VIRUS FUNGI BACTERIA DISEASE Page 3 The oral focal infection theory A concept generally negleted for several

l decades, is controversial yet has gained renewed interest with progress in clasification and identification of oral microorganisms. Additionally, recent evidence associating dental with artherosclerosis and other chronic disease has also helped resurrect the focal infection theory Page 4 Pathways of infection arising from oral bacteria Page 5 The three pathway that may link oral bacteria to secondary disease distant from the oral nidus are : 1. Metastatic infection attributable to transient bacteria in the blood 2. Metastatic immunologic injury 3. Metastatic toxic injury The scientific evidence weak a it is best supports of first pathway of transient bacteriemias of oral origin Page 6 Mechanical prosthetic valve (arrow) Page 7 Page 8 Page 9 Odontogenic infection Caries dental pulpitis Necrosis of the pulp pulp polyp Periapical abscess Page 10 Periodontal infection Periodontal abscess ANUG Gingivitis Page 11

Salivary infection Page 12 Mucositis Recurent Apthous Stomatitis Minor RAS Mayor Page 13 Penyakit Infeksi Bakteri Spesifik di Rongga Mulut Sifilis Gonorrhea Tuberkulosis Lepra Page 14 SIFILIS 1.Sifilis acquired Sifilis primer Sifilis sekunder Sifilis tertier 2.Sifilis kongenital Page 15 Penyebab: Treponema Pallidum Patogenesis Kontak seksual --- lesi primer ( chancre ) ---- hilang--lesi sekunder -----hilang --- tertier Transfusi darah --- lesi sekunder --- hilang --- tertier Kongenital ----- plasenta ibu yang terinfeksi ---tidak ada lesi primer Page 16 Sifilis Primer - Berkembang pada tempat masuknya kuman, 3-4 minggu - Lesi chancre -- plak keras, sedikit meninggi, ulserasi, bulat, indurasi dengan tepi bergulung, coklat berkrusta, dimulai dengan bercak atau papula --- ulser - Diameter 5 mm - beberapa cm - Tidak sakit - Hilang spontan sesudah 10 hari - Lesi dapat satu atau multiple. - Pembesaran kelenjar limfe regional Page 17 Manifestasi di rongga mulut - Lesi chancre - Lokasi bibir, mukosa mulut, lidah, palatum lunak, tonsil faring, jarang pada gusi

- Sedikit sakit karena infeksi sekunder - Ulser ditutupi lapisan putih keabuan - Pada ekstra oral bibir--- krusta coklat - Dapat multiple Page 18 Page 20 Diagnosa - Riwayat kontak dengan penderita - Smear mulut tidak terlihat - Pemeriksaan darah negatif - Eksudat dengan darkfield microscope positif pada akhir stadium primer Diagnosa Banding -Lesi herpes pada bibir -Squamous cell carcinoma stadium awal -Lesi trauma kronik -Tuberkulosis Page 21 Sifilis Sekunder Tanda-tanda umum - Terjadi 3-6 minggu setelah lesi primer - Lokasi tidak berhubungan dengan lesi primer - Erupsi difus pada kulit dan mukosa - Makula papula pada kulit - Pada mukosa dan kulit yang lembab terjadi : mucous patch split papula dan condyloma latum Mucous patch : area kecil, licin, eritematus atau erosi superfisial, putih keabuan pada genital dan mulut, multiple dan tidak sakit Split papula : Lesi doble papula pada area intertrigenus Condyloma latum : Papula besar, lembab, abu-abu, pada mukokutan yang lembab Page 22 Page 23 Manifestasi di rongga mulut Mucous patch - Lokasi pada lidah, mukosa bukal, tonsil, faring dan bibir pada gusi jarang - Lesi yang paling menular - Plak berwarna putih keabuan, sedikit meninggi, permukaan ulserasi, dasar eritematus - Bentuk ovoid atau tidak teratur - Multiple dan tidak sakit - Pada lidah, papilla hilang diatas lesi berbatas jelas - Trauma pada lesi dapat sakit dan berdarah Page 24

