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• 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)
• 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.
• 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.
• PrimaryinfectionwithVZV-varicella(chicken
pox)
• thevirusthenbecomeslatent,usuallyinthe
dorsalrootgangliaorganglia-shingles
• ophthalmicdivisionofthetrigeminalnerveis
thecranialnerve
• Resorptionandexfoliationofteethand
osteonecrosisofthejawbones,HIVdisease.
Ramsayhuntsyndrome
• Geniculateganglion--
Bellspalsy,
• vesiclesoftheexternal
ear,and
• lossoftastesensation
intheanteriortwo-
thirdsofthetongue
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.
• Treponemaspecies,Prevotellaintermedia,
Fusobacterianucleatum.
• immunocompromisedhost
• gingiva-scatteredpunched-outulcerations
interdentalpapillae-marginalgingivamaybe
affected.
• Supportivecareandpaincontrol
• Localdebridement.
• ram-negativeanaerobes,suchasb-lactams,
METRONIDAZOLE
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
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.
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
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