Week 3 – Oral Lesions – Infections and Manifestations in the Oral Cavity

1. Causative Agent and Modes of Transmission of Syphilis:

• Causative agent: Treponema pallidum, a spirochete bacterium.

• Modes of Transmission:

• Active lesions: This is the primary route of transmission, occurring through direct contact with syphilis lesions (chancres, mucous patches) during sexual activity (including oral sex).

• Blood transfusion: Infection through blood transfusions from a diseased individual to a healthy one.

• Mother-to-child transmission: Transmission from mother to child during pregnancy or at birth.

Note:

• Syphilis can be transmitted through contact with contaminated personal items such as razors, toothbrushes, etc.

2. Stages of Syphilis: Typical Symptoms of Each Stage

Syphilis progresses through three stages:

• Stage 1:

• Typical symptom: Chancre – a firm, painless, round nodule that usually appears at the site of bacterial entry.

• Duration: 10-90 days after infection.

• Stage 2:

• Typical symptoms: Syphilis rash (generalized rash), mucous patches, moist papules.

• Duration: 6 weeks to 6 months after infection.

• Stage 3:

• Typical symptom: Gummas – firm nodules that ulcerate, easily rupture, and typically appear on the skin, bones, liver, and brain.

• Duration: 1-30 years after infection.

3. Description of the Chancre:

• Solitary lesion: Only one ulcer is present.

• Diameter: Less than 2 cm.

• Depth: The ulcer is deep.

• Base: Red, brown, or purple, clean, covered with a grayish-white membrane.

• Edges: Slightly rounded and raised.

• Firm: Feels firm to the touch.

• Painless: Chancres are usually painless.

4. Clinical Features of Stage 1 Syphilis:

• Characteristic lesion: Chancre.

• Frequency in the mouth: Approximately 10%.

• Location:

• Lips.

• Tongue.

• Palate.

• Gums.

• Tonsils.

• Regional lymph nodes:

• Nodes usually appear on one side, are painless, and contain no pus.

• Self-healing: Heals on its own after 3-12 weeks, usually without scarring.

5. Key Differentiating Factor Between a Stage 1 Syphilis Ulcer and Other Ulcers?

• Painlessness: Chancres are painless, a crucial distinguishing feature from other ulcers.

6. Considerations When Suspecting a Chancre in the Mouth:

• Sensitive history-taking:

• Ask the patient about oral sexual contact, as this is the direct point of contact with Treponema pallidum.

• Careful infection control:

• During examination, focus on hygiene and prevention of transmission, as Treponema pallidum is highly contagious.

7. Main Types of Blood Tests:

• Specific tests: Detect antibodies against Treponema pallidum. Examples: FTA-ABS, TPPA, EIA/CIA.

• Nonspecific tests: Detect antibodies against antigens of Treponema pallidum. Examples: VDRL, RPR.

8. Which blood test is rapid, easy to perform, and can quantify bacteria?

• RPR (Rapid Plasma Reagin) test: This test is rapid, easy to perform, and can quantify antibody levels.

9. At what stage is blood testing effective, and when is it not?

• Stage 1: Nonspecific tests (VDRL, RPR) may not detect the infection. Specific tests may be positive but with low accuracy.

• Stage 2: Both specific and nonspecific tests are positive.

• Stage 3: Specific tests may be positive but often with low accuracy. Nonspecific tests may be falsely negative due to decreased antibody levels.

10. Main drawback of Treponema tests?

• Persistence after treatment: This test can remain positive even after treatment is complete, making it difficult to determine if the infection is active or resolved.

• Not useful in determining current or past infection: Specific tests cannot differentiate between patients currently infected or those who have been infected with syphilis in the past.

• More expensive and time-consuming: Specific tests are typically more expensive and time-consuming to perform than nonspecific tests.

11. What lesions should a chancre be differentiated from?

• Traumatic ulcers:

• Base: Covered with pseudomembrane, not dark in color.

• Appearance: At sites prone to injury.

• Painful: Traumatic ulcers are often painful.