Page 25 Split Papula - Lokasi pada komisura bibir berupa fisur yang membagi dua bibir atas dan bawah oleh papula - Dapat terjadi pada dorsum lidah - Tidak spesifik Condyloma latum - Jarang pada mulut - Berwarna abu-abu silver, rata, seperti kutil, ulserasi - Tidak sakit Page 26 Diagnosa Banding Mucous patch - Lesi herpes masa penyembuhan - Lesi traumatik - Eritema multiform - Kandidiasis - Proses alergi Split Papula - Angular cheilitis karena defisiensi Vitamin atau kurangnya ruang inter maksilar Diagnosa : Tes serologis biasanya positif Page 27 Sifilis Tertier Tanda-tanda umum - Asimtomatik atau simtom kompleks - Lesi gumma pada kulit, mukosa, liver, testis, tulang - Dapat melibatkan sistem kardiovaskular, CNS, jaringan dan organ tertentu - Neurosifilis ---- tabes dorsalis dan general paresis Tabes dorsalis --- colum, spinal cord, root ganglia posterior General paresis ---- jaringan cerebral Page 28 Manifestasi di rongga mulut - Lesi gumma , berupa massa nodular yang padat , ulserasi, nekrose, pada palatum --- perforasi palatum - Lokasi : palatum, lidah, kelenjar ludah, tulang rahang - Pada lidah --- atropi papilla, lidah keras --- luetic bald tongue - Tabes dorsales ---- rasa sakit kepala dan leher, kehilangan rasa pengecapan, nekrosis spontan pada prosessus alveolaris - General paresis ---- paresis bibir, lidah, hidung, pipi ulserasi tidak sakit pada palatum, septum hidung, kematian pulpa spontan - Atropik lidah ---- epidermoid carcinoma Page 29 Page 30 Diagnosa Banding

- Gumma ---- Fraktur yang tidak sembuh-sembuh Osteomielitis yang lama bertahan Karsinoma Page 31 Tindakan dokter gigi - Menghindari penularan ---- sifilis primer dan sekunder - Sebagai case finder -Mencegah bakterial endokarditis Perawatan - Sifilis primer, sekunder dan laten -- Benzathine penisilin G - Bila alergi penisilin --- tetrasiklin atau eritromisin Page 32 Sifilis kongenital ( prenatal sifilis ) Tanda-tanda umum - Manifestasi pada 2 tahun pertama kehidupan - Tidak ada lesi primer - Rinitis, hidung sumbat, kehilangan berat badan, tumit berkerut dan bersisik - Makula, papula, bula, vesikel, deskuamasi superfisial. - Kulit berkerut dan bersisik - Petechie, mucous patch, condyloma latum - Kepala bentuk empat segi, lobus frontal menonjol - Manifestasi lanjutan sesudah 2 tahun, interstitial keratitis, vaskularisasi kornea, ketulian, artopati - Umur 10-12 tahun, saddle nose, deformiti tulang hidung perforasi palatum Page 33 Umur 10-12 tahun - Saddle nose, deformiti tulang hidung atau perforasi palatum - Melibatkan tulang fasial dan gigi - Dapat terjadi frontal bosse, maksila yang pendek, palatum yang tinggi, mulberry molar. Tanda khas - Triad Hutchinson : Hipoplasia Incisivus dan Molar Ketulian syaraf 8 Keratitis interstitial Page 34 Manifestasi di rongga mulut 1. Post Rhagadic scarring pada mulut - daerah linear merah tembaga ditutupi krusta lunak pada bibir - Bila sembuh seperti sikatrik 2. Perobahan pada gigi - Perobahan bentuk, warna dan ukuran gigi - Resorbsi akar yang berkurang pada gigi desidui - Hipoplasia gigi pada I, C dan M satu permanen bentuk obeng, runcing pada I, bud shaphe pada M DD dengan terapi Tetrasiklin atau Riketsia 3. Perobahan dentofasial : malokklusi dan open bite

