Microbiology of the Orofacial

Region
ABEL ABRAHAM
TABLE OF CONTENTS

 INTRODUCTION
 BACTERIAL MICROBIOLOGY
 COMMENSAL FLORA
 Pathogenesis of Acute and Chronic Bacterial Infections
 Common Bacterial Pathogens of the Ear, Sinuses, and Contiguous Regions
 Common Bacterial Pathogens of the Oral Cavity
 Non-bacterial microbiology
 Conclusion
 References
INTRODUCTION

 The head and neck regions of the human body are home to a wide variety of
microorganisms that inhabit both the skin and mucosal surfaces.
 Traditionally, the clinical microbiology laboratory has used various nutrient-rich culture
media to grow and identify bacteria from patient specimens.
 Although these methods remain the cornerstone of work in the microbiology laboratory,
the introduction of molecular techniques to identify bacteria that both colonize and infect
the human body is changing our understanding of the important role bacteria play in both
causing disease and maintaining health.
 A recent revolution has occurred in our understanding of the interaction between humans
and bacteria, a result of deep sequencing DNA technology that has expanded our
knowledge of the microbes that constitute this diverse, complex population
 The National Institutes of Health recently established the Human Microbiome Project to
document the different populations of bacteria that colonize the human body, including
areas of the head and neck, to explore how differences in colonizing bacterial flora impact
human health.
Commensal Flora

 Contrary to views held earlier, deep sequencing has shown that we are possibly colonized
in utero and are certainly colonized with bacteria immediately at birth. Factors governing
colonization include:
 type of delivery
 breast feeding or formula
 length of time in the hospital
 exposure to antibiotics
 transition to solid food
 presence or absence of teeth.
 Environmental factors include:
 Available nutrients
 pH
 Moisture levels
 Other competitive bacteria occupying the same niche
 Exposure to the host immune system
Pathogenesis of Acute and Chronic Bacterial
Infections
Acute Infection

 Acute infections occur when a change in the host environment or the bacterial population
in a region permits invasion of a pathogenic bacteria, resulting in infection.
 Acute infection initially requires that bacteria express surface molecules that facilitate
adhesion to an epithelial, mucosal, or artificial surface.
 Attached bacteria then secrete a variety of virulence factors that interact with host tissue
and the immune response to produce inflammation consistent with symptomatic infection.
 If the bacteria are able to penetrate the host surface into a previously sterile site and
replicate, effectively dealing with host defenses, then invasive disease occurs.
Surface Adhesion

 Bacteria may possess one or more multiple surface structures or surface-exposed proteins
that facilitate adhesion to the epithelial cell layer.
 For example, both S. pneumoniae and Haemophilus influenza pathogens express the
phosphorylcholine(ChoP), which in pneumococcus binds the platelet-activating factor
receptor found on epithelial cells of the nasopharynx.
Virulence Factor Production

 Gram negative pathogens have lipopolysaccharide (LPS) on the cell surface that interacts
with Toll-like receptor (TLR) 4 of the innate immune system to generate proinflammatory
response.
 Although this response can lead to bacterial death and resolution of infection, it can also
cause tissue damage that facilitates bacterial invasion across surfaces into sterile sites.
 Several bacteria possess needlelike structures that insert into host cell membranes. These
structures allow bacteria to pump virulence factors directly into the cytosol of host cells,
resulting in cell death and facilitating bacterial invasion.
Surviving the Host Response to Infection

 Many gram negative and gram-positive bacteria possess a polysaccharide capsule that is
antiphagocytic.
 In addition to the extrapolysaccharide (EPS) capsule, surface proteins such as the M-
protein of Streptococcus pyogenes (group A streptococcus) also prevent engulfment by
host cells.
 Another important immune defense mechanism that bacteria must deal with is the
neutrophil extracellular trap (NET), extracellular fibrils that engulf and destroy bacteria.
 Some respiratory pathogens secrete enzymes that degrade the DNA component of NETs,
eg: DNAse of S. pyogenes.
 Others exhibit surface molecules that allow for survival within the NET after engulfment.
 Additional secreted proteins cleave antibody or complement or inactivate host defensin
molecules to survive the host response.
Chronic Infection and Biofilm Formation

