口腔微生物免疫學

1. 口腔微生物免疫學 Bacterial infection 細菌感染 陳玉昆副教授: 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw

2. 學 習 目 標 • Understand: • Virulence factor of bacteria • Koch postulates • Two main oral bacterial lesions • - Caries/periapical lesions • - Periodontitis • 4. Tuberculosis • 5. Syphilis

3. 參考書目 References • Siqueira JF. Endodontic infections: Concepts, paradigms, and perspectives. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:281-93 • Hoang MD et al, Secondary syphilis: a histologic and immunohistochemical evaluation. J Cutan Pathol 2004: 31: 595-9 • Zeltser R & Kurban AK. Syphilis. Clin Dermatology 2004;22:461-8 • Yepes JF et al, Tuberculosis: Medical management update. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:267-73 • 結核病教學參考教材-衛生署疾病管制局 • 黃吉志 結核病的歷史回顧與展望 高醫醫訊 94年7月 • 張肇益 淺論牙周病病原菌、內毒素及宿主免疫反應 牙橋 2003;16:30-7 • Slots J & Taubman MA. Contemporary oral microbiology & Immunology. First edition, 1992 Chapter 11, p. 165-190 • Kaohsiung Medical University, Oral Pathology Department • Ficarra G, Carlos R. Syphilis: The renaissance of an old disease with oral implications. Head and Neck Pathol DOI 10.1007/s12105-009-0127-0

4. Bacterial Infection No damage (latent/dormant) Commensal Host Parasite Pathogen Damage Virulence factors Adherence, extracellular enzymes, fibrinolysin, toxin

5. Koch’s postulates The microorganism occurs in every case of the disease can account for the pathologic changes and clinical course of the disease The microorganism occurs in no other disease as a fortuitous and nonpathogenic parasite

6. After it is isolated from the diseased host & grown in pure culture, the microorganism can induce the diseaseanew Koch’s postulates Organism isolated from lesions Grown in pure culture in vitro Pure culture Animal A similar disease Organism reisolated Help! I have been infected 哈 哈

7. Shortcomings Koch’s postulates Isolated from patients both with and without cholera, Vibrio choleraefailed to experimentally induce the disease in animals • Place considerable emphasis on pathogenicity, which • resides particularly in the microorganism • Dependence on host susceptibility is an unquestionable issue • Emphasize the ability to cultivate the causative micro- • organism in pure culture • Some diseases, such as syphilis and leprosy, for which • the causative bacterium has not yet been cultured Limitations

8. Koch’s postulates • Imply that all strains of a given microbial species are • equally virulent • It is known that different strains within a species vary • in virulence • Suggest that only a single species causes each disease • There are some diseases, such as periradicular diseases, that are induced by a mixture of different microbial species Limitations • Require that the suspected microorganism, after reino- culation into an animal, produce the S/S of the disease • Several human pathogens either do not cause the disease in animals or cause a disease with different characteristics from the human form of the disease

9. 牙 周 病 細 菌 口腔兩大疾病 病原菌: Streptococus mutans Gram (-) Two Main Bacterial Infections 齲 齒 • > 200 different microbial species can be found in infected root canals, usually in combinations of 4 to 7 species/canal • Theoretically, any one of these species would have the • potential to be an endodontic pathogen

10. The microorganism must be present in sufficient number to initiate and maintain the periradicular disease The microorganism must possess an array of virulence factors, which should be expressed during root canal infection The microorganism must be spatially located in the root canal system in such a way that it or its virulence factors can gain access to the periradicular tissues The root canal environment must permit the survival and growth of the microorganism and provide signals or cues that stimulate the expression of virulence genes Requirements for endodontic pathogen (1)

11. Inhibiting microorganisms must be absent or present in low numbers in the root canal environment The host must mount a defense strategy at the periradicular tissues, inhibiting the spread of the infection. This process will result in tissue damage Requirements for endodontic pathogen (2) Ref: 1

12. 病 原 菌 Specific Non- specific Specific Gram (-) A. Actinomycetemcomitans P. gingivalis P. Intermedia C. Rectus B. Forsythus Spirochete Amoeba Bacteroides Spirochete 1890 1930 1990 1970 牙 周 病 細 菌 牙科兩大 疾病 Two Main Bacterial Infections 齲 齒

