Oral microfolora

microbial flora

1. MICROBIAL FLORA OF ORAL CAVITY By N.Nitya Krishna 1 st Year Post Graduate Department of Public Health Dentistry 1

2. CONTENTS INTRODUCTION HISTORY NORMAL MICROBIAL FLORA BACTERIAL ORAL FLORA FUNGI PROTOZOA IN THE ORAL CAVITY DENTAL IMPLICATION IN MICROBIOLOGY Dental plaque Dental caries Periodontal disease Endodontic infections Dental abscess ROLE OF FLORA IN SYSTEMIC DISEASES PREVENTIVE APPROACH TO ORAL INFECTIONS ORAL MICROFLORA IN DISEASE ROLE OF PUBLIC HEALTH DENTIST TO KNOW ABOUT ORAL MICOFLORA CONCLUSION 2

3. INTRODUCTION The mouth is the gateway of the body to the external world and represents one of the most biologically complex and significant sites in the body. This is where the first stages of the digestive process take place and, consequently, the mouth is richly endowed with sensory functions (taste, smell, temperature and texture). It also plays a critical role in communication, whether by speech or via facial expressions, and makes a significant contribution to our appearance. It has been estimated that the human body is made up of over 10 14 cells of which only around 10% are mammalian. The remainder are the microorganisms that comprise the resident microflora of the host. 3

4. HISTORY Louis Pasteur – Father of Microbiology Antony Van Leeuwenhook in 16 th century identified bacteria and its shapes – rods , cocci and spiral forms . Willoughby D. Miller proposed that carbohydrate from food were broken down by oral bacteria and the resulting acids caused dissolution of the enamel . Pierre Fauchard in 1745 described tartar and plaque . J.K. Clark in 1942 identified coccus from carious lesion and named as Streptococcus mutans 4

5. NORMAL MICROBIAL FLORA Normal oral cavity contains a mixture of organisms which include bacteria, fungi, protozoa and occasionally viruses. Types of flora 1. indigenous flora E.g :- alpha haemolytic strptococci , lactobacilli etc. 2. Transient flora E.g :- streptococcus pneumoniae , niesseria meningitidis etc. 3. Supplemental flora Benefits of Oral Flora Oral bacteria produce certain vitamins and cofactors which are needed by humans . Prevention of colonization by exogenous pathogens . Helps in maturation of host immune system 5

6. BACTERIAL ORAL FLORA Bacteria are by far the most predominant type of microorganisms present in human oral cavity . 30 genera of bacteria are detected in human mouth and 25 of which are regular members of the oral flora . 6

7. Bacterial stagnation areas created as a result of : * shape of the teeth * the topography of the teeth { Occlusal fissures } * malalignment of teeth * Poor quality of restorations { fillings and bridges } Oral bacteria can be classified Primarily as: Gram – positive ( purple ) Gram – negative ( pink ) Oral bacteria can be classified Secondarily as: Aerobic Anaerobic 7

8. GRAM STAINING 8

9. CLASSIFICATION Cocci Bacilli Gram positive cocci Streptococcus mutans Strept.sanguis Strept . mitior Strept . milleri Enterococcus species Peptostreptococcus species Micrococcus species Staphylococcus species Gram positive bacilli Lactobacilli species Actinomyces species Propionobacterium species Arachnia species Bifidobacterium species Bacterionema species Eubacterium species Gram negative cocci Veilonella species Neisseria species Branhamella species Gram negative bacilli Actinobacillus species Fusobacterium species Bacteroides species Capnocytophaga species Leptotrichia species Treponema species Haemophilus species Stenomona species Eikenella species Wollinella species 9

10. Besides bacteria, the normal flora of mouth may contain fungi and protozoa group Organism Fungi Candida albicans C. tropicalis C. Pseudotropicalis Protozoa Entamoeba gingivalis Trichomonas tenax 10

11. FUNGI 11

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13. CLASSIFICATION • Primary Oral Candidiasis – ACUTE • Pseudomembranous • Erythematous –CHRONIC • Hyperplastic • Erythematous • Pseudomembranous –CANDIDA ASSOCIATED LESION •Denture stomatitis •Angular stomatitis •Median rhomboid glossitis • Secondary candidiasis – Manifestation of Systematic mucocutaneouscandidiasis– thymic aplasia and candida endocrinopathy syndrome 13