 The bacterial strategy for long-term survival in the host now known to be an important
component of most chronic infections is the formation of surface-associated bacterial
biofilms
 They are organized communities of bacteria that colonize a surface and are resistant to
antibiotic therapy.
 There is an inverse relationship comparing the bacterial lifestyle of tissue destruction,
invasion, and acute infection with that of surface colonization, biofilm formation, and
chronic disease.
 May serve to explain how initial acute infections become chronic and more difficult to
treat over time with the same strain of bacteria.
 Biofilm formation follows a series of organized steps and
is initiated with surface contact and adhesion.
 Attachment to a foreign or host surface requires many of
the same factors mentioned for acute infection, such as
flagella, pili, or surface adhesins.
 Next, the bacteria aggregate into microcolonies followed
by cell division and the formation of a mature biofilm
with channels that allow for gas exchange and nutrient
acquisition.
 Biofilms are not static, and bacteria released from the biofilm are capable of colonizing
nearby surfaces, spreading infection within the host.
Common Bacterial Pathogens of the Ear,
Sinuses, and Contiguous Regions
Streptococcus pneumoniae

 Pneumococcus is a gram-positive, catalase-negative,

facultative anaerobic bacterium that typically produces
αlpha-hemolysis (partial hemolysis) on blood agar plates
 Gram stain classically reveals lancet-shaped diplococci.
 Pneumococci are susceptible to optochin, which is used
for presumptive identification and distinguishes it from
other pathogenic streptococci.
 The negatively charged polysaccharide capsule is required for virulence and protects
against upper respiratory secretions and phagocytosis.
 The capsule does not promote binding to epithelial cells, and its size is decreased when
the bacteria interacts with host epithelial cells.
 Additional surface adhesions bind components of the extracellular matrix, such as
fibronectin, as well as epithelial cell receptors.
 S. pneumoniae strains secrete antimicrobial peptides, including those that target other
pneumococcal serotypes to colonize a mucosal surface already crowded with other
commensal flora
 Pneumolysin is a cytotoxic protein that targets the cholesterol-containing membranes of
host membranes for pore formation and cell lysis.
 Resistance to penicillin resulting from mutations in penicillin-binding proteins required
for cell wall synthesis has been described.
 Resistance to other drugs such as the macrolides and quinolones is on the rise, hence
antibiotic susceptibility testing is recommended to guide therapy when pneumococcus is
isolated from an invasive head and neck infection
Moraxella catarrhalis

 Oxidase-positive, catalase-positive, gram-negative

diplococci that exhibits γ-hemolysis (no hemolysis) when
grown on blood agar plates
 Specifically binds the respiratory epithelium and the
extracellular matrix of the human upper respiratory tract,
 Has been recovered from the biofilms of children with
chronic otitis media
 Expresses numerous surface adhesins
 Eg: the outer membrane proteins, lipooligosaccharide, and ubiquitous surface protein A
(UspA)
 UspA1 binds both epithelial cells and extracellular matrix to facilitate colonization.
 UspA2 functions to bind and inactivate complement.
 Lipooligosaccharide and outer membrane proteins function in reducing serum-dependent
bacterial killing.
 M. catarrhalis also possesses surface fimbriae called type IV pili, which are important for
epithelial cell binding and biofilm formation.
 The vast majority of M. catarrhalis secrete a β-lactamase that confers resistance to therapy
with ampicillin alone.
 Successful treatment requires either the addition of a β-lactamase inhibitor to a penicillin,
or a cephalosporin if a β-lactam antibiotic is preferred, or an antibiotic from an alternative
class.
Haemophilus influenzae

 Fastidious, thin, gram-negative rod that is oxidase positive and that requires both factors
V (nicotinamide adenine dinucleotide) and X (hemin) for growth.
 Grows well on chocolate agar that contains lysed red blood cells
 Six encapsulated serotypes (a-f) exist, and historically H. influenzae type B (Hib) was the
cause of most invasive disease. Following widespread vaccination, this has brought about
a change.
 Now, the majority of infections caused by H. influenzae, such as acute otitis media, are
due to unencapsulated, nontypeable strains.
 Nontypeable H. influenzae has a number of virulence factors that are similar to M.
catarrhalis
 Surface pili bind both host cells and extracellular matrix
components.
 The outer membrane protein P2 displays antigenic variation
to avoid recognition by antibody, allowing for the persistence
of chronic infection despite the host immune response.
 The invasion of epithelial cells occurs by multiple endocytic pathways and requires actin.
 H. influenzae can also penetrate epithelial cell layers between cells, disrupting tight
junctions, without causing cell death.
Streptococcus pyogenes