• Aphthous ulcers:

• Painful: Aphthous ulcers are typically painful.

• Soft to the touch: Aphthous ulcers are soft, not firm.

• Carcinoma:

• Early stage: Painless, but painful in later stages.

• Base: Often contains necrotic tissue, not as clean as a traumatic ulcer.

12. Common systemic lesions in syphilis patients:

• Syphilis rash (generalized rash): A red rash, often appearing on the palms of hands, soles of feet, trunk, and chest.

13. Systemic manifestations of Stage II syphilis:

• Skin and mucous membrane lesions:

• Syphilis rash.

• Mucous patches.

• Moist papules.

• Presence of lymph nodes: Enlarged lymph nodes.

• Lymphadenopathy:

• Body’s response to infection.

14. How long after the first stage does Stage II occur?

• 4-10 weeks: Stage II usually appears 4-10 weeks after infection.

15. What is the percentage of oral manifestations in Stage II syphilis, and where are they commonly found?

• Percentage: Approximately 30%.

• Location:

• Corners of the mouth.

• Tongue.

• Tonsils.

• Pharynx.

• Larynx.

16. Two types of oral lesions seen in Stage II syphilis:

• Moist papules:

• Commonly found at the corners of the mouth.

• Characterized by cracking.

• Mucous patches:

• Often seen on the cheeks, tongue, tonsils, pharynx, and larynx.

17. What are the characteristics of mucous patches in Stage II syphilis?

• Ulcerations: One or multiple shallow ulcers, uneven, slightly raised, covered with a grayish-white membrane, with a red inflammatory ring around them.

• Note: In the COOP book, these are classified as “white lesions.”

18. If you encounter moist papules, what test should be performed?

• Blood test:

• To differentiate from fungal infections and carcinoma.

19. Differentiate mucous patches from what other lesion?

• Differentiate from aphthous ulcers:

• Aphthous ulcers:

• Typically flat, not raised.

• Painful.

• Mucous patches:

• Slightly raised.

• Usually painless.

20. Oral manifestations of Stage III syphilis:

• Characteristic features:

• Gummas – firm nodules that ulcerate, easily rupture, and typically appear on the skin, bones, liver, and brain.

• Luetic tongue – enlarged tongue with cracks.

• Location:

• Hard palate.

• Soft palate.

• Lips.

• Tongue.

21. Size of the chancre:

• Less than 2 cm.

22. Rank the contagiousness of syphilis in the three stages:

• Stage 2 > Stage 1 > Stage 3

23. How long do Stage II syphilis lesions last?

• 5-10 weeks: Stage II syphilis lesions can last 5-10 weeks, often with multiple outbreaks before becoming latent.

24. Describe mucous patches in Stage II syphilis:

• Shallow ulcerations: One or multiple shallow ulcers.

• Uneven and shallow: Ulcers are shallow and have an uneven shape.

• Slightly raised: Ulcers are slightly raised above the surrounding tissue.

• Covered with a grayish-white membrane: Ulcers are covered with a grayish-white membrane.

• Red inflammatory ring around them: The area around the ulcers has a red inflammatory ring.

• Usually painless: Mucous patches are typically painless.

25. What type of lesion is a gumma?

• Firm nodule/ulcer: Gummas are firm nodules that can ulcerate and easily rupture.

26. In which condition can a connection between the nasal and oral cavities occur?

• Stage III syphilis:

• Ulcerative lesions on the palate, with necrosis, can lead to perforation of the palate, creating a connection between the nasal and oral cavities.

27. List the specific blood tests for syphilis:

• FTA-ABS (Fluorescent Treponemal Antibody Absorption): Detects antibodies against Treponema pallidum.

• TPPA (Treponema Pallidum Particle Agglutination): Detects antibodies against Treponema pallidum.

• EIA/CIA (Enzyme Immunoassay / Chemiluminescent Immunoassay): Detects antibodies against Treponema pallidum.

28. Differentiate carcinoma from Stage 1 syphilis:

• Similarities:

• Both can be solitary ulcers.

• Both have raised edges.