14. LAB DIAGNOSIS OF ORAL CANDIDIASIS 14

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17. PROTOZOA IN THE ORAL CAITY Entamoeba gingivalis Trichomonas tenax E. gingivalis – found in soft calculus, periodontal pockets and infection of tonsils Can become opportunistic pathogen T.tenax – only parasitic flagellate in oral cavity --number increases in periodontitis 17

18. ROLE OF SALIVA Saliva is widely used as the main sample to study the microbial flora . W.D Miller isolated microrganisms from saliva. On an average 750 million microrganisms are present in each ml of saliva and this number may reach upto 5.5 billion / ml . The cultivable organisms in saliva can be 10 – 100 million / ml . The organisms present in saliva include veillonella species , streptococcus oralis , s. salivarius , s.mutans and actinomyces species. 18

19. ACQUISITION OF NORMAL ORAL FLORA At birth infants mouth is microbiologically sterile . Within few hours of birth S.Salivarius species establish themselves in the mouth and these are transmitted from mother through feeding. By the end of 1 st year : Other species of streptococci , staphylococci , nisseriae and veillonellae develop in the oral cavity . Eruption of teeth : S.mutans , S.sanguis , A.viscous establish on dental hard tissues. 19

20. Adolescence The greatest number of organisms in mouth occur when permanent teeth erupt. These teeth have deep fissures, larger inter proximal spaces and deeper gingival crevice, allowing a great increase in anaerobes. Adulthood Its chief characteristic is its complexity of oral flora. There is an increase in Bacteroides and Spirochetes with maturity of dental plaque. As the teeth are lost the available sites for microbial colonisation decreases and several species diminish disproportionately in numbers. Edentulous persons harbour few Spirochetes or Bacteroides but carriage of Yeast increases. S.sanguis & mutans disappear. 20

21. DENTAL IMPLCATIONS OF MICROBIOLOGY Dental plaque Dental caries Periodontal disease Endodontic infections Dental abscess 21

22. MICROBIOLOGY OF DENTAL PLAQUE According to WHO : Plaque is a highly specific and selective but structurally variable clinical entity characterized by sequential colonization of microorganisms on the surface of teeth, restoration and other parts of the oral cavity. It is made up of mucins , desquamative epithelial cells and microorganisms embedded in an extracellular matrix. 22

23. CLASSIFICATION OF PLAQUE 23

24. 24 Subgingival Tissue associated St. oralis , St. intermedius Peptostreptcoccus micros P. gingivalis , P. intermedia T. Forsythis , F. Nucleatum

25. DEVELOPMENT OF DENTAL PLAQUE: Microrganisms don’t colonize on the mineralised tooth surface. The teeth are always covered by an acellular proteinaceous film ,the pellicle that forms on the naked tooth surface within mins to hours. The bacteria colonize the tooth surface only when pellicle is in place for hours. The pellicle consists of salivary glycoproteins adsorbed to the enamel mineral to forma a membranous biofilm Attachment of single bacterial cell (0-4h) Growth of attached bacteria leading to formation of distinct micro colonies. (4-24h) Microbial succession and co-aggregation .(1-14 days) Climax community plaque.(2 weeks or older) 25

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27. Function of pellicle- Protect enamel. Reduces friction. Provide matrix for re-mineralization. Pellicle contains- lysozyme,albumin,IgA,IgG . Early colonisation : Plaque builds up first in small defects or pits on the enamel surface and then spreads over the tooth surface. Early succession evolves adhesion between pellicle and pioneer organism. S.sanguis , A.viscosus,A.naeslundii and peptostreptoccous attaches within 1 hr. 27

28. COMPOSITION OF DENTAL PLAQUE 28

29. DIFFERENCES BETWEEN EARLY AND MATURE SUPRA GINGIVAL PLAQUE Characteristics Early Mature Gram reaction + _ Morphotypes branching rods, cocci Cocci , rods, spirochetes Energy metabolism Facultative aerobic Facultative anaerobic Tolerated by host Well Can cause caries and gingivitis 29

30. Effects of plaque formation 1. Calculus formation Both supragingival and subgingival plaque become calcified. Calcified plaque is named as dental calculus. 2. Dental caries Inorganic components of teeth are demineralized by acids produced by the plaque microflora . Demineralization leads to weakening of the tooth syructure , cavity formation and eventual loss of tooth. 3. Periodontal disease It may affect the marginal gingiva , periodontal ligament, cementum or alveolar bone. 4. Other oral disease Infections of dental plaque or periapical abscess. Acute necrotizing ulcerative gingivitis. Periodontal abscess. 30