 A catalase-negative, gram-positive coccus that is seen in long chains when visualized

using Gram stain.
 It is β-hemolytic (complete hemolysis) when grown on blood agar plates and is
distinguished from other β-hemolytic streptococci in that it is bacitracin susceptible
 Causes pharyngitis and invasive soft tissue disease, and can both colonize and invade the
skin and throat
 The most recognized virulence factors that determine the serotype is the surface M
protein
 M protein has multiple functions: It acts as an adhesin, binds fibrinogen to prevent
phagocytosis and, along with the DNase SDA1 and a hyaluronidase capsule, prevents
killing by NETS.
 Phagocytosis is also inhibited by the IgG peptidase IdeS, which cleaves the heavy chain
of S. pyogenes’ surface associated IgG, disrupting opsonization
 Streptolysin O is a pore-forming cytolysin that induces apoptosis in immune cells and
facilitates invasion into sterile sites
Staphylococcus aureus

 A gram-positive catalase and coagulase-positive organism that

classically forms clusters when visualized with Gram stain.
 When recovered from primary clinical specimens such as
abscesses,
S. aureus may appear as pairs of cocci or as a single bacterium.
 β-hemolytic (complete hemolysis) on blood agar, and many
colonies have a gold or tan appearance
 Both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus
(MRSA) can colonize the skin and nasal mucosa and cause invasive disease.
 Methicillin resistance occurs when S. aureus expresses the mecA gene encoding
penicillin-binding protein PBP2a that is not present in MSSA strains.
 S. aureus has a number of microbial surface components recognizing adhesive matrix
molecules (MSCRAMMs) that bind extracellular matrix components such as fibronectin
and collagen to enable adhesion to the host.
 Protein A is an MSCRAMM that is intimately involved in interactions with the immune
response, binding IgG to prevent opsonization, C3 of the complement pathway, and a
receptor for tumor necrosis factor-alpha
 S. aureus also expresses multiple toxins that contribute to pathogenesis.
 The Panton-Valentine Leukocidin toxin, a pore-forming toxin consisting of the LukS and
LukF proteins, requires interaction with a host receptor for the lysis of white blood cells.
 The coagulase activity of S. aureus is due to two enzymes that promote fibrin clots,
binding prothrombin and converting fibrinogen to fibrin.
 These fibrin clots enhance abscess formation and promote biofilm formation when
bacteria are attached to surfaces such as catheters.
 This activity is counterbalanced by staphylokinase, which converts plasminogen to
plasmin, resulting in the breakdown of fibrin clots. This allows the escape of the bacteria
from the clot
Common Bacterial Pathogens of the Teeth,
Mouth, and Pharynx
Viridans Group Streptococci

 Gram positive, display α−hemolysis, resulting in a green color around the colonies that
gives rise to the name (viridis is Latin for “green”).
 Common viridans streptococci include S. mitis, S. anginosus, S. mutans group, S.
salivarius, and S. bovis.
 Not inhibited by optochin, and the colonies are not soluble in deoxycholate (bile)
 Viridans streptococci are the most prevalent colonizers of the healthy human mouth
 implicated in the formation of dental caries.
 They are pathogenic when introduced into fascial planes of the head and neck, forming
abscesses.
 In addition, viridans streptococci bacteremia is a known cause of subacute native and
prosthetic valve endocarditis.
 For initial colonization of oral mucosal surfaces, viridans streptococci produce a series of
adhesins similar to those found in pneumococcus
 Viridans streptococci are fierce competitors in the colonization of the mucosal surface of the
mouth, producing bacteriocidins that have bactericidal activity against other organisms, killing
more virulent species of streptococci and staphylococci.
 In the mouth, the polysaccharides produced by exoenzymes from S. mutans are the main
constituents of the insoluble matrix on which plaque biofilms form and dental caries develop.
 In the blood stream, S. mutans expresses two bacteriophage-encoded proteins (PblA and PblB)
that bind directly to platelets and contribute to the pathogenesis of subacute endocarditis
 Type k S. mutans produces a collagen-binding protein that interacts with damaged cerebral
blood vessels to convert ischemic to hemorrhagic stroke
Actinomyces Species

