Braz Dent J (2000) 11(2): 161-165  ISSN 0103-6440

The aetiology of mouth ulcers is diverse and may include several types of trauma, systemic disease and infection. The size, depth, outline, base, aspect of the floor, pain, time of evolution and resolution of oral ulcers are discussed. Both past and present medical history, biopsy, blood tests and microbiological tests are also considered in order to assure precise identification. This paper reports a case of a lip ulcer caused by Klebsiella pneumoniae.

Key Words: bacteria, infection, mouth, lip ulcer, Klebsiella pneumoniae.

Introduction

Mouth ulcers are lesions resulting from the destruction of the epithelium and part of the adjacent connective tissue (Trabulsi, 1991). They are the second most common lesion of the oral cavity, only behind periodontal inflammatory disease (Woods et al., 1990). Ulcers may have a primary origin in the mouth, may occur due to trauma or be a consequence of a systemic disease (Tomasi, 1985) or immunological conditions such as AIDS, some tumors and infection (Woods and Goaz, 1983).

Shafer et al. (1987) reported that bacterial infection is closely related to the aetiology of many lesions or to a posterior contamination of a primary lesion of a different aetiology. The literature shows that at least 29 different microorganisms are found in the normal flora of the mouth. This complex biosystem is maintained by means of a complex equilibrium; however, other microorganisms may be introduced into this biosystem altering, under specific conditions, the equilibrium (Burnet et al., 1978).

Zegarelli et al. (1982) reported that oral ulceration may be classified into two major groups: acute and chronic. However, Woods and Goaz (1983) used different terminology to describe lesions with similar characteristics: short- and long-term course, respectively. Zegarelli et al. (1982) described acute ulcers as painful lesions which appear very quickly and persist for one to three weeks. On the other hand, chronic ulcerative disease has a gradual evolution and long-term duration. Woods and Goaz (1983) added that short- duration ulcers are superficial and that long-term lesions are often exophytic.

Kerr et al. (1977) reported that oral ulcers should be examined carefully especially regarding their size, depth, outlining, base, aspect of the floor, pain, time of evolution and resolution. It is also necessary to consider both past and present medical history in order to assure a precise identification. In addition, biopsy, blood tests and microbiological tests should also be carried out (Woods et al., 1990).

Case Report

M.B.S., a 74-year-old, married, retired, white male, was examined at the Oral and Maxillofacial Clinic of the Postgraduate Section of Dentistry (CCS-UFPE, Recife, PE, Brazil) complaining of pain and burning sensation in the lower lip for two months. The patient reported the development of a nodular lesion on his lip, which he had tried to excise several times with a domestic scissors. The lesion become ulcerated, and increased in size and bled occasionally. Due to pain, eating was difficult. Although the patient had no other complaints, he reported recent episodes of fever and a smoking habit since the age of five. Mouth examination showed very poor oral hygiene. The patient did not report chest problems and there was no evidence of immunological disease. The patient did not mention the use of any kind of medication. The shallow ulcerated reddish lesion was located on the outer lower lip measuring approximately 1.5 x 2.0 cm. It had irregular and mildly indurated margins, was painful on palpation and its floor was granulated and a mild exudate was present (Figure 1). The presumptive diagnosis was that of a squamous cell carcinoma.

A biopsy of the lesion was taken and the material was sent for routine histopathological examination. The result of the biopsy showed an intense inflammatory reaction with epithelial hyperplasia. In order to clarify the diagnosis a microbiological culture of the lesion was carried out. The result of the culture showed the presence of Klebsiella pneumoniae.

Because this was a long-term ulcerated lesion which was exposed to local irritant factors and intense sunlight, and also considering that it was disturbing the normal daily life of the patient, the lesion was excised using a CO₂ laser (Sharplan 20C, Laser Industries, Tel Aviv, Israel), with an output of 4 Watts, CW, in the superpulsed mode. There were no complications following the surgery and the post-operative period was uneventful (Figure 2).

The patient was also referred to a physician in order to verify the possibility of additional infection. There was no infection by Klebsiella pneumoniae elsewhere. The patient has been followed up for two years and there are no signs of recurrence of the lesion.

Discussion

Although the oral cavity is considered to be a reservoir for saprophytic microorganisms, some of them may be pathogenic, especially those which are not part of the normal flora. K. pneumoniae infections are not frequent in the mouth.

This paper reports a case of an infection of a lip ulcer by Klebsiella pneumoniae. The initial hypothesis was that of a squamous cell carcinoma because of both the aspect and history of the lesion. An immediate biopsy was carried out and excluded the possibility of a squamous cell carcinoma.

Microbiological culture was used for further investigation. It is known that some conditions may increase the pathogenicity of some microorganisms, including the use of antibiotics such as penicillin which reduces the number of gram-positive bacteria resulting in an increase in number of gram-negative microorganisms (Trabulsi, 1991) and clorohexidine which is used to clean the mucosa before surgery (Brow et al., 1990).

klebsiella pneumoniae is a gram-negative microorganism of the Enterobacteriaceae family present in the digestive tract, classified as coliform. klebsiella pneumoniae is also known as Friedländer bacillus, and belongs to the same root of K. rinosceromatis which causes rhinoceromatosis, a type of destructive granuloma (Burnet et al., 1978; Schafer et al., 1987).

Although Burnet et al. (1978) consider K. pneumoniae to be a normal component of oral and nasal cavities, Trabulsi (1991) only referred to colonization of the nasopharynges by this bacteria. Other studies have shown that its presence is more common in the dental plaque of vegeterians (Sedgley et al., 1996) and in AIDS patients (Zambom et al., 1990).

