TONSILLITIS AND

PHARYNGITIS

 Inflammatory conditions of the tonsils and
pharyngeal mucosa
 May be due to many different organisms
 Clinical features may include sore throat, fever,
tonsillar hyperplasia, and erythema of the
oropharyngeal mucosa and tonsils.
 Spread by contact with infectious nasal or oral
secretions
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Diagnosis and Management
 Laboratory tests can confirm streptococcal cause.
 Group A β (beta)-hemolytic streptococci are related
to scarlet fever and rheumatic fever.
 Scarlet Fever
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 Usually occurs in children
 Patients have a fever and a generalized red skin rash
caused by a toxin released by the bacteria.
 Oral manifestations in addition to streptococcal
tonsillitis and pharyngitis include:
 Petechiae on the soft palate “Strawberry” tongue
 Erythema of hard palate and a white-coated tongue
with erythematous, edematous, fungiform papillae.
 Later the tongue becomes beefy red (strawberry
tongue).
“Strawberry” tongue: Fungiform papillae are red and prominent
with the dorsal surface of the tongue exhibiting either a white

coating or erythema .
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 Rheumatic Fever

 A childhood disease that follows a group A β-
hemolytic streptococcal infection
 Characterized by an inflammatory reaction involving
the heart, joints, and central nervous system
 Heart valve damage may occur
 This may require the patient to be premedicated
prior to dental hygiene treatment
 SYPHILIS
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Etiology:
 Treponema pallidum (a spirochete).
 Identified by silver stains (Warthin-Starry, Steiner or
Leveditti).
Clinical features:
 Transmission:
a. Sexual intercourse with infected partner.
b. contact with open wound (e.g. dentists).
Three clinical stages occur for Acquired
syphilis

A. Primary syphilis (chancre)
 It forms where the spirochete enters the body.
 Ulcer (chancre) appears 1-3 weeks after contact.
 Site: penis, vulva, cervix (95% of cases).
 Oral: lip, tongue, palate, tonsil, buccal mucosa.
 Chancre is indurated, painless, (or painful + regional
lymphadenopathy).
 Ulcer exhibits many spirochetes if smeared thus it is highly
infectious.
 Histology: ulcer with many plasma cells.
 Heals spontaneously within a few weeks and the disease
enters a latent period.
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B. Secondary syphilis (skin rash and mucous patches)
 Occurs 1-3 months after primary lesion.
 Diffuse eruptions occur on skin and mucous membranes
 Skin rash: macules and papules.
 Oral: mucous patch and “snail track” ulcers
 Mucous patches are highly infectious; these are multiple,
painless, grayish white plaques covering ulcerated
mucosa
 They heals spontaneously in a few weeks, but may recur
many times for months or years.
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C. Tertiary Syphilis:
 Occurs 1-3 or more years after secondary lesions.
Manifestations:
• Gumma (necrotic tumour-like firm mass exhibiting
granulomatous inflammation).
 Gummatous perforation of the hard palate.
 Syphilitic glossitis (previously associated with
carcinoma).
 Cardiovascular lesions: aortic aneurysms.
 CNS: neuronal loss; dementia.
 This stage is not infectious.
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Congenital syphilis:
 Acquired in-utero from infected mother.
 Rare today because of routine serologic tests.
Features:
 frontal bossing of skull.
 Short maxilla with high palatal vault.
 Saddle nose.
 Hypoplastic teeth (Hutchinson’s incisors and Mulberry molars).
 Rhagades: fissures around mouth.
Hutchinson’s triad:
 Mulberry molars + Hutchinson’s incisors.
 Interstitial keratitis (scarred cornea).
 8th nerve deafness.
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 Chancre—painless ulceration with indurated borders
on the lip, tongue, buccal mucosa, or oropharynx
with lymphadenopathy.
 Mucous patches—oval plaques on the tongue with a
white or gray pseudomembrane. Split papules,
macerated, flat-topped papules at the oral
commissures (condyloma lata). chronic oral
ulcerations
 Interstitial glossitis with atrophy of filiform and
fungiform papillae and fissuring of the tongue, pre-
malignant leukoplakia, gummas involve palate
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Serologic tests for syphilis:
 VDRL = venereal disease research laboratory test.
 Wasserman, STS = standard test for syphilis,
Treatment:
 Antibiotics (penicillin).
 ACTINOMYCOSIS
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Etiology:
 Actinomyces species (A. bovis, israeli).
 Note that: this organism is a bacterium, not a fungus,
although it has been called a “ray fungus”.
 A filamentous bacterium
 The organisms are common, normal inhabitants of the
oral cavity.
 Predisposing factors have not been identified but
infection is often preceded by extraction or an abrasion of
mucosa.
 Forms abscesses that tend to drain by sinus tracts
 
