Vesicular, Bullous and Erosive Lesions l Oral medicine MCQs for dental students

Vesicular, Bullous and Erosive Lesions  l Oral medicine MCQ (multiple choice question) for dental students 

 Oral ulcers

Reactive ulcers :

• in infants are called Riga Fede Disease
• Ulcers with very well defined borders → indicate a specific disease
• Ulcers with irregular border → trauma
• Usual sites for trauma = buccal mucosa , lateral border of the tongue
• The most important thing in traumatic ulcers = establishing a cause and effect relationship

 

Chronic ulcers :

•  indurated + pain is disproportionate compared to the appearance of the lesion
• Three examples:

1. Factitious ulcers [ self inflicted ulcers] – appear in accessible areas , have abnormal appearance and mostly linked to psycological disturbances
2. Traumatic Eosinophilic Ulcer : significant eosinophilic presence
3. Necrotizing Sialometaplasia

 

Necrotizing sialometaplasia:

• Cause: vasoconstriction induced by LA → ischemia and necrosis [ iatrogenic cause]
• M/S= Squamous metaplasia of ductal epithelium + Pseudo-epitheliomatous hyperplasia + necrosis of salivary glands
• Treatment: Reassurance, mouthwash and observation of healing
• The complication that is most limiting to the continuation of chemotherapy is mucositis

 N.B :

• Viral diseases will cause Vesicles / bullae that rupture to form an ulcer but bacterial or fungal infections cause ulcers right away!

BACTERIAL INFECTIONS CAUSING ULCERS

Syphilis

• Caused by treponema pallidum
• Route = sexually, by blood transfusion or trans-placental
• Three stages; deep ulcers are seen in the primary stage (chancre)
• You can see oral manifestations of shyphilis in all 3 stages :

1.           Primary stage [ chancre – deep indurated painless ulcers]
2.           Secondary stage [ condyloma latum ]
3.           Tertiary  stage [ gumma]

•  Dx: Darkfield examination of exudate + Silver stain
• Treatment : penicillin

Gonorrhea

• caused by nissesira gonorrhea - route : sexual contact – Tx: penicillin

Tuberculosis

• Caused by acid-fast aerobic bacillus Mycobacterium [ has fungal and bacterial features]
• Route = airborne
• Bacteria are not degraded by macrophages because of their thick waxy coat → macrophages aggregate to form multinucleated giant cells and granulomas result
• [ the granuloma forms because the body cannot digest the TB]
• Oral TB infections [ chronic , indurated , non healing ulcers] are secondary to lung infections through seeding by sputum [ the infection is in the lungs but when the pt coughs the infected sputum will go to the mouth causing the oral ulcers]
• In TB the bacteria is not harmful [ because it is contained in the granuloma ]
• MS=

1. Granulomatous inflammation with caseous necrosis [ a granuloma is a tissue that forms to prevents the further spread of bacteria , it is not a place where cells live it is where cells die]
2. Langhans multinucleated giant cells
3. Presence of acid-fast bacilli (detected by ZiehlNeelsen stain or Fite stain)

• Treamtent: Strong antibiotics and chemotherapeutic agents

FUNGAL INFECTIONS CAUSING ULCERS

Deep fungal infections

• Fungi inhaled → pulmonary disease → oral ulcers (seeding by infected sputum) - chronic , indurated , non healing ulcers
• Deep fungal infections :
• Histoplasmosis – Coccidioidomycosis- Blastomycosis – Cryptococcosis
• MS=

1.     Pseudo-epitheliomatous hyperplasia
2.     Granulomatous inflammation
3.     Sometimes with abscess (blastomycosis)

• Treatment: amphotericin B or Azoles [ antifungals]

 

Oppurtonistic fungal infections

• phycomycosis (mucormycosis) and Aspergillosis
• route = GIT or pulmonary
• Affects medically-compromised patients
• Cause necrosis and ulceration of the tissues and can perforate palate, nasal cavity and orbit, and extends to the brain → Death
• Treatment: amphotericin B + surgical debridement

 

IMMUNE MEDIATED ULCERS

Recurrnet aphthous ulcers [RAS] / canker sores :

• seen in higher socio-economic class, and in more developed countries

• causes:

1. Genetic
2. Haematological deficiency [ Iron (Fe-deficiency anaemia) , B12 (pernicious anaemia) , Folic acid (folic acid anaemia) ]
3. Cyclic neutropenia
4. GIT disorders [Coeliac disease , Crohn’s disease , Ulcerative colitis, H. pylori ]
5. Hormonal changes [Relation to drop in progesterone ]
6. Food allergies
7. Stress