• Differences:

• Carcinoma:

• Often appears in individuals over 40 years old.

• Usually has precancerous lesions such as lichen, erythroplakia, leukoplakia.

• The base often contains necrotic tissue.

• Painless in the early stage, but painful in later stages.

• Stage 1 syphilis:

• Painless.

• Clean base, covered with a grayish-white membrane.

29. When taking a history for suspected syphilis, what should you ask about?

• Sexual history:

• Inquire about recent sexual encounters, including oral sex.

30. Where is the VDRL test suitable?

• Cerebrospinal fluid: VDRL is commonly used to test for syphilis in cerebrospinal fluid.

31. False positives with nonspecific syphilis tests:

• Other viral infections:

• Certain viruses can produce antibodies similar to syphilis antibodies, leading to false-positive results.

• After vaccination:

• Some vaccines can trigger a false-positive reaction with nonspecific tests.

32. False negatives with nonspecific syphilis tests:

• Stage 1 syphilis:

• In the early stage of syphilis, antibody levels may not be high enough for detection.

• Late syphilis:

• In the late stage of syphilis, antibody levels can decrease, resulting in false-negative results.

• High antibody levels masking the presence of the antigen:

• Excessively high antibody levels can mask the presence of the antigen, leading to false-negative results.

33. Does a decrease in antibody titer indicate successful or unsuccessful treatment?

• Success: A decrease in antibody titer indicates successful treatment.

34. Syphilis bacterium:

• Treponema pallidum

35. 3 modes of syphilis transmission, which one is most common?

• Active lesions (most common, STD):

• Direct contact with syphilis lesions.

• Blood transfusion:

• Receiving blood from a diseased individual.

• Mother-to-child transmission:

• Transmission from mother to child during pregnancy or at birth.

36. Characteristics of each syphilis stage:

• Stage 1: Chancre.

• Stage 2: Syphilis rash.

• Stage 3: Gummas.

37. Which stage of syphilis affects the central nervous system?

• Stage 3:

• Late syphilis can cause damage to the central nervous system.

38. Syphilis Treatment:

• Penicillin: The primary treatment for syphilis.

• Erythromycin: A prophylactic medication for individuals allergic to penicillin.

• Tetracycline: A treatment option for individuals who cannot take penicillin.

39. NOMA (Cancrum Oris) Treatment:

• Inpatient care:

• Early:

• Fluid and nutritional support.

• Antibiotics (clindamycin, piperacillin, gentamicin, aminoglycosides).

• Removal of necrotic tissue.

• Late:

• Reconstructive surgery and rehabilitation.

40. Causative agent of cat scratch disease:

• Bartonella henselae

41. Incubation period for cat scratch disease:

• 3-14 days:

• Symptoms typically appear 3-14 days after being scratched by a cat.

42. Treatment for cat scratch disease:

• Self-healing: Cat scratch disease usually resolves on its own after 4 months.

• Drainage of pus:

• If pus is present, draining it helps to relieve pressure and support treatment.

43. Significance of draining pus:

• Air inhibits the growth of anaerobic bacteria: Air helps to reduce the growth of anaerobic bacteria in the pus.

• Antibiotics can more easily penetrate the lesion: Draining the pus allows antibiotics to penetrate the lesion more easily, aiding in treatment.

• Relieves pressure for the patient: Draining pus helps to relieve pressure on the patient.

44. Modes of syphilis transmission. What is the most common route?

• Active lesions: Direct contact with syphilis lesions.

• Blood transfusion: Receiving blood from a diseased individual.

• Mother-to-child transmission: Transmission from mother to child during pregnancy or at birth.

• Most common route: Active lesions.

45. Common locations of Stage 1 syphilis:

• Lips.

• Tongue.

• Palate.

• Gums.

• Tonsils.

46. Characteristic lesion of Stage 1 syphilis:

• Chancre: A firm, painless, round nodule.

47. How long does a chancre last?

• 3-12 weeks: Chancres typically heal on their own after 3-12 weeks.

