Oral candidiasis

Department of Pediatric Dentistry
St Joseph Hospital

Resident’s Name: Joanne Lewis Date: July 17, 2009
Article title: Oral candidiasis in children with immune suppression: Clinical appearance and therapeutic considerations
Author(s): Catherine M. Flaitz, DDS, MS; M. John Hicks, DDS, MS, PhD, MD
Journal: Journal of Dentistry for Children
Month, Year: May-June 1999
Major topic: Oral candidiasis in immuno-suppressed children
Type of Article: review
Main Purpose: to review the clinical appearance, diagnosis, and treatment of oral candidiasis
Key points/Summary: Oropharyngeal candidiasis is of considerable importance in any condition that results in an immune suppressed state; it is particularly important in individuals with HIV infection. The development of oral candidiasis is considered to be an ominous sign, indicative of a severely depressed immune system. Oral candidiasis may present in several forms: 1.) pseudomembranous candidiasis (thrush) – white to yellow plaques overlying the oral mucosa – can be removed with gauze – symptoms include tenderness, burning, and dysphasia. 2.) erythematous (atrophic) candidiasis – marked erythematous mucosa on palate and/or dorsum of tongue – associated with broad-spectrum antibiotics and corticosteroid therapy. 3.) papillary hyperplasia – anterior hard palate, small ovoid nodules raised 2-3 mm above erythematous palatal mucosa – response to a chronic fungal infection. 4.) chronic hyperplastic candidiasis – thickened hyperkeratotic mucosa, looks like a localized area of leukoplakia – seen in long-standing fungal infections – presents on dorsum of tongue or retrocommissural region 5.) angular chelitis – seen at the commissures, may become encrusted secondary to fissuring and erosion – seen commonly in children with a lip-licking habit. 6.) median rhomboid glossitis – lesion surface varies from nodular to fissured to smooth and depapillated. Diagnosis: clinical appearance (most common), exfoliative cytology, biopsy, or culture (when lesions are resistant to anti-fungal therapy). Treatment: 1.) topical – nystatin creams, rinses, pastilles, ketoconazole cream, clotrimazole creams and lozenges, amphotericin B cream and lotion – usually have high sucrose or dextrose content, long term use may increase caries risk. 2.) prophylactic – chlorhexidine rinses. 3.) systemic – clotrimazole, ketoconazole, fluconazole, itraconazole (azole class) – side effects include – nausea, vomiting, pruritus, skin rash, abdominal discomfort, headache, abnormal liver function, drug-induced hepatitis – assess liver function at time of administration. Fluconazole and itraconazole have been more effective at treating oral candidiasis. Prophylaxis with antifungal agents in children and adolescents with HIV infection is not routinely recommended, but may be indicated on a case-by-case basis.
Assessment of article: good review.

Herpesvirus Infections

LUTHERAN MEDICAL CENTER

Dental Residency Program

Literature Review Form

Resident: Adam J. Bottrill Date: 17JUL09 Region: St. Joseph’s

Article title: HERPESVIRUS INFECTIONS

Author(s): Greenberg, Martin S. DDS

Journal: Infectious Diseases and Dentistry

Volume #; Number; Page #s): Vol. 40; Number 2, pp. 359-367

Year: 1996

Major topic: Herpesvirus

Minor topic(s): NA

Type of Article: Topical Review

Main Purpose: Review various presentations and treatments of multiple forms of the herpesvirus.

Overview of method of research: Literature review and summary.

Findings: N/A

Key points in the article discussion:

A. All 7 herpesviruses have the following common characteristics.

1. Four Layers (DNA, capsid, tegument, lipid envelope)

2. Primary infection followed by latent period.

3. Recurrent infections (symptomatic or asymptomatic)

4. Transmitted through direct contact with saliva or genital secretions.

5. Shed in the saliva of asymptomatic hosts.

6. Known to transform cells in tissue culture.

B. Herpes Simplex Virus: Two major herpes simplex viruses are HSV 1 and HSV2. HSV1 is MOSTLY transmitted via saliva and associated with “upper body” infections. HSV2 is MOSTLY transmitted via genital secretions and associated with anal/genital infections. Rate of HSV1 infection goes up after 6 mo. And peaks between 2 and 3 y.o. HSV2 infection rate increases after sexual activity begins.