 

Other disorders with similar RAS presentation :

• Behçet disease (oral, genital ulcers, eye lesions and skin papulopustular lesions)
• HIV-related ulcers
• PFAPA (Periodic Fever, Aphthus, Pharyngitis, Adenitis)
• Sweet syndrome (oral ulcers, conjunctivitis and inflamed skin nodules)

 

NOTE:

•    Per-ulcerative RAS lesions have CD4+ cells - Ulcerative lesions have CD8+ cells (cytotoxic)

 

RAS is diagnosed when other diseases with oral ulcers are excluded

• Recurrent aphthous ulcers [ Floor is white (CT) then turns yellow (Fibrin) then turns grey (granulation tissue) ] + Surrounded by an erythematous halo ]

minor

1.       Small round to oval ulcers
2.       Seen mainly on non-keratinized mucosae
3.       Heals in about 1 week without a scar
4.       Painful

Major

1.     Large round to oval ulcers (around 1cm in diameter)
2.     Seen on any mucosal surface
3.     Heals in about 10-40 days - Might leave a scar
4.     Can be painful

 

Herpetiform

1.     Multiple minute pinhead ulcers which coalesce into large ragged ulcers
2.     Seen on any mucosal surface
3.     Heals in at least 10 days
4.     Recurs very frequently, almost continuous oral ulceration
5.     extremely painful

 

Treatment:

1. R/o systemic cause
2. Encourage high standards of oral hygiene [ pain is caused by the secondary bacterial infection on the ulcers , by maintaining oral hygiene you reduce the pain and accelerate the healing]
3. Topical corticosteroids / Intra-lesion injection of corticosteroids
4. Immune suppressants 

Behçet’s syndrome

• seen in countries around the Silk Road (Middle East to Japan).
• Mostly males - oral, genital ulcers, eye lesions and skin papulopustular lesions
• Cause = vasculitis related to immunecomplexes affecting the involved tissues
• Strong link with and HLA-B51 [ used for screening]
• Ulcers are similar to minor RAS but they are larger , located in posterior mouth, and show more ragged edges.
• Dx of behcet’s syndrome:

1.    RAS, plus two of the following
2.    Recurrent genital ulceration
3.    Eye lesions (posterior uveitis)
4.    Skin lesions (erythema nodosum, acneiform nodules)

Positive pathergy test :

•     pricking the skin with a sterile needle and look for erythema or papule formation .

N.B : 

• Bechet’s disease  is a leading cause of blindness in young males, and might result in death from CNS or CVS complications.

 

Erythema multiforme:

• Allergic reaction [ acute, or even explosive onset] affects the mouth and the skin
• Ranges in clinical symptoms → that’s why it’s called multiforme

Three types:

• Minor EM, Major EM (SJS) and Toxic Epidermal Necrolysis (TEN).
• Affects anterior mouth – non keratinized tissue
• Lips are cracked, crusted and edematous + blisters and ulcers + skin has target lesions [ iris lesions]

1. Minor form → affects one site, and is less severe (self-limited).
2. Major form [ steven jhonson’s syndrome] → oral mucosa (severe pain, lip crusting) + Preceded by a prodromal flu-like symptoms + Involvement of [pharynx, eyes , genitals , Symmetrical involvement of skin]

Cause:

• Abnormal reaction to microorganisms or drugs [ most cases] leading to immune complexes depositing in the superficial Blood vessels of skin and mucosa [ vasculitis] → necrosis

Treatment:

• Supportive therapy + referral to ophthalmology and dermatology
• If viral induced → give acyclovir
• If drug induced → give corticosteroids [ don’t give corticosteroids if it is cause dby infection]
• Plasmapheresis

 

Q: plasma cell infiltrate ins seen in ?

• contact allergy

Q: valsculitis is seen in ?

• behcet’s syndrome and erythema multiforme

Q: stevenes jhonson’s syndrome is ?

• major EM

Q: target lesions are seen in ?

• Erythema multiform 

Orofacial granulomatous diseases

• Mainly seen involving the upper lip, then lower lip, then cheeks.
• Should R/O:

1. Crohn’s disease
2. Sarcoidosis [ mostly affects lymphoid tissue]
3. Foreign body reaction