31. Dental caries Dental caries is characterised by demineralization of the inorganic components of the tooth, leading to weakening of tooth structure, cavity formation and eventual loss of tooth. Etiology 1. Host 2.Diet 3.Time 4. Microbial flora in plaque HOST Structure of enamel and the nature of saliva play a significant role in dental caries. Quality and quantity of saliva significantly influences the occurrence and progression of dental caries. High calcium and phosphorous in saliva are important for remineralization during early stage of the disease. 31

32. 2. DIET Microflora in the oral cavity ferment dietery carbohydrates with the production of acid which destroys the dental tissue. Highly cariogenic carbohydrate- sucrose-acts as substrate. 3. TIME Prior to the ingestion of carbohydrates, the pH in the oral cavity is slightly acidic or alkaline. After ingestion of carbohydrates the plaque pH rapidly drops by 2 or more. Length of time that this acidic environment (low pH) is sustained to damage the enamel is extremely important in occurrence of dental caries. . 32

33. 4.Microbial flora in plaque 33

34. Prevention of dental caries Reduction of microbial flora of oral cavity by proper oral hygiene and use of antimicrobials. Regular brushing and flossing may prevent stagnation of food debris and thus reducing the incidence of caries. Control of dietary carbohydrate intake especially sucrose rich diet. Improvement of tooth resistance by incorporation of fluorides in water and by topical fluoride application. Removal of dental plaque by mechanical methods ( scaling). Microbiological tests to assess dental caries Salivary counts of S. mutans and lactobacilli have been advocated for the detection of patients who are at higher risk for developing caries 34

35. Periodontal diseases Periodontal disease is a term used for many pathological conditions of the gingiva , periodontal ligament, cementum and alveolar bone. Etiology Multifactorial Induced by dental plaque Appear as a transient, reversible inflammation called gingivitis If the disease persists, inflammation extends into deeper tissues and the gingival connective tissue is progressively destroyed. Periodontal microflora , host defences and extrinsic factors play role in production of disease. Since anerobes are the major bacterial species in the subgingival microflora , they are involved in infections of the periodontium . 35

36. These include Spirochetes, Bacteroides , Fusobacterium etc. Intrinsic factor- nutrition, immunological defects and metabolic disorders- decrease the host defence against subgingival microflora . Extrinsic factor- poor oral hygiene, calculus- accumulation of subgingival bacteria. Various periodontal disease Gingivitis Periodontitis Localised juvenile periodontitis Acute necrotizing ulcerative gingivitis 36

37. 1.CHRONIC GINGIVITIS Gram positive : Actinomyces viscosus Actinomyces naeslundii Streptococcus sanguis Streptococcus mitis Peptosreptococcus micros Gram negative: Fusobactecterium nucleatum P. intermedia Veillonella parvula Wolinella Haemophilus species 37

38. Chronic Periodontitis It is characterised by destruction of connective tissue attached to the teeth. Etiology Bacteroides gingivalis B. intermedius Streptococcus milleri P. gingivalis P. Intermedia A. Actinomycetemcomitans 3. Localised juvenile periodontitis Found in adolescents, especially females Etiology Actinobacillus actinomycetemcomitans 38

39. 4.Acute necrotizing ulcerative gingivitis Acute necrotising ulcerative gingivitis is a relatively rare condition and is characterised clinically by necrosis of the free gingival margin, the crest of the gingiva and the interdental papillae. “Punched-out” erosion of the interdental papillae occurs Etiology Borellia vincenti - fusiform bacillus- spirochete. Laboratory diagnosis It is done by examination of smear prepared from the ulcerated lesion. Gram staining of the smear shows spirochetes, fusobacterium and leycocytes . Systemic spread of periodontal disease Infection of damaged valve of rheumatic heart patients, joint prostheses and endocardial implants may occur by bacteria derived from periodontal disease 39

40. Endodontic infections 40

41. Source Most important source of endodontic infection is infected carious lesion. From the carious lesion the bacteria migrates to the pulp. Periodontitis is another source of infection of endodontic tissues. Endodontic infections can act as source for spreading infection to various organs through blood. Septicemia, bacteremia , endocarditis etc. occur secondary to endodontic infections. Lesions Granuloma and cysts Abscesses Cellulitis Osteomyelitis Ludwigs angina 41