1. Primary: Frequently subclinical or are difficult to distinguish from URI’s. Can be preceded by fever, chills, malaise, nasea and lymphadenopathy. Oral manifestations include vesicles and ulcers of oral mucosa.

2. Reactivation: Stimulated by trauma, fever menstruation etc. Recurrences appear most commonly on the lips but can be present on the hard palate and gingiva.

3. Dx: Typically diagnosed clinically but may be done via lab tests. SHOULD ALWAYS BE RULED OUT WRT THE IMMUNOCMPROMISED (IC) PT.

C. Cytomegalovirus: Frequent cause of asymptomatic infection in humans. Clinically significant cases are rare except in neonates and IC Pt’s. Xmitted via genital secretions, breast milk, saliva and blood. CMV can cause potentially fatal congenital infection cytelomegalic inclusion disease. Infant CMV almost always involves enlarged salivary glands. In adults, can cause a mono-like disease with clinical manifestations including hepatitis, pneumonitis, lymphadenopathy, splenomegaly and myocarditis. At-risk individuals include organ transplant, HIV and IC pts. Oral lesions in AIDS pts have been described as slowly enlargening ulcers.

1. Dx: Histologic evaluation and culture of suspected lesions (owl eye cells) or viral culture. Culture can take up to 1 month but is most diagnostic.

D. Varicella-Zoster Virus:

1. Primary: Chicken pox (varicella) is usually a benign illness of children spread by direct contact with lesions or nasopharyngeal secretions. Lesions are typically pruritic macules and papules that become vesicles with erythematous halo.. 10-20 day incubation and pts are infectious for about 1 week after symptoms begin. Adults have 15x higher mortality rate due to increased incidence of encephalitis. Other symptoms include pneumonitis and Reye’s syndrome (progressive encephalopathy).

2. Recurrent: Shingles (herpes zoster) occurs when the latent virus (dorsal root nerve ganglia) becomes reactivated. Typically occurs at C-3, T-5, L-1, L-2. When trigeminal nerve involved, usually involves ophthalmic. Symptoms initially include pain, tenderness and parasthesia. This is followed by unilateral vesicles forming along the course of the affected nerve (Ramsay-Hunt syndrome). 15-20% of trigeminal infections involve 2nd and 3rd division leading to possible intra-oral lesions. Can be life-threatening to IC pts. Course of the zoster can be shortened with large doses of acyclovir. Additional sequela of herpes zoster may take the form of postherpetic neuralgia.

3. Dx: Typically made via characteristic clinical signs and proper medical history. When atypical cases present, tissue culture and viral isolation can confirm.

E. Epstein-Barr Virus: Affinity for B lymphocytes. Virus is spread by infected saliva or blood.

1. Primary: Typically subclinical or mild in children. Young adults present with infectious mononucleosis. Symptoms of “mono” include fever, malaise, pharyngitis, lymphadenopathy and possible splenomegally. Most pts recover within a month.

2. Dx: Based on clinical signs and bloodwork (detection of activated T-lymphcytes and heterophil antibodies).

3. Important note: EBV is associated with: Hairy leukoplakia, Burkitt’s lymphoma, nasopharyngeal carcinoma and possibly B cell lymphoma.

F. Human Herpes Virus 6: Discovered in 1986, has a strong affiliation for CD4 lymphocytes. Causes roseola (common disease among children) which presents with fever and a rash. Suspected the HHV6 is related to mono, pneumonia, meningitis and encephalitis.

G. Human Herpes Virus 7: Most recently discovered herpesvirus detected on CD4 lymphocytes. Distinguishable from HHV-6 by DNA analysis. Can initially infect in the 2nd yr of life (later than HHV-6). Transmitted via saliva.

Summary of conclusions: There are more than 80 known viruses of the herpes group. This article presents brief summaries of seven of them

Assessment of article: Though not an experimental research-based article, it did provide concise summaries of the seven aforementioned herpesviruses. One area not covered was effective treatment methods. It is possible that there may be a more recent summary article with more updated information on this.