13. 牙 周 病 特 定 病 原 菌 的 條 件 該種細菌必須能夠大量於發病時存在， 而於健康時則僅有少數或甚至沒有 該種細菌所引發之抗體價在血清，唾液 或牙齦溝液中必須要高 清除或抑制該種細菌將迅速去除或舒緩病症 病巢部的組織，若使用該種細菌之抗體來操作 螢光抗體染色法，病巢部之組織能被染色標記 該種細菌必須能夠產生致病毒素或致病原因子 該種細菌之接種必須能夠讓實驗室的無菌動物 也引發相同的病程及症狀

14. Principal bacteria associated with periodontal diseases Adult periodontitis Refractory periodontitis Localized juvenile periodontitis Periodontitis in juvenile diabetics Pregnancy gingivitis ANUG Porphyromonas gingivalis, Prevotella intermedia, B. forsythus, Campylobacter rectus Bacteroides forsythus, P. gingivalis, Campylobacter rectus, P. intermedia P. intermedia, Intermediate-sized- spirochetes Actinobacillus actinomycetemcomitans, Capnocytophaga Capnocytophaga Actinobacillus actinomycetemcomitans, P. intermedia

15. 牙 周 組 織 牙 周 病 病 原 菌 直 接 效 應 間 接 效 應 Inhibition of PMN Leukotoxin, chemotaxis inhibitors, phagocytosis & intracellular killing, resistance to C-mediated killing Lymphocyte alterations Endotoxicity IgA, IgG proteases Fibrinolysin Superoxide dismutase Catalase Enzymes Collagense, hyaluronidase, phospholipase, phosphatases Exotoxin Endotoxin Cell inhibitors Ammonia Fimbria 牙 周 病 病 原 菌 之 致 病 力

16. Endotoxin - lipopolysaccharide (LPS) 化學結構 O antigen Side chain Core Polysaccharide Lipid A O antigen polysaccharide Core polysaccharide Lipid A Outer membrane Smooth- 8-10 O antigen Phospholipid Lipoprotein Semi-rough- 1-2 O antigen Peptidoglycan Rough- no O antigen Inner membrane Refs: 7,8

17. Endotoxin - lipopolysaccharide (LPS) 毒性強, 可直接對組織產生傷害, 亦會產生不良的免疫反應 可 : 造成 Leukopenia 活化XII blood clotting factor, 影響凝血機制 活化變異的補體反應 毒害fibroblast 引發骨吸收 活化巨噬細胞以製造IL-1,TNF-種種組織分解酶 亦產生過氧化物或離子基

18. Tuberulosis Granulomatous inflammation & tubercle Lung Caseation necrosis (liquefy, cavitation, fibrosis & calcification) Ghon complexe (radiodensities) Mycobacterium tuberculosis Miliary tuberculosis Koch phenomenon (partial immunity to reinfection) High lipid content Difficult to destain with acid once stained (acid-fast stain) Virulence factor: Cord factor ( a glycolipid of trehalose & mycolic acid) inhibition of PMN, attack mitochondrial memb causing damage to respiratory &/or oxidative system, elicit granulomatous formation : PPD (purified protein derivative) (no toxin) Aerosols Hematogenate route Ref: 9

19. Ref: 5

20. 結核桿菌 Mycobacterium tuberculosis Ref: 5

21. M tuberculosis Bacilli Fc receptors High molecular weight lipids Glycolipids Mycolic acids Surfactant protein receptor Complement receptors CD 14 Cell wall Cell wall • Aerobic • Non-motile • Non-spore forming • Slow growing Refs: 4, 9

22. Latent Primary Infection Coughing Bacilli Pulmonary manifestation 80-84% Active Extrapulmonary manifestation 16-20% • Immunosuppression • Malnutrition • Vitamin D deficiency Refs: 4, 9

