Download Lesions that Appear as Vesicles

Chapter 11
Lesions That Have a Vesicular
Appearance
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Vesiculobullous Disorders
• Grouped as
− Inflammatory
− Traumatic
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Common Names for the Mucocele
The Mucocele
• Common names
Histology of Mucocele
•
• Mucous retention cyst
(lined with epithelium) A
true cyst sialolith or
salivary gland stone is
the cause.
• Mucous extravasation
phenomenon (lined with
granulation tissue).
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Locations of the Mucocele
• May be found on
• Most common sites
− Lower lip
− Lower lip—trauma
− Palate
− Floor of the mouth
− Retro molar area
− Ventral tongue—
trauma
− Upper lip
− Ventral tongue region
− Lingual frenum
− Buccal mucosa
− Palate
− Buccal mucosa
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Epidemiology—Mucocele
• Younger age groups in
second decade
• Damage to the salivary
duct
• Equal sex predilection
• Exhibits spilled mucin—
lodges in tissues
• Most commonly caused by
trauma
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Traumatic Versus Inflammatory
Traumatic
Inflammatory
Histology
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Clinical Characteristics of the Mucocele
• Moveable
• Soft
• Painless
• Soft blue opalescent hue
• Dome-shaped
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Mucocele Versus Mucous Retention Cyst
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Ranula
• Found in the floor of the mouth
• Severed and damaged salivary duct in the floor of the
mouth (discussed in Chapter 17)
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Differential Diagnosis
• Neoplasms
• Lipomas
• Vascular malformations
• Dermoid cyst or ranula—in the floor of the mouth
• Mucoepidermoid CA—in the palate region
• Clinically, they may be mistaken for OLP, papilloma,
fibroma, or HSV infections
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Treatment
• Removal of the damaged duct
• Removal of blockage when sialolith is involved
• Caution the patient to avoid trauma to the area
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Infectious Viral Diseases
• Cytotoxic viruses
− Replicate within the host cells
− Destroy the cell and release new particles
− Progressive cellular destruction
− Symptoms develop.
− Relevant when the body’s defenses are low
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Noncytotoxic Viruses
• Do not cause cellular destruction
• May cause some local damage on intermittent basis
• Virus may lie dormant (HSV).
• May replace some of the host DNA and become part of
the cell
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Herpes Simplex
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Herpes Simplex Facts
• Member of human herpes virus (HHV)
• HHV—associated with primary herpetic gingivostomatitis,
recurrent oral herpes, and herpes labialis
• HHV—also causes genital herpes
• Recurrent herpes—reactivation of the virus
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Primary Herpetic Gingivostomatitis
• Usually occurs at a young age—initial infection of the
HSV
• Painful vesicles throughout the mouth, perioral tissues,
vermilion borders of the lips
• Vesicles progress to form ulcers.
• Fever, malaise, and lymphadenopathy
• May also be subclinical even if exposed
• In many cases, symptoms persist for 1 to 2 weeks.
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Primary Herpetic Gingivostomatitis (cont.)
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Recurrent or Secondary Herpes Simplex
Infection/Reactivation
• HSV becomes latent and is harbored in the trigeminal
nerve ganglion.
• Most common characteristics of recurrent herpes
− AKA: cold sore or fever blister
− Herpes labialis (occurs on the lip and perioral tissues)
− Pain
− May recur monthly or periodically
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Herpes Labialis
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Recurrent Herpes
• Occurs on keratinized tissue
• Small, painful vesicles
• May occur with varied frequency in individuals
• Prodromal sensations
• Dental treatment should be postponed—virus can be
spread to other areas of the body.
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Herpetic Lesions and Aphthous Lesions
Herpetic
Aphthous Ulcers
• Keratinized tissue
• Nonkeratinized tissue
• Multiple vesicles
• Single lesions
• Usually appear in groups
of small lesions
• Larger lesions with
yellow center and a halo
appearance
• Painful
• May or may not be
painful
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Varicella–Zoster Virus—HHV Type 3
• Chickenpox
• Herpes zoster or
shingles—caused by
reactivation of the virus,
usually occurs in later life
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Herpes–Zoster Infections
• Varicella is the original
infection.
• Herpes zoster is the
reactivation of the virus.
• Result: chickenpox
• Result: shingles
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Chickenpox
• Young children
• Two-week incubation
• Vesicles resolve in several
weeks.
• Pruritus is complaint.
