ULCERATIVE VESICULOBULLOUS LESIONS

ULCERATIVEVESICULOBULLOUS

LESIONS

•  Macules: These are well-

circumscribed, flat lesions

that are noticeable because

of their change from

normal skin or mucosa

color.

•  Plaques: These are solid

raised lesions that are

greater than 1 cm in

diameter; they are large

papules.

•  Nodules:Theselesionsarepresentdeeperinthe

dermisormucosa.

•  Papules: These are solid

lesions raised above the

skin or mucosal surface

that are smaller than 1 cm

in diameter.

•  Vesicles:Theseare

elevatedblisters

containingclearfluid

thatarelessthan1cm

indiameter.

•  Bullae:Theseare

elevatedblisters

containingclearfluid

thataregreaterthan

1cmindiameter.

•  Erosions:Theseareredlesionsoftencausedby

theruptureofvesiclesor

bullaeortraumaandare

generallymoistonthe

skin.

•  Ulcers: These are well-

circumscribed, often

depressed lesions with an

epithelial defect that is

covered by a fibrin clot,

causing a yellow-white

appearance.

•  Pustules: These are blisters

containing purulent material

•  Purpura: These are reddish

to purple bruises caused by

blood from vessels leaking

into the connective tissue.

These lesions do not blanch

when pressure is applied and

are classified by size as

petechiae (less than 0.5 cm)

or ecchymoses.

▼Thepatientwithacutemultiplel

esions

–  HerpesSimplexVirusInfections

–  Varicella-ZosterVirusInfections

–  CytomegalovirusInfections

–  CoxsackievirusInfections

–  NecrotizingUlcerativeGingivitis

andPeriodontitis

–  ErythemaMultiforme

–  StevensJohnsonSyndromeand

ToxicEpidermalNecrolysis

–  (LyellDisease)

–  OralHypersensitivityReactions

▼ThePatientwithRecurringOral

Ulcers

–  RecurrentAphthousStomatitis

–  BehçetDisease

▼ThePatientwithChronicMultipleLesions

–  PemphigusVulgaris

–  ParaneoplasticPemphigus

–  PemphigusVegetans

–  SubepithelialBullousDermatoses

–  BullousPemphigoid

–  MucousMembranePemphigoid

(CicatricialPemphigoid)

–  LinearIgADisease

–  EpidermolysisBullosaAquisita

–  ChronicBullousDiseaseofChildhood

▼ThePatientwithSingleUlcers

–  TraumaticInjuriesCausingSolitary

Ulcerations

–  TraumaticUlcerativeGranuloma

(EosinophilicUlcerofTongue)

–  Histoplasmosis

–  Blastomycosis

–  Mucormycosis(Phycomycosis)

PRIMARYHERPETIC

GINGIVOSTOMATITIS

•  childrenandteenagers

•  1-to3-dayviralprodromeoffever,Submandibularlymphadenopathy

•  lossofappetite,malaise,myalgia,headacheandnausea.

•  clustersofvesicles–Keratinized&non-keratinized.

•  Gingiva-oftenfieryred,andthemouthisextremelypainful,causingdifficultywitheating-Marginalgingivitis.

•  resolveswithin10to14days

HERPETICWHITLOW

virusisinoculatedintothefingersthroughabreakintheskin.This

wasacommonoccupationalhazard(dentalprofession)beforethe

Widespreaduseofgloves.

•  infectionsoftheskinspreadthroughthe

sportofwrestling

RECCURENTHERPESLABIALIS

•  travelsalongthesensorynerveaxonsand

establisheschronic,latentinfectioninthe

sensorygangliontrigeminalganglion

•  extraneuronallatency-HSVremaininglatentin

cellsotherthanneuronssuchastheepithelium-

lips(trauma/sunlight/fever/stressmensturation)

•  RECRUDESCENTHSVinfectionintheformof

localizedvesiclesorulcers-travelscentripetally.

INTRAORALRECRUDESCENTHSV

•  Iimmunocompetenthost-keratinizedmucosaofthehardpalate,attachedgingiva,anddorsumofthetongue.

•  painfululcerswithabrighterythematousborder

•  lesionsappearas1to5mmpainfulvesicles

MANAGEMENT

•  paincontrol,supportivecare,anddefinitivetreatment

•  acyclovirat15mg/kgfivetimesadayinchildrenreducesthedurationoffever,reducesHSVshedding,haltstheprogressoflesions,improvesoralintake,andreducestheincidenceofhospitaladmissions.

•  5%acyclovircream,3%penciclovircreamand10%docosanolcreamareefficacious-RHL-REDUCESINFECTIVITY.

