Department of Health and Human Services

U.S. PUBLIC HEALTH SERVICE

Suggested Citation

U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General.
Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial
Research, National Institutes of Health, 2000.

ii
Diseases and Disorders

Refractory Periodontitis. Refractory periodontitis is Defects in neutrophil function noted in both forms of
not a specific form of disease, but refers to cases in the disease (Schenkein and Van Dyke 1994) may
which patients continue to exhibit progressive dis- explain why patients are highly susceptible to other
ease at multiple sites despite aggressive mechanical infections as well (Suzuki 1988).
therapy to remove biofilm and calculus, along with
the use of antibiotics. Refractory sites exhibit elevat-
ed levels of a number of different bacteria, with the SELECTED MUCOSAL INFECTIONS
dominant species different in different subjects. It is AND CONDITIONS
not known whether variations in pathogenicity of the Like the skin, the mucosal lining of the mouth serves
bacteria, defects in the subject’s defense systems, or to protect the body from injury. This lining is itself
combinations of these factors are responsible for the subject to a variety of infections and conditions,
refractory nature of the disease (Haffajee et al. 1988). ranging from benign canker sores to often fatal
The adoption of new diagnostic technology to detect cancers.
predominant bacterial species, followed by selective
antibiotic treatment, may help resolve infection and
Oral Candidiasis
disease in these patients.
Chronic hyperplastic candidiasis is a red or white
Early-onset Periodontitis lesion that may be flat or slightly elevated and may
adhere to soft or hard tissue surfaces, including den-
The forms of periodontitis occurring in adolescents tal appliances. It is caused by species of Candida,
and young adults generally involve defects in neu- especially Candida albicans, the most common fungal
trophil function (Van Dyke et al. 1980). Localized pathogen isolated from the oral cavity. Normally, the
juvenile periodontitis (LJP) mainly affects the first fungi are present in relatively low numbers in up to
molar and incisor teeth of teenagers and young 65 percent of healthy children and adults and cause
adults, with rapid destruction of bone but almost no no harm (McCullough et al. 1996). Problems arise
telltale signs of inflammation and very little when there is a change in oral homeostatis—the nor-
supragingival plaque or calculus. Actinobacillus actin- mal balance of protective mechanisms and resident
omycetemcomitans has been isolated at 90 to 100 per- oral flora that maintain the health of the oral cavity—
cent of diseased sites in these patients, but is absent so that defense mechanisms are compromised (Scully
or appears in very low frequency in healthy or mini- et al. 1994). Under these circumstances the fungal
mally diseased sites (Socransky and Haffajee 1992). organisms can overgrow to cause disease. A primary
It is possible that the bacteria are transmitted among disruption in homeostasis occurs with the use of
family members through oral contacts such as kiss- antibiotics and corticosteroids, which can markedly
ing or sharing utensils, because the same bacterial change the composition of the oral flora. Deficiencies
strain appears in affected family members. However, in the immune and endocrine systems are also
evidence of a neutrophil defect argues for a genetic important. Indeed, the diagnosis of candidiasis in an
component. Another organism frequently associated otherwise seemingly healthy young adult may be the
with LJP is Capnocytophaga ochracea. Neither of first sign of HIV infection. Other causes of candidia-
these bacteria dominate in the generalized adult form sis include cancer chemotherapy or radiotherapy to
of the disease, where Porphyromonas gingivalis is con- the head and neck, xerostomia resulting from radia-
sidered of greatest significance (Schenkein and Van tion to the head and neck, medications, chronic
Dyke 1994). mucosal irritation, certain blood diseases, and other
Prepubertal periodontitis is rare and can be systemic conditions. Also, tobacco use has been iden-
either general or localized. The generalized form tified as a cofactor.
begins with the eruption of the primary teeth and Candidiasis often causes symptoms of burning
proceeds to involve the permanent teeth. There is and soreness as well as sensitivity to acidic and spicy
severe inflammation, rapid bone loss, tooth mobility, foods. Patients may complain of a foul taste in the
and tooth loss. The localized form of the disease is mouth. However, it can also be asymptomatic.
less aggressive, affecting only some primary teeth. Genomic analysis of the Candida albicans genome is
The infection involves many of the organisms associ- helping investigators identify numerous genes that
ated with periodontitis, but the mix may differ some- code for virulence factors, including enzymes that
what, with Actinobacillus actinomycetemcomitans, can facilitate adhesion to and penetration of mucous
Prevotella intermedia, Eikenella corrodens, and several membranes. At the same time, researchers are explor-
species of Capnocytophaga implicated (Caton 1989). ing novel gene technologies to increase production of