48. Characteristics of a chancre:

• Ulcer: A chancre is a solitary ulcer.

49. Diagnostic tests for syphilis:

• Darkfield microscopy: To see Treponema pallidum.

• Fontana-Tribouleau stain: A stain to visualize Treponema pallidum.

• Blood tests: Detect antibodies against Treponema pallidum.

50. Disadvantage of specific syphilis tests:

• Can remain positive after treatment is complete: Specific tests can remain positive after treatment is complete, making it difficult to determine if the infection is active or resolved.

51. Differentiate a chancre from a traumatic ulcer:

• Traumatic ulcer:

• Base: Covered with pseudomembrane, not dark in color.

• Appearance: At sites prone to injury.

• Painful: Traumatic ulcers are often painful.

• Chancre:

• Base: Clean, covered with a grayish-white membrane.

• Painless: Chancres are usually painless.

52. Differentiate a chancre from an aphthous ulcer:

• Aphthous ulcer:

• Painful: Aphthous ulcers are typically painful.

• Soft to the touch: Aphthous ulcers are soft, not firm.

• Chancre:

• Painless: Chancres are usually painless.

• Firm: Chancres are usually firm.

53. Differentiate a chancre from cancer:

• Cancer:

• Early stage: Painless, but painful in later stages.

• Base: Often contains necrotic tissue, not as clean as a traumatic ulcer.

• Chancre:

• Painless: Chancres are usually painless.

• Base: Clean, covered with a grayish-white membrane.

54. Differentiate a chancre from which other lesions? List them:

• Traumatic ulcer.

• Aphthous ulcer.

• Cancer.

55. Characteristic features in Stage II syphilis patients:

• Skin and mucous membrane lesions: Syphilis rash, mucous patches, moist papules.

• Presence of lymph nodes: Enlarged lymph nodes.

• Characteristic feature: Syphilis rash: A red rash, often appearing on the palms of hands, soles of feet, trunk, and chest.

56. Percentage of oral manifestations in Stage I and Stage II syphilis:

• Stage 1: 10%.

• Stage 2: 30%.

57. Where are characteristic oral lesions of Stage II syphilis commonly found?

• Corners of the mouth.

• Tongue.

• Tonsils.

• Pharynx.

• Larynx.

58. At what stage of syphilis is the infection most contagious?

• Stage 2: Stage II syphilis has the highest level of contagiousness.

59. Describe mucous patches:

• One or multiple shallow ulcerations: Shallow ulcers, uneven in shape.

• Shallow: Ulcers are shallow in depth.

• Uneven: Ulcers have an irregular shape.

• Slightly raised: Ulcers are slightly raised above the surrounding tissue.

• Covered with a grayish-white membrane: Ulcers are covered with a grayish-white membrane.

• Red inflammatory ring around them: The area around the ulcers has a red inflammatory ring.

60. Differentiate aphthous ulcers from mucous patches:

• Aphthous ulcer:

• Flat: Ulcers are flat.

• Painful: Aphthous ulcers are typically painful.

• Mucous patches:

• Slightly raised: Ulcers are slightly raised.

• Usually painless: Mucous patches are typically painless.

61. Common location of moist papules:

• Corners of the mouth: Moist papules often appear at the corners of the mouth.

62. Progression rate to Stage III syphilis:

• 15%: Approximately 15% of patients with Stage II syphilis may progress to Stage III.

63. Common antibiotics used to treat syphilis:

• Penicillin: The primary treatment for syphilis.

• Erythromycin: A prophylactic medication for individuals allergic to penicillin.

• Tetracycline: A treatment option for individuals who cannot take penicillin.

64. Tuberculosis and syphilis, which lesions can heal?

• Neither fully heals: Lesions caused by both tuberculosis and syphilis can leave scars and do not fully heal.

65. Describe the tuberculin skin test when suspecting tuberculosis, what is positive in which case?

• Injection of antigen under the skin: A small amount of tuberculin antigen is injected under the skin.

• Measure diameter: The diameter of the area of skin around the injection site is measured after 24-72 hours.

• Positive:

• > 10mm: Positive.