LUTHERAN MEDICAL CENTER

LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form

Resident: Dan Boboia Date: 7/17/09
Article title: Differential Diagnosis of Oral Enlargements in Children
Author(s): Flaitz et al.
Journal: Pediatric Dentistry
Volume #; Number; Page #s): 17:4
Year: 1995
Type of Article: Review
Main Purpose: To review soft tissue and bony enlargements that typically occur in the oral and perioral region in children
SOFT TISSUE LESIONS:
Papillary enlargements:
- Viral-induced epithelial proliferation resulting in pale, spongy-to-firm enlargements with a pebbly or papillary appearance and rough surface texture; painless with limited growth potential; divided into isolated or multiple lesions; spontaneous resolution or protracted course

Acute Inflammatory Enlargements:
- Characterized by sudden onset, rapid progression, and compressible tissue distension; fluid-filled or edematous lesion, frequently tender to palpation and may fluctuate in size; systemic effects such as fever, malaise, and lymphadenopathy may develop as the lesion progress; divided into infectious and noninfectious processes with localized or diffuse tissue involvement
Reactive Hyperplasia:
-A benign group of lesions that frequently mimic neoplastic disease; most develop in response to a chronic reoccurring injury that stimulates tissue repair; exhibit moderate growth, absence of pain, and limited growth potential; divided into primary or multifactorial causes for initiation and growth; if source of injury is removed partial regression of the lesion may occur
Benign Submucosal Cysts and Neoplasm:
-Nodular, well delineated, and freely movable enlargements with intact mucosal surfaces; slow persistent growth pattern causing alteration of tissues; usually asymptomatic unless traumatized or they impinge on adjacent tissues
Aggressive / Malignant Soft Tissue Enlargement:
-Rapid progressive growth, infiltrative margins are defining features of this group; irregular surface changes with areas of erythema and ulceration; early lesion are asymptomatic but as progression occurs pain, paraesthesia, lymphadenopathy, and obstruction can occur; prognosis depends on lesion size, malignancy, and proximity to vital structures.
BONEY ENLRAGEMENTS OF THE MAXILLA AND MANDIBLE:
-Three categories: inflammatory lesions of the jaw, benign cystic and neoplastic lesions, and aggressive and malignant lesions.
Inflammatory lesions of the jaw:
-Rapid enlargement, pain, erythema, and drainage; cause is usually a mobile or nonvital tooth; poorly defined radiolucent or radiolucent-radiopaque; may also notice widened PDL, lamina dura loss, internal or external resorption of the root.
Benign cystic and neoplastic lesions of the jaws:
-locally expansile but slow growing; delayed tooth eruption and facial asymmetry are notice; well-delineated unilocular or multilocular with cortical plate expansion; radiolucent, radiopaque, or mixed; can be accompanied by blunt root resorption or displacement of anatomic structures
Aggressive and malignant neoplasms of the jaw:
-Diffuse enlargement with moderate growth rate; pain mucosal ulceration, extrusion of teeth, and paresthesia are common complaints; poorly defined radiolucent or mixed lesion with cortical destruction; irregular root-resorption, loss of lamina dura, widening of the PDL space, and appearance of floating tooth.
Assessment of article: Great review; excellent flow charts