Page 35 Diagnosa - Riwayat dilahirkan ibu penderita sifilis - Lesi-lesi yang khas Perawatan Injeksi Penisilin Page 36 Fungal infection Are oral fungal infections common ? No, most are associated with an underlying systemic condition immunosuppression imunodeficiency syndrome cancer therapy anemia diabetes uremia leukemia Page 37 Patients who have conditions that modify the normal oral environment are at increased risk of fungal infection Among these individuals are patients with _ xerostomia _ have taken broad spectrum antibiotics Page 38 Diagnosis of oral fungal infection based on : History Clinical appearance Culture Potassium hydroxide preparation Biopsy What is the most common fungal infection to affect the mouth? Oral candidiasis caused by Candida Albicans Page 39 What is the typical clinical presentation of oral candidiasis ? Pseudomembranous candidiasis Hyperplastic candidiasis Erythematous candidiasis Angular cheilitis Page 40 Pseudomembranous candidiasis ( Thrush ) Most typical clinical presentation of the infection White, cottage cheesy-looking raised lesions Most often of tongue or palate Can be scrapped off, leaving a painful, raw

bleeding base Page 41 Page 42 Hyperplastic Candidiasis Less common As area leukoplakia at corners of the mouth or the cheeks Unlike pseudomembranous forms, these lesions cannot be scraped off Page 43 Page 44 Erythematous Candidiasis Most often present on the dorsal surface or edges tongue and palate The degree of mucosal erythema may be variable Patients with this form of candidiasis often complain of a burning mouth Page 45 Angular cheilitis Page 46 Viral infection Are viral infections of the mouth common or rare ? Viral infections are among the most common causes of oral lesions Page 47 Symptoms of acute viral infections that affects the mouth Vesicles or rupture small ulcers History suggesting viremia : fever, malaise, myalgia, upper respiratory symptoms, anorexia Pain associated lesions Page 48 Group of viruses for most oral infections: HS type 1,2 Varicella-zoster virus The epstein-barr virus Cytomegalovirus Herpes virus 6,7,8 ( infectious in immunocompromisefd patient Page 49

Page 50 HIV HAS BEEN ISOLATED FROM BODY FLUIDS : HUMAN BLOOD. SEMEN VAGINAL SECRETIONS. BREAST MILK. TEARS. URINE. SALIVA. CEREBROSPINAL FLUID. AMNIOTIC FLUID. Page 51 DIAGNOSTIC TESTING FOR HIV : 1. Detection of serum antibody ELISA. 2. Detection of viral antigen in patients blood or tissue WESTERN BLOT TEST. Page 52 PREVALENSI : 40 90% HIV-related lesions have particular significance because : - They are often the first sign of HIV disease. - They have prognostic value. - They are a frequent cause a morbidity and mortality. - Knowledge and proper treatment can add to the quality of life of HIV patients. Page 53 SAN FRANSISCO, AUG. 17, 1990 : I. CANDIDIASIS. A. Pseudomembranous candidiasis. B. Erythematous candidiasis. C. Angular cheilitis. II. GINGIVITIS / PERIODONTITIS. A. HIV associated gingivitis. B. HIV associated periodontitis. Page 54 III. NECROTIZING STOMATITIS. IV. HERPES SIMPLEX. A. Intra oral form. B. Perioral form. V. CYTOMEGALOVIRUS. Page 55 VI. VARICELLA ZOSTER VIRUS VII. APHTHOUS ULCERATION. A. Minor.

B. Mayor. C. Herpetiform. VIII. HAIRY LEUKOPLAKIA. Page 56 IX. HIV SALIVARY GLAND DISEASE. X. ORAL KAPOSI SARCOMA. XI. ORAL WARTS / PAPILOMA. A. Papilloma. B. Focal epithelial hyperplasia. Page 57 TREATMENT OF THE ORAL LESIONS ASSOCIATED WITH HIV INFECTION. CONDITION THERAPY I. Candidiasis Antifungal (topical and / I. Candidiasis Antifungal (topical and / or systemic). II. HIV- associated Plaque removal, debrigingivitis dement, chlorhexidine, povidone iodine. Page 58 CONDITION THERAPY HIV- associted Plaque removal, debriperiodontitis dement, chlorhexidine, metronidazole. Necrotizing stoDebridement, chlorhematitis xidine, metronidazole. matitis xidine, metronidazole. III. Herpes simplex If not self limiting, if prolonged, if frequently recurrent acyclovir. IV. Herpes zoster Oral Acyclovir. Page 59 CONDITION THERAPY V. Aphthous ulcer Topically steroid