42. Etiology Strptococcus milleri - most common Bacteroides endodontalis and B. gingivalis - predominant anaerobes Other bacteria- Fusobacterium sp. , anaerobic streptococci, lactobacillus species etc. Laboratory diagnosis Specimens from root canal are collected under aseptic conditions. Anaerobic transport medium is used for transport of the specimen Both aerobic and anerobic culures are done according to conventional methods. Dental abscess Types- Periodontal Gingival periapical 42

43. PERIODONTAl ABSCESS GINGIVAL ABSCESS PERIAPICAL ABSCESS 43

44. Role Of Oral Flora In Systemic Disease It has been recognized that plaque related oral diseases, especially periodontitis, may alter the course and pathogenesis of a number of systemic diseases. 44

45. SYSTEMIC DISEASES AND CONDITIONS CAUSED BY ORAL FLORA Cardiovascular disease Atherosclerosis etc. Cerebrovascual disease Stroke Pregnancy outcome low birth weight infants Respiratory system Chronic obstructive pulmonary disease Bacterial pneumonia Diseases of connective tissues, bones and joints Rheumatoid arthritis 45

46. CARDIOVASCULAR DISEASE Cardiovascular disease  ( CVD ) is a class of diseases that involve the heart or blood vessels  which includes coronary heart diseases (CAD). Most of the coronary heart diseases are caused by atherosclerosis. Genetic factors include age, lipid metabolism, obesity, hypertension, diabetes etc. Environmental risk factors include socioeconomic status, exercise stress, diet, smoking, and chronic infection etc . Evidence linking chronic infection such as periodontal disease has shown to be capable of causing cardiovascular disease. . 46

47. ATHEROSCLEROSIS 47

48. Author And Journal Aim Of The Study Materials And Methods Results Mahendra J et al Indian J Dent Res 2015 Mar-Apr;26(2):189-95 to assess the prevalence of eight putative periodontal pathogens in atherosclerotic plaque of coronary artery disease patients and comparing them with non cardiac subjects. 250 patients with CAD were screened. 51 cardiac and non cardiac subjects within the age group of 40-80 years,who met the eligibility criteria, were selected and categorized as the experimental and control group respectively. Plaque Index and Oral Hygiene Index (OHI). Periodontal pocket depth and clinical attachment level were assessed. Both, subgingival and the coronary atherosclerotic plaque samples were subjected to polymerase chain reaction (PCR) analysis for identification of the periodontal bacteria. Association of Tannerella forsythia ( T.f ), Campylobacter rectus ( C.r ), Eikenella corrodens ( E.c ), Porphyromonas gingivalis ( P.g ), Treponema denticola ( T.d ), Prevotella nigrescens ( P.n ) , Aggregatibacter actinomycetemcomitans ( A.a ), P.g ( fi mA gene) and Prevotella intermedia ( P.i ), was significantly associated. A. Actinomycetocomitans was present only in the experimental group 48

49. Author And Journal Aim Of The Study Materials And Methods Results Khatri et al Singapore Dent J 2016 Dec;37:9-13 to assess the interrelationship between periodontitis and  atherosclerosis by comparing the ultrasound and clinical markers of atherosclerosis in systemically healthy patients with and without periodontitis and whether periodontitis can be an independent risk factor for atherosclerosis. Total 40 subjects, of same socioeconomic status, belonging to age group of 35-65 years, were recruited and divided into two groups – Group I (Chronic Generalised Periodontitis without any systemic disease: CP-SH), Group II (Normal healthy patients without periodontitis and any systemic disease - SH) Carotid ultrasound revealed right and left intima media thickness (IMT) of 0.626±0.016mm and 0.715±0.037mm respectively in cases and 0.495±0.009mm and 0.518±0.009mm respectively in controls, with the difference being statistically significant. In cases, mean diastolic blood pressure (DBP) was 83.45±4.07mmHg and 79.25±3.63mmHg in controls, with the difference being statistically significant. 49