This bacteria is responsible for a severe type of pneumonia, and for a large number of hospital-acquired infections. It is also found in infection of the GI tract, peritonitis, enteritis, meningitis and septicemia, always associated with a suppurative process (Burnet et al., 1978; Gentry and Rodrigues, 1990; Hanna Jr., 1991) .

K. pneumoniae may also secondarily infect other areas from a primary focus of infection. Ogata et al. (1991) reported a case of pyogenic spondylitis in a diabetes mellitus patient with a K. pneumoniae GI infection. However, the report of mouth ulcers infected by K. pneumoniae is not common, except in patients who have undergone radiotherapy (Finegold and Martin, 1983), despite its link to odontogenic facial cellulite (Hanna Jr., 1991) and osteomyelites (Gentry and Rodriguez, 1990).

Sonis et al. (1995) reported that infected ulcers in irradiated patients result in discomfort and fever and clearly showed the importance of a criterious diagnosis because other systemic conditions may be present. This aspect is very important when considering the comments of Scannapieco and Mylotte (1996), who suggested that the microbiological agents of pneumonia originate in the oral cavity, and also recognized that good oral health is important in preventing pneumonia.

Conclusion

The literature review and the reported clinical case reinforce the importance of a very complete and precise anamnesis and clinical examination. This is very important in examining lesions of the mouth, when additional laboratory tests should be carried out. Special tests may be necessary especially in uncommon lesions found in the mouth.

Resumo

Pinheiro ALB, de Freitas AC: Um caso raro de úlcera labial infectada por Klebsiella pneumoniae: Relato de caso. Braz Dent J 11(2): 161-165, 2000.

A etiologia das úlceras bucais é diversa e inclui diversos tipos de trauma, doenças sistêmicas e infecção. O tamanho, profundidade, delimitação, base, aspecto do assoalho, dor, tempo de evolução e de cura das ulceras orais são discutidos. A história médica atual e a história médica pregressa, biópsia, exames hematológicos e testes microbiológicos são também considerados para assegurar uma identificação precisa. Este trabalho relata um caso de úlcera labial causada por Klebsiella pneumoniae.

Unitermos: bactéria, infecção, boca, úlcera labial, Klebsiella pneumoniae.

References

Brow AT, Shupe JA, Sims RE, Matheny JL, Lillich TT, Douglas JB: In-vitro effect of chlorhexidine and amikacin on oral gram-negative bacilli from bone marrow transplant recipients. Oral Surg Oral Med Oral Path 70: 715-719, 1990
Burnet GW, Sherp HW, Schuster GS: Microbiologia Oral e Doenças Infecciosas. 4th ed. Guanabara Koogan, Rio de Janeiro 1978
Finegold SM, Martin WJ: Diagnóstico Microbiológico. 6th ed. Panamericana, São Paulo 1983
Gentry LO, Rodrigues GG: Oral ciprofloxacin compared with parenteral antibiotics in the treatment of osteomyelitis. Antimicr agents and chemoth 34: 40-43, 1990
Hanna Jr CB: Cefadroxil in the management of facial cellulitis of odontogenic origin. Oral Surg Oral Med Oral Path 71: 496-498, 1991
Kerr DA, Ash Jr MM, Millard MD: Diagnóstico Oral. 4th ed. Panamericana, São Paulo 1977
Ogata M, Sato A, Takahashi Y, Amemiya T, Sato T, Hirata Y: A case of pyogenic spondylitis associated with diabetes mellitus. J Tokyo Women's Medical College 61: 645-650, 1991
Scannapieco FA, Mylotte JM: Relationships between periodontal disease and bacterial pneumonia. J Periodontol 67 (suppl 10): 1114-1122, 1996
Sedgley CM, Chu CS, Lo CM, Samaranayake LP: The oral prevalence of aerobic and facultatively anaerobic Gram-negative rods and yeasts in semi-reclused human vegetarians. Arch Oral Biol 41: 307-309, 1996
Shafer WG, Hine MK, Levy BM: Tratado de Patologia Bucal. 4th ed. Interamericana, Rio de Janeiro 1987
Sonis ST: Princípio e Prática de Medicina Oral. 2nd ed. Guanabara Koogan, Rio de Janeiro 1995
Tomasi AF: Diagnóstico de Patologia Bucal. 1st ed. Artes Médicas, São Paulo 1985
Trabulsi LR: Microbiologia. 2nd ed. Atheneu, Rio de Janeiro 1991
Woods NK, Goaz PW: Diagnóstico Diferencial das Lesões Bucais. 2nd ed. Guanabara Koogan, Rio de Janeiro 1983
Woods MA, Mohammad AR, Turner JE, Mincer HH: Oral ulcerations. Quintessence Intern 21: 141-151, 1990
Zambom JJ, Reynolds HS, Genco RJ: Studies of the subgingival microflora in patients with acquired immunodeficiency syndrome. J Periodontol 61: 699-704, 1990
Zegarelli EV, Kutsher AH, Hyman GA: Diagnóstico das Doenças da Boca e dos Maxilares. 2nd ed. Guanabara Koogan, Rio de Janeiro 1982

Correspondence: Prof. Antonio L.B. Pinheiro, Faculdade de Odontologia, Universidade Federal da Bahia, Av. Araújo Pinho, 62, Canela, 40110-150 Salvador, BA, Brasil. E-mail: albp@ufba.br

Accepted October 8, 1999
Eletronic publication october, 2000