Oral Path - Vesicular Lesions

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Mucocele

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* AKA: Mucus Extravasation Cyst
* Description: Mucin retained in surrounding tissue
* Cause: Trauma and Severing of a Salivary Excretory Duct
* Found in: Younger groups
* Location: Lower/Upper Lip, Palate, Retromolar area, Ventral Tongue, Buccal Mucosa Floor of Mouth, or Lingual Frenum
* Color: Skin-tone, blue in color
* Treatment: Removal of damaged duct or blockage (sialolith). Caution Pt. to avoid trauma to area.
* Clinical Characteristics: Movable, Soft, Painless, Dome-shaped

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Sialolith

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* Description: Salivary gland stone that causes obstruction. May cause retention cyst.
* Location: Floor of mouth
* Treatment: Surgical removal.

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Infectious Viral Diseases: Cytotoxic

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* Replicate within the host cells and DESTROY them.
* Release viral particles into adjacent tissue then move into and destroy other host cells.

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Infectious Viral Diseases: Non-cytotoxic

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* NO or INTERMITTENT cellular destruction.
* May lie dormant for long periods of time (ie. herpesvirus)
* May replace host DNA and become part of the cell.

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Infectious Viral Diseases: Herpes Simplex Virus (HSV)

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* At least 8 HHV
* May occur in primary or systemic forms

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Infectious Viral Diseases: What are HHV-1 associations?

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* Primary herpetic gingivostomatitis, recurrent oral herpes, and herpes labialis.
-- May cause genital lesions due to genital-oral contact.

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Infectious Viral Diseases: What are HHV-2 associations?

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* Genital Herpes
-- Type 2 may cause oral lesions due to oral-genital contact

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Infectious Viral Diseases: Primary Herpetic Gingivostomatitis

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* Description: (before rupture) Multiple vesicles w/ red margins, (after rupture) multiple ulcers surrounded by erythema.
* Cause: HHV-1
* Characteristics: migrates along trigiminal nerve and remains latent in the ganglion until triggered by event. Painful lesions, possible temperature, generalized malaise, cervical lymphadonopathy and sore throat.
* Treatment: Soft diet, non acidic/carbonated liquids, cold foods (ie. ice-cream), Topical Benadryl elixir and Kaopectate (for pain).

* Postpone Dental Care
Course: 10-14 days.
* Initial Exposure is called a primary infection (often subclinical)

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Infectious Viral Diseases: Secondary/Recurrent Herpes Simplex

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* Description: (Before rupture) Clusters of vesicles on vermillion border, perioral skin or keratinized intraoral surface; (after rupture) crusted ulcers
* Cause: Event reactivated Latent Virus
--Event is often immune compromising: Cold/fever, Sunburn, Emotional stress, Trauma, Infection, Menstruation, Systemic disease, Allergy, Pregnancy, Debilitation, Scaling/Root planning/Periodontal Surgery.

* 20-40% affected after primary infection
* Postpone Dental Care

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Infectious Viral Diseases: Herpes Labialis

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* Description: (Before rupture) Clusters of vesicles on vermillion border, ; (after rupture) crusted ulcers
* Treatment of outbreak: Antiviral topical ointments or creams reduce duration or stop lesion formation. + USE APPLICATOR + Avoid Sunburns, Avoid triggers. Take acyclovir orally (EXPENSIVE)

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Infectious Viral Diseases: Herpetic Lesions vs Aphthous Ulcers

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Front 12

Infectious Viral Diseases: Herpetic Whitlow

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* Cause: HSV-1 on finger - usually a primary infection but can recur.
* Location: on finger but may infect mouth, nose,e eyes, or other mucosal lining.

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Infectious Viral Diseases: Herpes Simplex Virus - 2

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* AKA: Genital Herpes
* Transmission: Genital secretions

* Cannot visually differentiate between type 1 or 2
* Oral sex increases likely hood of type-1 (oral) on genitellia and type-2 (genital) on mouth. Also implicated in certain head and neck cancers caused by HPV.

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Infectious Viral Diseases: Primary Varicella-Zoster HSV-3

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* AKA: Chickenpox (varicella -Original infection) and Shingles (zoster - Reactivated infection)
* Transmission: air droplets or direct contact w/ lesions.

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Infectious Viral Diseases: Chickenpox to Shingles: Order and Differences

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* Chickenpox - more often in children
-- NO pain (itchy instead)
-- Only Treatment is relief of itching (pruritus)

* Shingles - more often in elderly
-- Pain and paresthesia lasting 2-3 weeks
-- can cause chickenpox in not-prevously-exposed people
-- May also cause fever, malaise and lymphadenopathy.
-- Prevention includes vaccination or isolation.
-- Treatment includes management of skin lesions, pain control, and antiviral meds ( oral acyclovir 800mg 5xday for 7-10 days
- Effects may include: post-herpetic neuralgia for years, facial paralysis, diminished hearing, vertigo, tooth exfoliation (rare) and necrosis of the mandible (rare).

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Infectious Viral Diseases: Entrovirus 71

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* AKA: Coxsackie Entrovirus

* Can cause Hand-foot-and-mouth disease, Herpangia, and acute lymphonodular pharyngitis.

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Infectious Viral Diseases: Hand-Foot-and-Mouth Disease

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* Transmission: airborne and oral/fecal
* Mostly in children under age 5
* Description: Rash on soles of feet and palms, vescifles that may or may not rupture, fever, sore throat, malaise and lymphadenopathy.