42 ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL

a family of native salivary proteins, the histatins, that Normally, the immune system mounts a success-
have known anticandidal and other antimicrobial ful attack on the viruses, with symptoms abating by
effects. the time neutralizing antibodies appear in the blood-
The most common form of oral candidiasis is stream, in about 10 days. However, herpes viruses are
denture stomatitis. It occurs when tissues are trau- notorious for their ability to avoid immune detection
matized by continued wearing of ill-fitting or inade- by taking refuge in the nervous system, where they
quately cleaned dental appliances and is described as can remain latent for years. In oral herpes the virus
chronic erythematous candidiasis. Another form, commonly migrates to the nearby trigeminal gan-
candidal angular cheilosis, occurs in the folds at the glion, the cluster of nerve cells whose fibers branch
angles of the mouth and is closely associated with out to the face and mouth. In about 20 to 40 percent
denture sore mouth (Tyldesley and Field 1995). of people who are virus-positive, the virus may reac-
Other common forms of Candida infection are tivate, with infectious virus particles moving to the
pseudomembranous candidiasis (thrush), which may oral cavity to cause recurrent disease (Scott et al.
affect any of the mucosal surfaces, and acute erythe- 1997).
matous candidiasis, a red and markedly painful vari- The usual site of a recurrent lesion is on or near
ant commonly seen in AIDS patients. the lips. Recurrences are rarely severe, and lesions
In most cases, Candida infection can be con- heal in 7 to 10 days without scarring (Higgins et al.
trolled with antifungal medications used locally or 1993). The recurrences may be provoked by a wide
systemically. Control is difficult, however, in patients range of stimuli, including sunlight, mechanical trau-
with immune dysfunction, as in AIDS, or other ma, and mild fevers such as occur with a cold.
chronic debilitating diseases. Often the organisms Emotional factors may play a role as well.
become resistant to standard therapy, and aggressive
approaches are necessary (Tyldesley and Field 1995).
The spread of oral candidiasis to the esophagus or Oral Human Papillomavirus Infections
lungs can be life-threatening and is one of the crite- There are more than 100 recognized strains of oral
ria used to define frank AIDS (Samaranayake and human papillomavirus (HPV), a member of the
Holmstrup 1989). papovavirus family, implicated in a variety of oral
lesions (Regezi and Sciubba 1993). Most common
are papillomas (warts) found on or around the lips
Herpes Simplex Virus Infections and in the mouth. HPV is found in 80 percent of
In any given year, about one-half-million Americans these oral squamous papillomas (de Villiers 1989).
will experience their first encounter with the herpes The virus has also been identified in 30 to 40 percent
simplex virus type 1 (HSV-1), the cause of cold sores. of oral squamous cell carcinomas (Chang et al. 1990)
That first encounter usually occurs in the oral region and has been implicated in cervical cancer as well.
and may be so mild as to go unnoticed. But in some Whether a cancer or nonmalignant wart develops
people, particularly young children and young may depend on which virus is present or on which
adults, infection may take the form of primary her- viral genes are activated.
petic stomatitis, with symptoms of malaise, muscle Oral warts are most often found in children,
aches, sore throat, and enlarged and tender lymph probably as a result of chewing warts on the hands.
nodes, prior to the appearance of the familiar cold In adults, sexual transmission from the anogenital
sore blisters. These blisters usually show up on the region can occur (Franchesi et al. 1996).
lips, but any of the mucosal surfaces can be affected. In general, viral warts spontaneously regress
Bright-red ulcerated areas and marked gingivitis may after 1 or 2 years. The immune system normally
also be seen (Tyldesley and Field 1995). keeps HPV infections under control, as evidenced by
Herpes viruses also cause genital infections, the increased prevalence of HPV-associated lesions in
which are transmitted sexually. Both HSV-1 and HSV- HIV-infected patients and others with immuno-
2 have been found in oral and genital infections, with deficiency.
HSV-1 predominating in oral areas and HSV-2 in gen-
ital areas (Wheeler 1988). Herpes viruses have also
been implicated as cofactors in the development of Recurrent Aphthous Ulcers
oral cancers. Crowded living conditions can result in Recurrent aphthous ulcers (RAU), also referred to as
greater contact with infected individuals, which aids recurrent aphthous stomatitis, is the technical term
in transmission of HSV (Whitley 1992). for canker sores, the most common and generally

ORAL HEALTH IN AMERICA: A REPORT OF THE SURGEON GENERAL 43