VI. Hairy leukoplakia Usually no treatment, severe acyclovir VII. Kaposi sarcoma Excision, laser, radiation, chemotherapy VIII. Oral wart Excisison, laser IX. Xerostomia Salivary stimulation, artificial saliva. Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66 Page 67 Page 68 Page 69 Page 70 HIV The main targets for the virus are cells expressing the CD4 membrane reseptor, such as T4 helper lymphocyte, macrophages and monocyte Viral replication occures within the CD4 cel, leading to its destruction and loss of function. As a result the number of CD4 cell declines, and the patient become at high risk for opportunistic infections. Page 71 Many medication used to treat HIV have side effect Abacavir oral ulceration Flycotsine myelosuppression Foscarnet ou &m

 Ganciclovir m Hydroxyurea ou Interferon xerostomis,metallic taste & m Lopinavir u&x Pentamidine mt Rifampin salivary discoloration Ritonavir perioral paresthesia Saquinavir p, neutropenia, thrombocytopenia TMP/SMZP myelosup,ou, glositis Dideoxycytidine my & ou Zidovudine Neutropenia Page 72 Page 73 Page 74 Page 75 Page 76 Page 77 Page 78 Page 79 VIRUS VIRUS PENYAKIT Herpes Simpleks 1 & 2 Primary Gingivostomatitis Herpetica Herpes Labialis Recurrent Viral infection causing, or associated with diseases of the oral mucosa : Herpes Labialis Recurrent Herpes Intra Oral Recurrent Herpetic Whitlow Varicella - Zoster Chickenpox Herpes Zoster Coxsakie A Herpangina Hand, foot and mouth disease

Page 80 VIRUS PENYAKIT Cytomegalovirus Salivary gland disease Epstein Barr Virus Hairy leukoplakia Viral infection causing, or associated with diseases of the oral mucosa : Virus Paramyxovirus Measles Papilomavirus Viral warts HIV Manifestasi oral HIV Page 81 Page 82 HERPES SIMPLEX VIRUS INFECTION Family herpesviridae Herpes simplex virus Herpes simplex virus 1 Herpes simplex virus Herpes simplex virus 1 Herpes simplex virus Herpes simplex virus 2 Cytomegalovirus Varicella Varicella-zoster virus zoster virus Epstein Barr virus Human herpes virus Human herpes virus-6 Human herpes virus Human herpes virus-7 Human herpes virus Human herpes virus-8 Page 83 Herpes Simplex virus Herpes Simplex virus 1 perioral, eyes Herpes Simplex virus Herpes Simplex virus 2 genitals TRANSMISSION : 1. Airbone droplets 2. Intimate contact Page 84 HERPES SIMPLEX VIRUS

INFECTION PRIMARY INFECTION RECURRENT INFECTION Page 85 CHARACTERISTIC PROPERTY OF HERPES VIRUS : after primary infection after primary infection latent in cell host cell host reactivated by variety factors recurrent infection Trigger factors : - Fever - Emotional stress Emotional stress - Ultraviolet radiation Ultraviolet radiation - Menstruation Menstruation - Hormones - Immunosuppression Immunosuppression - Ionizing radiation Ionizing radiation Page 86 PATHOGENESIS OF HSV-1 INFECTIONS : Host (seronegative) Primary disease or Recurrent infection or HSV or Subclinical infection Host (seropositive) latent virus Reactivation Recurrent infection or Shedding asymptomatic Resolution Page 87 Page 88 Page 89 PRIMARY HSV-1 INFECTION : - Seronegative for HSV Seronegative for HSV - Children, young adult Children, young adult