50. INFECTIVE ENDOCARDITITS A. Acute infective endocarditis S. aureus Aerobic Gram negative bacilli- Pseudomonas B. Sub acute infective endocarditis Viridans strain of Streptococci Enterococci Fungi HACEK ( Haemophilus , Actinobacillus , Cardiobacterium , Eikenella and Kingella ) 50

51. PATHOGENESIS 51

52. A  stroke is a rapid loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a haemorrhage Ischemic cerebral infarction or stroke is often preceeded by systemic baterial or viral infection. Bacterial pathogens, antigens, endotoxins , and inflammatory cytokines of periodontitis contributes to atherogenesis and thromboembolic events . 52 Stroke

53. Author And Journal Aim Of The Study Materials And Methods Results Hashemipour MA et al Dent Res J (Isfahan) 2013 Sep;10(5):613-9 To investigate the gingivitis and periodontitis as a risk factor of stroke in Iranian population. A case-control study was conducted on 100 patients suffering from stroke as case group, and 100 hospitalized patients as control group. case group - 42 males 58 females, control group -44 males 56 females. Clinical attachment level, periodontal pocket, were recorded by gingival and periodontal indexes. The average of gingival index in men and women of case group in order was 1.22 ± 0.55 and 1.31 ± 0.55 with this fact that this number in women is more than men. Periodontal index in both groups in men was more than women and there was significant relationship between this index and gender ( P  = 0.031). Furthermore, periodontal index in case group was more than control group ( P  = 0.001). Relationship between age and periodontal disease in case group was significant ( P  = 0.03) 53

54. Author And Journal Aim Of The Study Materials And Methods Results Grau AJ et al Stroke 2004; 35(2); 87-95. investigated whether periodontal disease, including periodontitis and gingivitis, is a risk factor for cerebral ischemia. a case-control study with 303 patients examined within 7 days after acute ischemic stroke or transient ischemic attack, 300 population controls, and 168 hospital controls with nonvascular and noninflammatory neurological diseases Results revealed that   Patients had higher clinical attachment loss than population ( P <0.001) and hospital ( P =0.010) controls . Subjects with severe periodontitis (mean clinical attachment loss >6 mm) had a 4.3-times-higher risk of cerebral ischemia than subjects with mild or without periodontitis (≤3 mm). 54

55. LOW BIRTH WEIGHT 55

56. Author And Journal Aim Of The Study Materials And Methods Results Jacob PS et al J Periodontal Implant Sci . 2014 Apr ;44(2):85-93 To determine whether periodontitis among mothers in the rural population of india is a risk factor for low birth weight babies. A hospital-based case control study was conducted among 340 postpartum mothers. The cases consisted of 170 women who had given birth to babies weighing <2,500 g, while the control group consisted of 170 women who had given birth to babies weighing ≥2,500 g. Low Birth Weight cases had a significantly worse periodontal status than the controls, having an odds ratio (OR) of 2.94 (P=0.01). 56

57. Author And Journal Aim Of The Study Materials And Methods Results Moliterno LF et al J Clin Periodontol 2005 Aug;32(8):886-90. To verify a possible association between periodontitis and low-birth-weight babies 151 mothers were examined. Cases- 76 mothers with ( mean age 25.6 years), babies birth weight - <2500 g. Control- 75 mothers with ( mean age 24.4 years), baies birth weight - > 2500 g. Probing pocket depth ( ppd ) and clinical attachment loss (cal) in six sites  were measured. The median number and percentage of sites with PPD>4 and CAL>3 mm was 8% and 5.6%, respectively, in the case group. The corresponding numbers for the control group were 4% and 2.5%, respectively. The mean weight at birth was 1924 ( 417)g in the case group and 3253 ( 412) g in the control group. The results of the present study showed that the adjusted OR for the association between periodontitis and LBW was 3.48. 57

58. Aspiration of oral pathogens into lungs, Chronic Obstructive Pulmonary Disease 58

59. Author And Journal Aim Of The Study Materials And Methods Results Prasanna SJ J Indian Soc Periodontol   2011 Oct;15(4):359-65 To evaluate the potential association between periodontal health and COPD and to assess the potential health status of patients with and without COPD Observational study 100 patients Group A - 50 COPD patients Group B - 50 patients without COPD. Gingival Index (GI) and Papilla Bleeding Index (PBI) were used to assess the gingival status. Periodontal indices included Russell's Periodontal Index (PI) and Periodontal Index were assessed. The mean indices of all variables between groups were found to be highly significant (P<0.001). The scores were highly significant in COPD group than in non- copd group. 59