Pemphigus Vulgaris in Adolescence: case report

Department of Pediatric Dentistry

Luthern Medical Center

7/17/2009

Residents Name: Tyler Roberts
Article title: Pemphigus Vulgaris in adolescence: case report
Author: Fabio Ramoa Pires, DDS et al
Journal: Pediatric Dentistry
Volume #, pages: 22: 2, 159-162
Year: September 1999
Major topic: Pemphigus Vulgaris
Type of article: case report
Main purpose: review signs and symptoms of Pemphigus Vulgaris (PV) involving a rare case of adolescence.
Method of research: case review
Key pts and findings:
Pemphigus Vulgaris (PV), an autoimmune disease, is an intraepithelial blistering disease caused by auto antibodies against desmosomal antigens. Recently this antigen was cloned and found to be a member of the cadherin family of molecules.
In fifty percent of patients affected by PV, oral lesions will be the first sign of the disease. At some point ninety percent of patients will manifest these types of symptoms. Other forms of Pemphigus such as foliaceus, erythematosus, and vegetans almost exclusively affect the skin. PV most often affects middle aged adults in their fifties and sixties and tends to predominate in females. However, much like the case report found in this article it can and does show up in adolescents and even children.
This case report presents a 16 year old Brazilian female, diagnosed with PV. The patient reported that 5 months prior to her first visit to the hospital, she noticed painful oral ulcers. These oral lesions were soon followed by erythemetous and coalescent, irregularly shaped ulcers on her back. In addition, bilateral submandibular lymphadenopathy (swelling of the lymph nodes) was present. Her oral lesions were described as atrophic, erosive, desquamative lesions involving buccal mucosa, soft palate, togue, and buccal gingiva. Initially, the patient was started on 40 mg per day of prednisone, this however, was gradually reduced to 5 mg per day. The patient has since been in stable condition with candidiasis as her only side effect to the medication.

Conclusion: Dentist should be aware that oral lesions are frequently the first sign of complaints in patients with Pemphigus Vulgaris. No standard treatment protocol exist in adolescence and children due to its rarity.

Assessment of article: Interesting and insightful

Recurrent Apthous Stomatitis

Resident’s Name: Brian Schmid Date: 7/17/2009
Article title: Recurrent Apthous Stomatitis
Author(s): Jonathan Ship DMD, Elisa Chavez DDS et al
Journal: Quintessence International
Month, Year: 2000
Major topic: Review of recurrent apthous stomatitis
Type of Article: Review
Findings: RAS is the most common oral mucosal disease in humans with an incidence of 5-25% and much higher in selected populations (50-60% in med/dent students). Minor RAS consists of small (<10mm) painfululcers with a necrotic center and a gray-white pseudomembrane. They typically heal within 10-14 days without scaring and is typically located on nonkeratinized oral mucosa. Major RAS (aka Suttons Disease and periadenitis mucosa necrotica recurrens comprises 10-15% of RAS cases). These lesions are larger than 10mm and often scar. They can also last for months and be a major cause of dysphagia. Major RAS has a predilection for lips, tongue, soft palate and the palatal fauces. It is frequently found in HIV patients. Multiple small clusters of pin point ulcers characterize Herpetiform RAS.
The most common differential for RAS is herpes simplex, which differs from RAS in that the primary form causes fever and erythema and it typically occurs on attached tissue. Varicella Zoster virus can be differentiated by its unilateral patter of following the trigeminal nerve and a prodrom of pain and tingling/burning sensation. Herpangina lesions usually have correlated systemic symptoms like fever and will resolve in 1-2 weeks. Erythema multiforme lesions are accompanied by stargetoid skin lesions and occur on both attached and movable mucosa. Oral lichen planus can resemble RAS but lesions will typically also occur on the gingiva and hard palate, and is often not painful. Systemic lupus erythematosis, Crohns disease, Behcets disease, Reiters syndrome and HIV/AIDS can also present with RAS-like ulcers. While there is no hardline causation of hematological defects with RAS, a significant persentage of patients can be successfully treated with blood elements.
Chronic minor or major RAS can be a concern due to the myriad potential underlying systemic diseases and any chronic RAS patient should be referred for medical workup. Dermatology and internal medicine may be necessary for immunosupressant medications; Otolaryngology for infectious diseases such as pemphigoif and herpangina; GI for IBD and Crohns; Opthamology for Behcets or Reiters disease. Also, allergists, infectious disease and hematology may need to be consulted.
Anti-inflammatory topical gels and ointments are the first line of chemotherapeutic defense. They are most effective when applied early in the outbreak. The topical glucocorticoids of choice is fluocinonide, triamcinolone and clobetasol. These drugs mixed with Orabase can be an effective treatment. 5% amlexanox applied 4 times daily is also an effective and safe treatment. There are also effective topical rinses such as Sucralfate.

Key points/Summary: There are many possible treatments for RAS and even more potential causes. It is essential to cover your medical bases and account for any possible underlying causes.

Assessment of article: A super review of RAS related material.