HERPESZOSTER

•  PrimaryinfectionwithVZV-varicella(chicken

pox)

•  thevirusthenbecomeslatent,usuallyinthe

dorsalrootgangliaorganglia-shingles

•  ophthalmicdivisionofthetrigeminalnerveis

thecranialnerve

•  Resorptionandexfoliationofteethand

osteonecrosisofthejawbones,HIVdisease.

Ramsayhuntsyndrome

•  Geniculateganglion--

Bellspalsy,

•  vesiclesoftheexternal

ear,and

•  lossoftastesensation

intheanteriortwo-

thirdsofthetongue

MANAGEMENT

Coxsackievirus

(CV)Infection•  Fecal-oralroute,

althoughsome

sheddingoccursin

theupper

respiratorytract

•  Hand-foot-and-

MouthDISEASE

(HFM)

HERPANGINA

•  derivesfromherpes,

meaning“vesicular

eruption,”and

angina,meaning

“inflammationof

thethroat.”

•  Childhooddisease.

CMV

•  CMV-causeaninfectiousmononucleosis–likedisease.Manifestationsofinfectionanddiseasearemostevidentintheimmuno-compromisedpopulation.

•  Nonspecificoralulceration

•  -gingiva&tongue

•  Enlargedsalivaryglands

•  Decreasedsalivation

•  Resolespontaneously-

•  Ganciclovir-persistentcases.

ANUG

•  Treponemaspecies,Prevotellaintermedia,

Fusobacterianucleatum.

•  immunocompromisedhost

•  gingiva-scatteredpunched-outulcerations

interdentalpapillae-marginalgingivamaybe

affected.

•  Supportivecareandpaincontrol

•  Localdebridement.

•  ram-negativeanaerobes,suchasb-lactams,

METRONIDAZOLE

PART-II

ERYTHEMAMULTIFORME

RECURRENT APHTHOUS

STOMATITIS-MINOR

RECURRENTAPHTHOUS

STOMATITIS

RECURRENTAPHTHOUS

STOMATITIS-HERPETIFORM

BECHET’SSYNDROME-PATHERGY

TEST

PEMPHIGUS

TYPES:

•  PV-PVegetans

•  PFoliaceus-PErythematosus

•  PNPP

•  Druginduced

SIGNS:

•  Nikolskysign-Firm

slidingpressurewith

finger-separates

normalepidermis-

producingerpsions

•  AsboeHansensign-

lateralpressureonthe

edgeofablister–

spreadstheblisterto

clinicallyunaffected

skin

PemphigusVegetans–BENIGN

VARIANT

•  Neumanntype-

–  largebullaeand

denudedareas.

–  healingbydeveloping

vegetationsof

hyperplasticgranulation

tissue

•  Hallopeautype-

–  Lessaggressivepustules-

–  followedbyverrucous

hyperkeratotic

vegetations

PEMPHIGOID

Mucormycosis(Phycomycosis)

ORALHYPERSENSITIVITY

REACTIONS

•  Whatareantibodies?

– Proteins-producedbyplasmacells-Bcells-used

byimmunesystem.

–  Immunoglobulins–(Ig)

•  IgA-Mucousmembranes,foundinallsecretions.

•  IgE-Bindstoallergen–lungs,skin,mucousmembrane-

triggershistaminereleasefrommastcells

•  IgG-allbodyfluids-crossesplacenta-immunityto

bacterial,viralinfections-majority-immunity.

•  IgM-blood&lymph-fightsagainstnewinfections.

•  IgD-actsasantigenreceptoronBcells.

•  Undesirablereactionsproducedbynormal

immunesystem,includesallergiesand

autoimmunity.

COMPLIMENTSYSTEM

ADCC-ANTIBODYDEPENDENT-CELL

MEDIATEDCYTOTOXICITY

IMMUNECOMPLEX

ORALHYPERSENSITIVITY

REACTIONS

TYPE

IMMUNE

REACTANT

MOA

Rx

Oralallergysyndrome,

Angioedema

I IgE Anaphylaxis-allergy-

mastcell

degranulation(12

min)

Adrenalin,

antihistamins,

Steroids.

Pemphigus,hemolytic

anemia

II IgM/IgG Cytotoxic-bindsto

cellularantigens.

Steroids

Immunomodulat

ors.

SLE,RA,Bechetsyndrome III IgM&IgG Immunecomplex-

antigen-antibody

complex-deposited

ontissues

Steroids

Immunomodulat

ors

Fixeddrugeruptions,

contactallergicstomatitis,

lichenoidreactions,

Erythemamultiforme&

plasmacellstomatitis

IV T-cell Delayedtype-Tcells

(48-72hrs)

Allergen

removal-food,

drugs-topical,

dentalretotation

&prosthesis.

Steroids

Immunomodulat

ors

SOLITARYTRAUMATICULCER