- Does not imply clinical signs & symptoms Does not imply clinical signs & symptoms - Does not imply clinical signs & symptoms Does not imply clinical signs & symptoms subclinical - Incubation periode : several days Incubation periode : several days Incubation periode : several days 2 weeks - Primary Gingivostomatitis Herpetica Herpetic Whitlow Page 90 PRIMARY GINGIVOSTOMATITIS HERPETICA. CLINICAL APPEARANCES : - Prodromal symptoms : fever, malaise, nausea, Prodromal symptoms : fever, malaise, nausea, headache, lymphadenopathy. - Vesicle rupture round/oval ulcers, shallow, grey shallow, grey-white pseudomembrane, surrounded white pseudomembrane, surrounded by erythema area. - Ulcers can coalescent Ulcers can coalescent Ulcers can coalescent large ulcers. - Pain, disorders of swallowing, eating, Pain, disorders of swallowing, eating, secondarily infected. - Location: any intra oral. Location: any intra oral. - Acute gingivitis marginalis Acute gingivitis marginalis Acute gingivitis marginalis gingiva are swollen with red edges that bleed easily. - Heal : 10 Heal : 10 Heal : 10 12 days self limiting disease, without scar. Page 91 Page 92 Page 93 Page 94 Treatment : Goals : 1. To shorten the current attack. 2. To prevent recurrences. Medications : Analgesics.

 Vitamin. Anaesthetic topical. Antivirus. Page 95 RECURRENT HSV INFECTION : - Affect 20 40% 0f adult population. Affect 20 40% 0f adult population. - Antibody for HSV was present. Antibody for HSV was present. - Reactivation of latent virus by trigger Reactivation of latent virus by trigger factors. - Recurrent Herpes Labialis Recurent Herpes Intra Oral Herpetic Whitlow. Page 96 RECURRENT HERPES LABIALIS. CLINICAL APPEARANCES : - Prodromal symptoms : mild fever, tingling, Prodromal symptoms : mild fever, tingling, burning or pain in which lesions will appear. - Vesicles on the vermillion border of lip Vesicles on the vermillion border of lip Vesicles on the vermillion border of lip - Vesicles on the vermillion border of lip Vesicles on the vermillion border of lip Vesicles on the vermillion border of lip rupture shallow ulcer. - Yellow crust formation. Yellow crust formation. - Problems : pain, cosmetic disfigurement, Problems : pain, cosmetic disfigurement, psychosocial effect. - Heal : 1 Heal : 1 Heal : 1 2 weeks without scar. 2 weeks without scar. - Recurrences is variable. Recurrences is variable. Page 97 Page 98 Page 99 Page 100 Page 101 Page 102

Page 103 Page 104 Page 105 Page 106 RECURRENT HERPES INTRAORAL. CLINICAL APPEARANCES : - Prodromal symptoms Prodromal symptoms Prodromal symptoms mild. - Vesicles Vesicles Vesicles rupture ulcers. - Intraorally. Intraorally. - Intraorally. Intraorally. Recurrent Herpes Labialis maybe seen concurently with the intraoral lesions or they occur alone. Page 107 Page 108 HERPETIC WHITLOW : - Primary or secondary HSV infection involving Primary or secondary HSV infection involving the finger. - Because of the physical contact with infected Because of the physical contact with infected individual. - Fever, lymphadenopathy. Fever, lymphadenopathy. - Fever, lymphadenopathy. Fever, lymphadenopathy. - Pain, redness, swelling are prominent. Pain, redness, swelling are prominent. - Duration : 4 Duration : 4 Duration : 4 6 weeks. - Locations : paronychial, eponychial or subungal portions of the distal phalanges, other area of the finger. Page 109 Page 110 Page 111