60. BACTERIAL PNEUMONIA Pneumonia is an infection of pulmonary parenchyma caused by a wide variety of infectious agents, including bacteria, fungi, parasites, and viruses. Failure of host defense mechanisms to eliminate them, multiplication of the microorganisms, result in subsequent tissue destruction. Anerobic organism from periodontal pockets may serve as the primary inoculum respiratory diseases Among the oral bacterial species implicated in pneumonia are A. actinomycetemcomitans , Actinomyces israelii , Capnocytophaga spp. , Eikenella corrodens , Prevotella intermedia , and Streptococcus constellatus are found in subgingival plaque Potential respiratory pathogens ( prps ) such as Streptococcus pneumoniae , Mycoplasma pneumoniae , and Haemophilus influenzae can colonize the oropharynx and can be aspirated into the lower airways. 60

61. Rheumatoid Arthritis Rheumatoid arthritis is a chronic destructive inflammatory disease characterized by the accumulation and persistence of an inflammatory infiltrate in the synovial membrane that leads to synovitis and the destruction of the joint architecture resulting in impaired function . Joints like ankles, knees, elbow, wrists are involved 61

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63. Author And Journal Aim Of The Study Materials And Methods Results Ranade SB et al J Indian Soc Periodontol.2012 Jan;16(1):22-7 To investigate any relationship between periodontitis and rheumatoid arthritis The study was done in parts: Part A: The study population comprised of 80 individuals between the ages 20-70 years, which were divided into two groups of 40 each. Group I: Subjects diagnosed with rheumatoid arthritis (RA group) Group II: Subjects in control group without rheumatoid arthritis Non-RA group Part A of the study evaluated and compared the periodontal condition of individuals having RA those who don′t have it. Part B: Complete periodontal treatment was done for 10 patients of group suffering from periodontitis. All parameters of periodontal indices were measured pre-operatively and weeks after completion of periodontal treatment. The prevalence of periodontitis in RA group was significantly high (97.5%). Only 1 - no periodontitis, 5 (12.5%) - mild periodontitis, 30 (75%) - moderate periodontitis, 4 (10%) had -severe periodontitis. There was statistically, significant reduction in parameters postoperatively with concomitant decrease in periodontal parameters in RA group. 63

64. PREVENTIVE APPROACH TO ORAL INFECTIONS Oral health is an integral element of general health and well-being. Oral diseases are highly prevalent and their impact on both individual and society is significant. There are many ways to prevent or reduce the risk of infection or diseases. Brushing and Flossing are most basic ways to reduce these risks. These two help to get rid of bacteria which stick to surfaces in our mouth to form plaque. Current dental therapy is focussed on removing whole dental plaque. There are new approaches towards selective inhibition of pathogens and modulations of microbial composition of dental plaque to control community-based oral microbial pathogenesis . 64

65. RECENT ADVANCES Photo disinfection of Oral cavity : Otherwise called as Photodynamic therapy for killing microbes . Composition for the present invention include tooth paste and an antimicrobial photosensitizer such as porphyrins / bacteriochlorins encapsulated within microspheres . The photosensitizer that upon irradiation of atleast 1 predetermined wavelength will reduce or eliminate microbes in oral cavity . 65

66. ORAL MICROFLORA IN DISEASE INFECTIONS OF THE MOUTH Infection Organism Dental caries Streptococcus mutans Periodontal diseases Bacteroides , Actinomyces Surgical infection Dry socket Dental abscess Osteomyelitis Ludwig’s angina Pericoronitis Actinomyces Oral streptococci Staphylococcus aureus β - haemolytic streptococci Bacteroides 66

67. INFECTIONS OF THE MOUTH Infection Organism Soft tissue infections Diphtheria ANUG Cancrum oris Tuberculosis Leprosy C. Diphtheriae Fuso- spirochaetes Fuso- spirochaetes M. Tuberculosis M. Leprae Viral infections Herpetic stomatitis Herpes Zoster Mumps Measles Herpes simplex Varicella -zoster Mumps virus Measles virus 67

68. INFECTIONS OF THE MOUTH Infection Organism Fungal infections Candidosis Histoplasmosis Candida albicans H. Capsulatum Miscellaneous Erythema multiforme StevensJohnson syndrome 68