• Trunk lesions
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Herpes Zoster
• Varicella reactivated
• Adults 60+ (vaccine
available)
• Painful vesicles
• May develop postherpetic
neuralgia (PHN)
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Clinical Characteristics of Herpes Zoster
• Small vesicles intraorally and extraorally that crust
• Vesicles stop at the midline of the body.
• Fever, malaise, lymphadenopathy
• Resolves in 2 to 3 weeks
• Oral pain is a complaint as is body pain.
• Rare findings: tooth exfoliation, necrosis of the mandible,
and postherpetic neuralgia (PHN)
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Enterovirus 71 (Coxsackie Enterovirus)
• Hand-foot-and-mouth
disease
• Herpangina
• Acute lymphonodular
pharyngitis
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Hand-Foot-and-Mouth Disease
• Transmitted airborne, oral,
fecal
• Viral shedding
• Usually children under 5
years old
• Rash orally, feet and
hands
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Herpangina
• May contact various
strains of coxsackievirus
• Sore throat, fever,
abdominal pain, and
vomiting
• Oral vesicles
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Acute Lymphonodular Pharyngitis
• Fever, sore throat, headache
• Lasts from several days to several weeks
• Lymphoid tissue is inflamed.
• Oral appearance may vary.
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Paramyxoviridae Virus (Rubeola—
Measles)
• MMR vaccine has caused
decline.
• Koplik spots—small
bluish white spots
• Cutaneous rash
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Toga Virus (German Measles)
• Replicates in the
oropharynx and lymph
nodes
• Spreads through the
bloodstream and crosses
the placenta (1 to 3
months—causes birth
defects)
• Rash, low-grade fever
• Small red, dark red and
pink papules
• Forchheimer signs in
soft palate
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Noninfective Vesiculobullous Diseases
• Pemphigus vulgaris
• Autoimmune
• Males = females
• Four to six decades—
familial
• May affect nose, etc.
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Pemphigus Vulgaris
• Begin with bullae
• Over 1 cm in size
• Quickly rupture
• Painful
• Nikolsky sign present
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Pemphigus Vulgaris Histology
• Tzanck cells
• Acantholysis
• Immunofluorescence is
needed in diagnosis along
with histology diagnosis.
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EBA
• Occurs in adults (has been reported in children)
• May mimic other blistering disease states
• Two forms are presented:
− Inflammatory
− Noninflammatory
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Pemphigoid
• Autoimmune
• May affect the eyes/skin
• Erythematous
• Gingiva is the target.
• Nikolsky sign
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Ocular Mucous Membrane Pemphigoid
• Eyes should be examined
and the patient should be
referred to an eye
professional for
evaluation.
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Differential Diagnosis
• Must rule out other skin
disorders—many appear
similar.
• Contact allergies such as
cinnamon
• Erythema multiforme
• Possibly a new disease
since original diagnosis
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Bullous Pemphigoid
• Autoimmune
• Affects seven to eight
decade of life
• Affects most oral tissues
• Usually affects skin first
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Epidermolysis Bullosa
Mitten-Like Scarring
EB Forms
• Four types
− Simplex (mild form)
− Junctional
− Dystrophic (digital
webbing mitten-like)
− Mixed (Kindler
syndrome)
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Organs Affected by Epidermolysis Bullosa
• Ocular involvement
• Blood due to poor iron absorption
• Skin—nails
• Esophagus
• Intestinal
• Musculoskeletal
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Additional Characteristics of Epidermolysis
Bullosa
Skin and Oral
• The deeper the cleavage,
the more scarring
• Areas affected
− Oral—tissue/teeth
− Knees, skin, hand,
alopecia, milia,
cornea, and nail
areas of contact
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Antiviral Medications
• Most effective in prodromal stage
− Individual experiences tingling, burning, and pruritic
sensations.
− Localized
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Epidermolysis Bullosa Acquisita
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Epidermolysis Bullosa Acquisita (cont.)
• Chronic blistering disease
• Affects the dermal–epidermal junction
• Antibodies to dermal protein in anchoring fibrils
• Subepithelial blisters
• Affects 0.2 million people
• No sex or race predilection
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Epidermolysis Bullosa Acquisita (cont.)
• Correlated with onset of
various systemic diseases
• Use of certain medications
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Dental Hygiene Procedures
• Hand scale—low-power ultrasonics can be used in less
severe cases.
• Low abrasive polish
• No air polishers!!
• Limited contact with the tissues because of stripping of
epithelium—fulcrums should never be placed on tissue.
• Apply medications with a cotton swab—no soft tissue
contact.
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Conclusions
• Always ask good questions!
• Always listen to your patients!
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