Clinical features:
 Cervicofacial (most common type; 66%).
 Pulmonary.
 Abdominal.
Multiple discharging
sinuses

Sulfur granules: The colonies of organisms appear in pus
as tiny, yellow grains.


Actinomycosis of the
tongue
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 
Histology:
 Induces abscesses with fistula formation.
Diagnosis:
 Identification of colonies in tissue from the lesion
 Calcified colonies of organisms are seen in a “sea” of
neutrophils (pus).
Treatment:
 Penicillin or tetracycline.
 GONORRHEA

Etiology:
 Neisseria gonorrhoeae – a gram negative paired coccus.
Clinical features:
 Spread: sexual contact. Organism sensitive to drying and
cannot penetrate intact stratified squamous epithelium.
 Acute purulent inflammation and discharge.
 Males: anterior urethra affected. Females: cervix,
endometrium, fallopian tubes.
 Complications: bacteraemia, myalgia, arthralgia,
polyarthritis, dermatitis with skin rash.
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Oropharyngeal involvement
 Occurs in 20% of patients.
 Transmission by fellatio, kissing, cunnilingus – therefore majority
reported in females or homosexual men.
 Sore throat; diffuse oropharyngeal erythema.
 Requires a large dose for oral lesions since saliva is a hostile
environment for this bacterium.
 Shallow, irregular painful ulcers. Edema with scattered pustules.
Diagnosis:
 Gram stain shows gram negative diplococci (within neutrophils).
Treatment:
 Cephalosporins (ceftriaxone) and doxycycline.
 TUBERCULOSIS
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Etiology:
 Mycobacterium tuberculosis, an acid fast bacillus.
 TB is a granulomatous disease characterized by
“granulomatous inflammation” which includes
epithelioid histiocytes + multinucleated giant cells +
lymphocytes.
 It is primarily a lung disease but can affect any organ.
 Source of infection: air borne droplet.
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Clinical features:
 Chills, fever, weight loss, fatigue, malaise, persistent
cough with haemoptysis.
 Miliary tuberculosis: Involvement of organs such as
kidney and liver in widespread areas of the body
 Scrofula: Involvement of submandibular and cervical
lymph nodes
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Oral lesions:
 Oral lesions may occur but they are rare seen in about
20% of patients
 Tongue lesions are common and are usually ulcers of the
tongue.
 Oral lesions of TB appear as painful, non-healing,
superficial or deep slowly enlarging ulcers
 Dentist is at risk of infection from direct contact or droplet
infection.
 Organisms are seen in 45% of oral washings.
 Tuberculoma: Tuberculous osteomyelitis of the jaw bones
may occur
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Investigations:
 Tests: BCG = Bacille Calmette-Guerin.
 PPD = purified protein derivative (Mantoux test).
 OT = old tuberculin.
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Diagnosis of Tuberculosis
1. Skin test:
 An antigen is injected into the skin.
 Purified protein derivative (PPD)
 A positive inflammatory reaction occurs if the
person has previously been exposed to the antigen.
2. Chest radiographs may be taken after a positive skin
test to see if active disease is present.
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Histology: -
 Granulomatous inflammation with or without
caseous (cheese-like) necrosis.
 Areas of necrosis surrounded by macrophages,
multinucleated giant cells (Langhans giant cells
which are horse-shoe shaped), and lymphocytes
 Ziehl-Neelsen stains: Acid fast bacilli (AFB) is red.
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Treatment:
 INH = isoniazid.
 Rifampin
 Duration: 18 to 24 months.
 Mycobacterium leprae: causes leprosy.
 Mycobacterium avium intracellulare: seen in AIDS.
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Histopathology of TB
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