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Infectious Viral Diseases: Herpangia from Coxsackie A-16

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* Transmission: oral/fecal
* Description: Oral lesions in posterior, soft palate, pillars and tonsils. Sore throat, fever, loss of appetite, abdominal pain, and vomiting, reddened tissues and vesicles that rupture and ulcerate.

* May be mistaken for strep throat.
* Treat for discomfort.

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Infectious Viral Diseases: Acute Lymphonodular Pharyngitis

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* Vary rare condition *
* Description: Fever Oral appearance may vary. Includes fever, sore throat, headache, and inflamed lymphoid tissue.
* Lasts several days to weeks.

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Infectious Viral Diseases: Measels

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* AKA: Rubeola
* Family: Paramyxoviridae
* Transmission: airborne and droplets.
* Description: Fever, malaise, upper respiratory congestion, cough, conjunctivitis, and a rash that can be found on buccal/labial mucosa before extraoral.
* Rash may last 7-24 days.

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Infectious Viral Diseases: Koplik's Spots

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* AKA: "Grains of salt on a wet background."
* Description: small, irregular red spots w. bluish white spec in each center, found on buccal and lingual mucosa often associated w/ measles.

* Pathognomonic of early stage measles, appearing a few days before rash arrives.

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Word of the day: Pathognomonic

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* A sign or symptom that is so characteristic of a disease that it makes the diagnosis.
* Comes from the Greek "pathognomonikos'" meaning "skilled in judging diseases."

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Infectious Viral Diseases: Rubella

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* AKA: German Measles
* Cause: Toga virus
* Transmission: respiratory droplets **HIGHLY CONTAGIOUS**
* Description: Mild erythematous rash w/ low grade fever, malaise, nausea, poor appetite, lymphadenopathy, w/ red and pink papules on the body.
* Forchheimer's signs (small, discrete, dark red papules) may be visible in soft palate region and are considered an early sign of infection.

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Noninfective Vesiculobullous (Autoimmune) Diseases: Pemphigus Vulgaris

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* Transmission: no modes
* Occurrence: Most often in 40-60 years of age, and of Jewish or Mediterranean descent.
* Description: Begin as bulla greater than 1cm that rupture quickly, form shallow ulcers covered by gray pseudomembrane.

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Microscopic Events of Pemphigus Vulgaris

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* Acantholysis (separation of epithelial cells) caused by autoantibodies that attack protein components of desmosomes.
* Protein component binds the epithelial cells together wich leads to bulla and ulceration of affected tissues.
* Immunofluorescence aids in diagnosis.

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Nikolsky's Sign of Pemphigus Vulgaris

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* First described by Russion dermatologist Pyotr Valilyewich Nikolsky in 1896.
*Initially described sign as appearing after rubbing skin with pemphigus foliaceus, causing a blistering or denudation of epidermis w/ glistening, moist surface underneath.
*Shows positive response in all phemphigus disorders.
* used to diagnose pemphigus.

*Pressure is applied to skin w/ finger or paperclip to blistered, perilesional or normal skin in pt suspected of having pemphigus. Positive response = extension of blister and/or removal of epidermis in area immediately surrounding blister or lesion.

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Treatment for Pemphigus Vulgaris

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* Good oral hygiene and Medical treatment is crucial
* Systemic corticosteroids and immunosupressive agents
* Topical steroids

DO NOT USE:
-- alcohol based products
-- abrasive dental products
-- tooth whitening products

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Noninfective Vesiculobullous (Autoimmune) Diseases: Mucous Membrane Pemphigoid

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* AKA: Desquamative gengivitis
* Description: Bulla form and break, leaving raw or ulcerated surface.
* Cause: Often contact allergy
* Location: Often oral cavity, especially gingiva.
* Treatment: Discontinue contact with aggravating product.
-- spicty foods, cinnamon, sodium laurel sulfate (in toothpaste) flavoring agents (in foods like salsa), processed foods, and soft drinks.

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Noninfective Vesiculobullous (Autoimmune) Diseases: Ocular Mucous Membrane Pemphigoid

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Eyes should be examined and patient should be referred to an eye professional for evaluation.

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Noninfective Vesiculobullous (Autoimmune) Diseases: Bullous Pemphigoud

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* Affects elderly 70-80 years of age
* Rarely affects intraoral areas - would be found on gingiva.
* Cutaneous bullae develop slowly - may last for weeks to months before breaking, causing painful, erythematous and ulverative lesions
* Treatment: Systemic corticosteroids w/ other immunosuppressants.

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Congenital or Genetic Diseases: Epidermolysis Bullosa

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* Fragility of the skin and mucosa which blister
* Four groups: Simplex, Junctional, Dystrophic, and Mixed (Kindler Syndrome).
* Can have enamel hypoplasia with a high rate of caries.
* Fluoride and non-cariogenic soft diet.
* Affected Organs: Eyes, Blood (poor iron absorption), skin-tails, esophagus, intestine, and musculoskeletal.

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Congenital or Genetic Diseases: Epidermolysis Bullosa Acquisita

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* Chronic Subepithelial Blistering Disease.
* Affects the dermal-epidermal junction.
* Classic form is characterized by fragility of the skin, including nikolsky's sign.
* affects 0.2 million people.

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Congenital or Genetic Diseases: Epidermolysis Bullosa Acquisita - Dental Procedures

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* Hand-scale (low-power ultrasonic in less severe cases)
* Low abrasive polish
* NO AIR POLISHERS
* Limited contact w/ tissue. NEVER fulcrum on tissue.
* Apply medications w/ cotton swab. NO soft tissue contact.