral Erythema , tonsillitis and other
infections in general can be caused by gonorrhea . and u can
diagnose the disease by Gram stained smear you can
diagnose the disease .

non _specific urethritis :

the bacteria Chlamydia species can induce urethritis and the

Reiter’s syndrome (reactive arthritis) the clinical picture is
similar to urethritis but this (Reiter's ) is with arthralgia
(pain in the feet )and swelling of the joint (accumulation of
the fluids in the joints) other features are involved like the
eye .

Circinate stomatitis is one of the presentation of Chlamydia

species are very similar to the geographic tongue with a
region of depapillated area and whitish margins of the tongue
the diagnosis is by the bacterial gram stain smear and the
treatment is by antibiotics

Acute Ulcerative Necrotizing Gingivitis (AUNG) :

We toke it in oral pathology and its one of the bacteria

affecting the oral mucosa mainly affecting the gingival and
the periodontal ligament the treatment is metranidazole coz
we are dealing with non aerobics bacteria fusiform bacillus &

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spirochete (Borrelia vincentii). As u see here the interdental
papilla is damaged by this disease and we need to improve
the oral hygiene and before that we need to scale the tooth
and remove all depridment then to enforce the oral hygiene
habits ..

Osteomyelitis :

We are trying to cover all the bacterial infections and caries is

one of them , chronic and aggressive periodontitis are caused
by bacteria as well but we didn’t talk about them but the
point is that the oral mucosa and the teeth are not the only
structures that can be affected we have also the bone that
can be infected by bacterial inflammation .

The main source of bacteria is either through periapical

infection (the main source) , or after operation or surgery
where contamination took place or fracture of the jaw that led
to communication between the oral cavity and the bone
deep tissue ..

The patient comes with acute symptoms very sever throbbing

pain combined with a swelling intraoral or extra oral , some
times when it stays for a long time there will be sinus track
showing intra or extra oral sinus , after these acute
symptoms there will be lymphadenopathy and fever and the
patient is not feeling well , to diagnose the disease you need
a radiograph , in the radiograph in the slides we see a
radiolucent area on the periapical region of the 6 (we call it
mouse eaten appearance)and there is sclerotic and fibrosis
tissue and with time it will have this appearance which is the
highly dense bone or condensed bone cause of the
inflammation here the treatment will be removing the source

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of infection and bone curettage and removing all the necrotic
bone of course with antibiotics ..

ThE EnD

The lecture didn’t include every thing in the slides so u have

to refer to them while reading the lecture .

،‫و شاهق‬ ّ ُ ‫عل‬

ُ ‫هل كان علينا أن نسقط من‬
‫درك أننا لسنا‬ ْ ُ ‫ لن‬...‫ونرى دمنا على أيدينا‬
‫ كما كنا نظن؟‬..‫ملئكة‬
At the end I wanna say sorry for being late but it was out of
my hands

And I just wanna say hi to every one in our dof3a starting by

my friends : maram , noor , do3a2 , ithar , zain , arwa ,
deema , '3ada , jomana m7esen , jomana ta3amneh , amal el
3omare , fatema as3ad , tina , dana …

Sorry if I forgot anyone

Done by : Abeer S. Al Najjar

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