23. 結 核 病 的 傳 染 途 徑 Ref: 5

24. Ref: 5

25. 只要number of cells = 10 可被感染 Ref: 5

26. Ref: 5

27. Ref: 5

28. Ref: 5

29. Ref: 5

30. 2002年 各國結核病發生率比較 台灣肺結核 Ref: 6

31. Bacilli New cases – 14,486 (2001) Ref: 5

32. Ref: 5

33. Risk Group (RG) = 3 Ref: 5

34. Primary (10 days to 10 wks, average 3 wks after contact) Chancre (genitalis, oral, perineal) Lymphadenopathy (lymph node) Tertiary (months or years after 2nd stage) Skin (gumma), CNS (tabes dorsalis), Circulatory system (aortic aneurysm) Secondary (2 to 12 wks, after chancre) Generalized rash, Flu symptoms, Bone lesions (anywhere or everywhere) Placenta Congenital Hutchinson triad Wassermann Ab Non-specificity IgM Index of severity Treponemal Ab Specificity IgG Index of severity 3 wks Syphilis Treponema pallidum

35. Exposure Primary incubation Central nervous system invasion 10-90 days from exposure Primary syphilis 25-60% Chancre formation Secondary incubation 4-10 weeks after chancre formation Early neurosyphilis Secondary syphilis Transmittable sexually or mother to child Symptomatic in only 5% Early latent syphilis (asymptomatic) 1 year or less postinfection Recurrence Meningitis Cranial neuritis Ocular involvement Meningiovascular disease Transmittable mother to child Late latent syphilis (asymptomatic) More than 1 year postinfection Tertiary syphilis late neurosyphilis Tertiary syphilis: cardiovascular syphilis Non- Transmittable 10% (20-30 years postinfection) Tabes dorsalis (2-9%) (Onset 3-50 years postinfection) Tertiary syphilis: gummatous disease General paresis (2-9%) (Onset 2-30 years postinfection) 15% (1-46 years postinfection) Natural history of untreated syphilis Ref: 3

36. Natural history of untreated syphilis TERTIARY SYPHILIS Ref: 10

37. Constitutional and mucocutaneous manifestations of secondary syphilis Symptoms: fever, malaise, weight loss Skin rash (symmetrical and generalized), alopecia Condyloma latum in intertriginous areas Lymphadenopathy Oral involvement: multiple mucous patches covered by grayish, white pseudomembranes and surrounded by erythema Ocular involvement: uveitis, iritis, optic neuritis Arthritis, periostitis Hepatitis Glomerulonephritis Neurologic involvement: headache, meningitis, cranial nerve paralysis, cerebrovascular accident Ref: 10

38. Syphilis: The Renaissance of an Old Disease with Oral Implications Painless oral ulcer Oral chancer An important diagnostic criteria Ref: 3

39. (頂端切平) Secondary syphilis: truncal macular- papular eruption Manifestations of untreated syphilis Chancer Ref: 3

40. Manifestations of untreated syphilis Secondary syphilis: oral mucous patch Secondary syphilis: papular syphilis of the palms Ref: 3

41. Manifestations of untreated syphilis Secondary syphilis: moth- eaten alopecia of the scalp Congenital syphilis: mulberry molar Tertiary syphilis: ulcerated gumma of the leg Secondary syphilis: loss of lateral eyebrow Ref: 3

42. Manifestations of untreated syphilis Secondary syphilis: maculopapular skin lesions of the neck Secondary syphilis: maculopapular and scaly lesions of the plantar area Secondary syphilis: moth-eaten alopecia Macerated plaques (condylomata lata) of the toe webs (浸軟) Ref: 10

43. Manifestations of untreated syphilis Ulceronodular skin lesion of lue maligna Secondary oral syphilis: mucous patches covered by grayish, white pseudo-membranes of the lower vestibular mucosa Ref: 10 Secondary oral syphilis: with lesions on the soft palate Oral chancre in a promiscuous woman who had unprotected oral sex

44. Detection of spirochytes Silver stain Immunocyochemical stain Immunocyochemical stain Immunocyochemical stain Ref: 2

45. Summaries • Knowing: • Virulence factor of bacteria • Koch postulates • Two main oral bacterial lesions • - Caries/periapical lesions • - Periodontitis • 4. Tuberculosis • 5. Syphilis