• > 15mm: Strongly positive.

• 5-9 mm: Indeterminate.

• <5mm: Negative.

• Positive in the case of:

• Tuberculosis infection: Individuals with tuberculosis infection.

• Tuberculosis vaccination: Individuals who have received the tuberculosis vaccine.

• Living in a tuberculosis endemic area: Individuals living or working in areas where tuberculosis is prevalent.

66. Is oral tuberculosis infection primary or secondary?

• Primary: Rare, direct infection from the environment.

• Secondary: More common, infection spreading from the lungs to the mouth through the bloodstream.

67. What types of lesions can oral tuberculosis manifest as?

• Chronic ulcers: Deep ulcers with ragged edges, slow to heal.

• Papillary or nodule hyperplasia in the gums: Often seen in primary tuberculosis infection.

69. Describe tuberculosis ulcers:

• Chronic ulcers: Ulcers that persist and are difficult to heal.

• Deep or superficial: Ulcers can be shallow or deep.

• Painful: Tuberculosis ulcers are often painful.

• Necrotic base: The base of the ulcer often contains necrotic tissue.

• Sinus tracts: Ulcers can form sinus tracts.

• Ragged edges: The edges of the ulcer are often irregular and ragged.

• Poor healing: Ulcers heal poorly and slowly.

• Often found on the dorsum of the tongue: Tuberculosis ulcers commonly appear on the back of the tongue.

70. Mechanism of secondary oral tuberculosis infection:

• Tuberculosis inoculation into the mouth:

• When a patient coughs or spits, tuberculosis bacteria can be inoculated into the mouth.

• Bacterial spread through the bloodstream to the submucosa:

• Tuberculosis bacteria spread through the bloodstream to the submucosa and cause ulcers in the mouth.

71. Possible results of the tuberculin skin test:

• > 10mm: Positive.

• > 15mm: Strongly positive.

• 5-9 mm: Indeterminate.

• <5mm: Negative.

72. Drawbacks of the tuberculin skin test:

• Does not indicate whether the lesion is active: The skin test only indicates that the individual has been exposed to tuberculosis bacteria, not whether the lesion is currently active.

73. When is a tuberculin skin test positive?

• Signs of chronic tuberculosis: Individuals with chronic tuberculosis infection.

• Latent tuberculosis infection: Individuals infected with tuberculosis but without symptoms.

• Living in a tuberculosis endemic area: Individuals living or working in areas where tuberculosis is prevalent.

• Tuberculosis vaccination: Individuals who have received the tuberculosis vaccine.

74. Differentiate tuberculosis from chancre:

• Similarities:

• Both are deep ulcers that heal slowly.

• Differences:

• Tuberculosis: Painful.

• Chancre: Painless.

75. Differentiate tuberculosis from deep fungal infections:

• Deep fungal infections:

• Very deep ulcers.

• Very ragged edges.

• Extensive pseudomembrane formation, sometimes foul-smelling.

76. Differentiate tuberculosis from aphthous ulcers:

• Aphthous ulcers:

• Even edges.

• Flat base.

• Relatively better-looking than chronic ulcers.

77. What age group is necrotizing ulcerative gingivitis most common in?

• Children, 80% under 10 years old:

• Necrotizing ulcerative gingivitis is most common in children under 10 years old.

78. Manifestations of necrotizing ulcerative gingivitis:

• Swelling, redness, pain, easy bleeding of the gums:

• The gums are swollen, red, painful, and bleed easily when touched.

• Ulcers and/or necrosis at the interdental papillae and gingival margins:

• Ulcers and/or necrosis occur at the interdental papillae and gingival margins.

• Pseudomembrane formation:

• A pseudomembrane forms over the surface of the ulcers.

• Halitosis:

• The breath has a foul odor.

79. Treatment for early necrotizing ulcerative gingivitis:

• Fluid and nutritional support:

• Provide fluid, electrolytes, and nutrition to the patient.

• Antibiotics:

• Use antibiotics to kill bacteria.