Page 112 VARICELLA VARICELLA ZOSTER VIRUS DNA untai ganda Neurotropic Penularan : kontak langsung, Penularan : kontak langsung, infeksi droplet. Infeksi primer dan rekuren bersifat laten Page 113 Varicella zoster virus PRIMARY INFECTION RECURRENT INFECTION CHICKENPOX / VARISELA HERPES ZOSTER / SHINGLES Page 114 Hospes (seronegative) Primary infection ( Chickenpox ) Recurrent infection ( Herpes zoster ) Hospes (seropositive ) Latency virus Reactivation : - age -Immunosupression, dll Immunosupression, dll ( Herpes zoster ) Page 115 VARICELLA ( CHICKENPOX ) : - seronegative individual. seronegative individual. - children. children. - incubation periode : 2 incubation periode : 2 incubation periode : 2 3 weeks. - prodromal symptoms : fever, chills, malaise, prodromal symptoms : fever, chills, malaise, - prodromal symptoms : fever, chills, malaise, prodromal symptoms : fever, chills, malaise, headache. - rash vesicles vesicles pustula / ulcerations. - heal : 2 weeks heal : 2 weeks heal : 2 weeks self limiting.

- intra oral : not consistently involved. intra oral : not consistently involved. discrete/scattered vesicles discrete/scattered vesicles rupture shallow round ulcer surrounded by red halo. Page 116 HERPES ZOSTER : Clinical appearancess : - Gejala prodromal : parastesi, gatal, rasa terbakar, nyeri di daerah dermatom yg terlibat. - Dermatom yg terlibat : T5, C3, L1, L2, s. trigeminal - Ruam makulopapular Ruam makulopapular Ruam makulopapular vesikel ulser dengan dasar eritematus eritematus krusta. eritematus eritematus krusta. - Distribusi unilateral. - Intra oral : vesikel Intra oral : vesikel ruptur ulkus. Cab. Maksilaris : palatum lunak, mukosa bibir atas, uvula mukosa pipi. Cab. Mandibularis : lidah, gimngiva, mukosa bibir bawah. Page 117 Page 118 Page 119 Page 120 Page 121 Page 122 Page 123 Page 124 TREATMENT : - Bed rest. Bed rest. - Local applications of heat. Local applications of heat. - Topical anesthetic. Topical anesthetic. - Topical anesthetic. Topical anesthetic. - Antiviral.

Antiviral. - Analgesics. Analgesics. - tranquilizers. tranquilizers. Page 125 Page 126 LOCALIZED FUNGAL INFECTIONS ORAL CANDIDIASIS DEEP-SEATED FUNGAL SEATED FUNGAL INFECTIONS ASPERGILOSIS CRYPTOCOCOSIS HISTOPLASMOSIS GEOTRICHOSIS BLASTOMYCOSIS Rarely affect the oral cavity Page 127 ORAL CANDIDIASIS A SUPERFICIAL INFECTION OF ORAL MUCOUS CAUSED BY THE YEASTLIKE FUNGUS CANDIDA ALBICANS Page 128 FACTORS PREDISPOSING TO ORAL CANDIDIASIS : LOCAL FACTORS SYSTEMIC FACTORS Denture wearing Saliva Xerostomia, low pH Commensal flora Physiological Old age, infancy, pregnancy Endocrine disorders Diabetes Melitus Nutritional deficiencies Iron, folate, vit.B 12 High-carbohydrate diet carbohydrate diet Smoking tobacco Iron, folate, vit.B 12 Malignancies Leukemia Immune defects HIV / AIDS Drugs / medication Broad spectrum antibiotics

Corticosteroids Cytotoxic drugs Page 129 CLASSIFICATION OF ORAL CANDIDIASIS : TYPE CLINICAL ACUTE : ACUTE PSEUDOMEMBRANOUS CANDIDIASIS = ORAL TRUSH Creamy / white patches on the surface of oral mucous; forming confluent; curd oral mucous; forming confluent; curd-like pseudomembranes. Pseudomembranes can be scraped off to reveal raw, erythematous base. = ORAL TRUSH erythematous base. ACUTE ATROPHIC CANDIDIASIS = ANTIBIOTIC SORE TONGUE Small lesions, usually on the tongue, with reddening / inflammation of surrounding tissue Page 130 TYPE CLINICAL CHRONIC : Chronic Atrophic Candidiasis = Denture Stomatitis Chronic erythema and edema of upper palate localized to occluded / traumatized tissue Chronic hyperplastic Candidiasis White patch adherent to mucous on an erythematous base which is not removable by digital pressure. = Candida Leukoplakia removable by digital pressure. Usually on the anterior buccak mucous Angular cheilitis =Perleche Erythema, fissure and encrustations at corners of mouth. Page 131 Page 132