 Facultative, anaerobic, non–spore forming, filamentous, gram-positive rods that

commonly inhabit the oropharynx.
 Although individual bacteria are filamentous, colonies form fungus-like branched
networks of hyphae.
 Actinomyces grow slowly in culture and are not acid-fast.
 Actinomyces species are pathogenic locally in the oral cavity or through direct extension
into fascial planes as abscesses.
 The most common pathogens include A. israelii, A. viscosus, A. naeslundii, A. turicensis,
and A. radingae.
 Actinomyces species are isolated from supragingival plaques and root surface caries, and
they are implicated in the development of gingivitis.
 Infection can spread when normal mucosal barriers are disrupted, leading to abscesses
with connecting sinus tracts.
 These abscesses are most commonly found in the face and neck as cervicofacial
actinomycosis.
 Its cell wall peptidoglycan has recently been shown to induce alveolar bone resorption
and osteoclastogenesis, in addition to recruitment of inflammatory cytokines.
Prevotella Species

 Small anaerobic gram-negative rods frequently identified when the microbiome of

different regions of the head and neck are determined with deep sequencing.
 The species of Prevotella most linked with human disease are:
P. intermedia, P. melaninogenica, P. bivia, P. nigrescens, and P. disiens
 P. intermedia is implicated in periodontal disease, usually in association with
Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans.
 Implicated in chronic sinusitis, middle ear infections, brain abscesses, and intraabdominal
abscesses.
 Virulence mechanisms for Prevotella species include attachment to the mucosa, immune
system evasion, and increased production of virulence factors when the organism
transitions from commensal to pathogen.
 Uses proteases to interfere with complement-mediated bacterial killing.
Fusobacterium Species

 Anaerobic, elongated, gram-negative rods.

 Most associated with human disease is F. necrophorum
 Causes periodontal disease, tonsillitis, peritonsillar abscess, and thrombophlebitis of the
jugular vein (Lemierre syndrome).
 Adhesins and fimbriae play a critical role in host cell attachment
 Leukotoxin facilitates abscess formation.
 Endotoxin and hemolysin also appear to be important virulence factors in the formation of
abscesses and for increased necrosis of locally infected tissue
 Hemagglutinin and a not yet identified factor leading to platelet aggregation are most
associated with the thrombotic consequences found in Lemierre syndrome.
Capnocytophaga Species

 Filamentous, thin, gram-negative rods with a tapered end (fusiform) that are capnophilic,
requiring increased levels of carbon dioxide for ideal growth that often takes 48 hours on
blood agar plates.
 Colonize the human oropharynx and are associated with periodontitis, septicemia in
patients with splenic or liver dysfunction, and rarely endocarditis.
 Virulence mechanisms are not well understood; however, some species produce EPS that
suppresses host complement.
 In addition, some strains produce β-lactamases
 Hence, empiric therapy for Capnocytophaga species should include a β-lactamase
inhibitor if a β-lactam antibiotic is considered
Nonbacterial Microbiology
Herpes Simplex Virus

 Humans are the natural host for HSV-1 and 2.

 HSV-1 is more commonly associated with oral, labial, and ocular infections, whereas
HSV-2 is more closely associated with genital infections.
 Transmission is by person-to-person contact through infected secretions and infected
mucocutaneous surfaces.
 After primary infection, the virus becomes latent in neural tissue, particularly the dorsal
root ganglion.
 Disease manifestations are more likely from reactivation of disease secondary to stress,
trauma, and immunosuppression.
 Cell mediated immunity contains the infection in their lytic state or active replication,
whereas HSV-specific antibody modulates latent HSV infection at the neurons.
 In patients with cell-mediated immunosuppression (e.g., AIDS, solid organ or
hematopoietic stem cell transplant recipients), disseminated disease could occur.
 Diagnostic techniques include Tzanck smear, viral culture, serology, immunofluorescence
staining, and polymerase chain reaction (PCR)
 Antiviral treatment includes acyclovir, valacyclovir, and famciclovir. These antiviral
treatments interfere with viral DNA synthesis.
Epstein-Barr Virus

 The Epstein-Barr virus (EBV) is another ubiquitous herpesvirus with seroprevalence

approaching 90% in adults.
 EBV acquired during childhood is largely subclinical.
 Transmission is by direct contact with salivary secretion because oral viral shedding persists
for a prolonged period.
 After primary infection, the virus achieves latency in the B cell compartment.
 Infectious mononucleosis is most commonly associated with EBV primary infection
 The treatment of mononucleosis is primarily supportive care. There is no proven benefit of
antiviral treatment
Cytomegalovirus

 The cytomegalovirus is a pervasive herpesvirus.