• Removal of necrotic tissue:

• Remove necrotic tissue to allow the gums to heal.

80. Treatment for late necrotizing ulcerative gingivitis:

• Reconstructive surgery and rehabilitation:

• Surgical reconstruction of the damaged gum area.

• Mortality rate < 10%:

• The death rate from necrotizing ulcerative gingivitis is low, less than 10%.

81. Contributing factors to necrotizing ulcerative gingivitis:

• Malnutrition:

• Nutritional deficiencies weaken the immune system.

• Systemic diseases:

• Tuberculosis, measles, pneumonia, sepsis.

• Malignancies:

• Cancer weakens the immune system.

• Immune disorders:

• Patients with immune disorders are more susceptible to infections.

82. Classify the two types of Actinomyces infections:

• Acute form:

• Rapid progression.

• Characteristic: Pus formation and “sulfur granules” (yellow granules resembling sulfur).

• Chronic form:

• Slow progression.

• Characterized by firm infiltration, fibrosis, and less pus formation.

83. Pathogenesis of Actinomyces infection:

• Actinomyces are anaerobic bacteria that are normal residents and do not typically cause disease:

• Under normal conditions, Actinomyces do not cause disease.

• When the natural barrier is breached, the bacteria can cause disease:

• Lesions in the oral mucosa, teeth, gums, etc., create favorable conditions for Actinomyces growth.

• Spreads from the initial site to other areas (face, neck, chest, abdominal skin):

• Actinomyces can spread from the initial site to other areas.

84. Who are Actinomyces infections common in, and what is the common location?

• Males, 40-50 years old:

• Actinomyces infections are more common in males between 40-50 years old.

• Infection following a factor that disrupts the natural barrier:

• Infections often occur after lesions develop in the mouth, teeth, gums, etc.

• The area around the jaw is the most common location:

• The area around the jaw is the most common location for Actinomyces infections.

85. Clinical signs of Actinomyces infection:

• Initial stage:

• Firm swelling, painless.

• In the area of the jaw angle, around the parotid gland, reddish-purple in color.

• Temporary jaw tightness is the most common location before drainage occurs:

• Patients often experience difficulty opening their mouths.

• Usually localized in soft tissues, involving the jaw bone usually occurs later:

• Actinomyces typically cause soft tissue damage before affecting the jaw bone.

86. Principles of treating Actinomyces infection:

• Drainage: Drainage of pus to relieve pressure.

• Antibiotics: Use antibiotics to kill bacteria.

87. Treatment for cat scratch disease:

• Self-healing:

• Cat scratch disease usually resolves on its own after 4 months.

• Drainage of pus:

• If pus is present, draining it helps to relieve pressure and support treatment.

88. Common lesions in cat scratch disease:

• Papules, pustules:

• Often characterized by papules or pustules at the site of the cat scratch.

89. Manifestations of lymph nodes in cat scratch disease:

• Appears 1-3 weeks later:

• Lymph nodes become enlarged 1-3 weeks after being scratched by a cat.

• Enlarged regional lymph nodes (often submandibular, pre-auricular, and cervical lymph nodes) accompanied by fever, discomfort, headache, and chills:

• Regional lymph nodes become enlarged, accompanied by fever, discomfort, headache, and chills.

• Painful lymph nodes, multiple centimeters in diameter, inflamed and red, lasting from 1 to 6 months:

• Lymph nodes are painful, enlarged, inflamed and red, lasting from 1 to 6 months.

• Later, they become softer, more fluid-filled, necrotic, and may rupture, releasing pus:

• Lymph nodes gradually become softer, may become necrotic, and rupture, releasing pus.

90. What are the characteristic oral features caused by congenital syphilis?

• Hutchinson’s incisors:

• Incisors are shaped like a screwdriver, smaller than normal.

• Mulberry molars:

• Molars have numerous bumps, creating a rough surface.

91. How long does Stage 1 syphilis heal, and does it leave scars?

• 3-12 weeks: Chancres typically heal on their own after 3-12 weeks.

• Usually does not leave scars:

• Chancres typically heal withou