Page 133 Page 134 Page 135 Page 136 Page 137 Page 138 Page 139 Page 140 DIAGNOSIS : CLINICAL APPEARANCES + LABORATORIUM EXAMINATIONS : LABORATORIUM EXAMINATIONS : * Culture * Cytologic * Serology Page 141 TREATMENT : To correct predisposing factors To correct sources of infection Antifungal drugs Page 142 ANTIFUNGAL DRUGS POLYENE AZOLES A.IMIDIAZOLE : - Clotrimazole - Ketoconazole - Miconazole B. TRIAZOLE : - Fluconazole - Itraconazole A. AMFOTERICIN B B. NYSTATIN Page 143 Penyakit Infeksi Bakteri Spesifik di Rongga Mulut Sifilis Gonorrhea

Tuberkulosis Lepra Page 144 SIFILIS 1.Sifilis acquired Sifilis primer Sifilis sekunder Sifilis tertier 2.Sifilis kongenital Page 145 Penyebab: Treponema Pallidum Patogenesis Kontak seksual --- lesi primer ( chancre ) ---- hilang--lesi sekunder -----hilang --- tertier Transfusi darah --- lesi sekunder --- hilang --- tertier Kongenital ----- plasenta ibu yang terinfeksi ---tidak ada lesi primer Page 146 Sifilis Primer - Berkembang pada tempat masuknya kuman, 3-4 minggu - Lesi chancre -- plak keras, sedikit meninggi, ulserasi, bulat, indurasi dengan tepi bergulung, coklat berkrusta, dimulai dengan bercak atau papula --- ulser - Diameter 5 mm - beberapa cm - Tidak sakit - Hilang spontan sesudah 10 hari - Lesi dapat satu atau multiple. - Pembesaran kelenjar limfe regional Page 147 Manifestasi di rongga mulut - Lesi chancre - Lokasi bibir, mukosa mulut, lidah, palatum lunak, tonsil faring, jarang pada gusi - Sedikit sakit karena infeksi sekunder - Ulser ditutupi lapisan putih keabuan - Pada ekstra oral bibir--- krusta coklat - Dapat multiple Page 148 Page 149 Page 150 Diagnosa - Riwayat kontak dengan penderita - Smear mulut tidak terlihat

- Pemeriksaan darah negatif - Eksudat dengan darkfield microscope positif pada akhir stadium primer Diagnosa Banding -Lesi herpes pada bibir -Squamous cell carcinoma stadium awal -Lesi trauma kronik -Tuberkulosis Page 151 Sifilis Sekunder Tanda-tanda umum - Terjadi 3-6 minggu setelah lesi primer - Lokasi tidak berhubungan dengan lesi primer - Erupsi difus pada kulit dan mukosa - Makula papula pada kulit - Pada mukosa dan kulit yang lembab terjadi : mucous patch split papula dan condyloma latum Mucous patch : area kecil, licin, eritematus atau erosi superfisial, putih keabuan pada genital dan mulut, multiple dan tidak sakit Split papula : Lesi doble papula pada area intertrigenus Condyloma latum : Papula besar, lembab, abu-abu, pada mukokutan yang lembab Page 152 Page 153 Manifestasi di rongga mulut Mucous patch - Lokasi pada lidah, mukosa bukal, tonsil, faring dan bibir pada gusi jarang - Lesi yang paling menular - Plak berwarna putih keabuan, sedikit meninggi, permukaan ulserasi, dasar eritematus - Bentuk ovoid atau tidak teratur - Multiple dan tidak sakit - Pada lidah, papilla hilang diatas lesi berbatas jelas - Trauma pada lesi dapat sakit dan berdarah Page 154 Page 155 Split Papula - Lokasi pada komisura bibir berupa fisur yang membagi dua bibir atas dan bawah oleh papula - Dapat terjadi pada dorsum lidah - Tidak spesifik Condyloma latum - Jarang pada mulut - Berwarna abu-abu silver, rata, seperti kutil, ulserasi - Tidak sakit