 Seroprevalence of CMV is 60% by 6 years of age and it increases with age, approaching
90% by the age of 80 years.
 Primary infection can be transmitted via exposure to saliva, genital secretions, blood or
tissue, and perinatally.
 After primary infection, it establishes latency in the host after the acute infection. The virus
establishes its latency in most cells or tissues, including polymorphonuclear cells, T
lymphocytes, endothelial vascular tissue, fibroblasts, salivary glands, and renal epithelial
cells.
 Reactivation from latent infection can occur with immunosuppression, such as HIV
infection, transplantation, or acute illness.
 CMV mononucleosis is self-limited and is managed by supportive care. On the other
hand, CMV disease, such as CMV esophagitis and CMV retinitis, requires antiviral
treatment with either intravenous ganciclovir or oral valganciclovir.
Human Immunodeficiency Virus

 HIV is a retrovirus that infects T helper cells (CD4+), macrophages, and dendritic cells. CD4+
count declines because of direct viral killing and by cytotoxic-mediated cell (CD8+) killing of
infected cells.
 HIV can be transmitted by sexual contact, blood exposure, needle-stick injuries, and maternal
to fetal transmission.
 Acute retroviral syndrome or acute HIV infection can manifest with fever, malaise, cervical
lymphadenopathy, and pharyngitis similar to infectious mononucleosis. Patients with these
symptoms should be screened for HIV.
 The Centers for Disease Control and Prevention (CDC) guidelines as of 2013 recommend
universal screening with a fourth-generation combined antigen/antibody immunoassay with
confirmatory HIV-1/HIV-2 antibody differentiation assay and a RNA test to resolve reactive
immunoassay with a negative confirmatory test result
 Because of CD4+ T cell count decline, infected patients are susceptible to opportunistic
infections. Oral conditions including candidiasis, Kaposi Sarcoma, and hairy leukoplakia
are often indicative of the degree of immunosuppression.
 Other common head and neck lesions include aphthous stomatitis, periodontal disease,
non-Hodgkin lymphoma, and lymphadenopathy.
 The mainstay of HIV treatment is antiretroviral therapy in all patients with HIV infection,
regardless of CD4 cell count.
Fungal Infections

 Mycoses represent infection by fungal organisms. With rare exception, mycoses are not
transmissible from patient to patient, and contact isolation in the health care setting is not
indicated. Mycoses are divided into yeast or yeast-like and molds.
Conclusion

 It is increasingly apparent that the commensals of the head, neck, and oral cavity play a
critical role in maintaining human health. New DNA sequencing techniques have shown
commensal organisms to be ubiquitous throughout the oral cavity and contiguous spaces.
These commensals can become infective when host defenses, including the protective
epithelial barrier of the surface, are damaged. Pathogenic bacteria have evolved similar
strategies to successfully colonize mucosal surfaces, evade the host immune response, and
invade soft tissue.
 Local oral cavity infections, such as caries, gingivitis, periodontitis, or abscess (periapical
or periodontal), wreak havoc in the mouth, potentially affecting patient comfort and
socialization. These infections can extend to surrounding structures, leading to life-
threatening necrotizing infections, severe abscess formation, or local vascular
complications, resulting in significant morbidity and occasional mortality.
THANK YOU
References

  Hupp, J. and Ferneini, E., 2015. Head, Neck And Orofacial Infections: An

Interdisciplinary Approach. 1st ed. Elsevier
 Topazian, Goldberg, Hupp, 2009. Oral and Maxillofacial Infections. 4th edition.
Elsevier
 Ananthanarayan, Panicker, 2017. Textbook of Microbiology. 10th ed.