Page 156 Diagnosa Banding Mucous patch - Lesi herpes masa penyembuhan - Lesi traumatik - Eritema multiform - Kandidiasis - Proses alergi Split Papula - Angular cheilitis karena defisiensi Vitamin atau kurangnya ruang inter maksilar Diagnosa : Tes serologis biasanya positif Page 157 Sifilis Tertier Tanda-tanda umum - Asimtomatik atau simtom kompleks - Lesi gumma pada kulit, mukosa, liver, testis, tulang - Dapat melibatkan sistem kardiovaskular, CNS, jaringan dan organ tertentu - Neurosifilis ---- tabes dorsalis dan general paresis Tabes dorsalis --- colum, spinal cord, root ganglia posterior General paresis ---- jaringan cerebral Page 158 Manifestasi di rongga mulut - Lesi gumma , berupa massa nodular yang padat , ulserasi, nekrose, pada palatum --- perforasi palatum - Lokasi : palatum, lidah, kelenjar ludah, tulang rahang - Pada lidah --- atropi papilla, lidah keras --- luetic bald tongue - Tabes dorsales ---- rasa sakit kepala dan leher, kehilangan rasa pengecapan, nekrosis spontan pada prosessus alveolaris - General paresis ---- paresis bibir, lidah, hidung, pipi ulserasi tidak sakit pada palatum, septum hidung, kematian pulpa spontan - Atropik lidah ---- epidermoid carcinoma Page 159 Page 160 Diagnosa Banding - Gumma ---- Fraktur yang tidak sembuh-sembuh Osteomielitis yang lama bertahan Karsinoma Page 161 Tindakan dokter gigi - Menghindari penularan ---- sifilis primer dan sekunder - Sebagai case finder -Mencegah bakterial endokarditis Perawatan - Sifilis primer, sekunder dan laten -- Benzathine penisilin G

- Bila alergi penisilin --- tetrasiklin atau eritromisin Page 162 Sifilis kongenital ( prenatal sifilis ) Tanda-tanda umum - Manifestasi pada 2 tahun pertama kehidupan - Tidak ada lesi primer - Rinitis, hidung sumbat, kehilangan berat badan, tumit berkerut dan bersisik - Makula, papula, bula, vesikel, deskuamasi superfisial. - Kulit berkerut dan bersisik - Petechie, mucous patch, condyloma latum - Kepala bentuk empat segi, lobus frontal menonjol - Manifestasi lanjutan sesudah 2 tahun, interstitial keratitis, vaskularisasi kornea, ketulian, artopati - Umur 10-12 tahun, saddle nose, deformiti tulang hidung perforasi palatum Page 163 Umur 10-12 tahun - Saddle nose, deformiti tulang hidung atau perforasi palatum - Melibatkan tulang fasial dan gigi - Dapat terjadi frontal bosse, maksila yang pendek, palatum yang tinggi, mulberry molar. Tanda khas - Triad Hutchinson : Hipoplasia Incisivus dan Molar Ketulian syaraf 8 Keratitis interstitial Page 164 Manifestasi di rongga mulut 1. Post Rhagadic scarring pada mulut - daerah linear merah tembaga ditutupi krusta lunak pada bibir - Bila sembuh seperti sikatrik 2. Perobahan pada gigi - Perobahan bentuk, warna dan ukuran gigi - Resorbsi akar yang berkurang pada gigi desidui - Hipoplasia gigi pada I, C dan M satu permanen bentuk obeng, runcing pada I, bud shaphe pada M DD dengan terapi Tetrasiklin atau Riketsia 3. Perobahan dentofasial : malokklusi dan open bite Page 165 Diagnosa - Riwayat dilahirkan ibu penderita sifilis - Lesi-lesi yang khas Perawatan Injeksi Penisilin