DENT 880 Summer 2024 Vesiculobullous & Ulcerative Lesions Handout PDF

VESICULOBULLOUS & ULCERATIVE LESIONS ANUPAMA GRANDHI, BDS, DDS inpalate  7 1...

VESICULOBULLOUS & ULCERATIVE LESIONS ANUPAMA GRANDHI, BDS, DDS inpalate  7 1 cause 01 fads seenm.si w quaking edl pziysidometePor shortperiod.at amanIdpad traumatica are they acute angstanding neverexposed trine ftp.tnophilic chronic Traumatic ulceration canciname i martinis e ieiiEi neoflam i iii we malignan infect HBM Diagnostic Features of Common Oral Ulcerative Lesions: An Updated Decision Tree. International Journal of Dentistry. Volume 2016. Mortazavi, H, et al. Zoglis Kaposissomeone HV Varicella virus Hygiene Hw g VEN three_ EBV Hope zoster  primary5gfÉk v5 cytomegalovirus chickenpo shingles tandfootmffffay.ms common in Calleyfever California Recurrent secadafialix Heupel Oral mucosal ulceration-A clinician’s guide to diagnosis and treatment. Fourie J et al. SADJ. November 2016, Vol 71, no 10, p500-508 mucosaFfmpeg right buccal depressed lesion  4 _singe Traumatic Ulaeemacos futgd avg.AT movabl week.mn chrgigEia for6monthe DIFFERENTIAL DIAGNOSIS FOR NON-HEALING ULCERS able to not find Gypsyoftaume u Traumatic Q u Neoplastic: u Infectious Traumatic e.g., squamous cell carcinoma ulcer u If the ulcer doesn’t heal within 2 weeks after conservative therapy (e.g., removal of the source of trauma) or if there is a high suspicion of malignancy during the initial visit (and no identifiable sources of trauma are present), a biopsy needs to be performed before proceeding with further treatment stomat's b almnase recurrent Aphthous fy.gg labial mucosa ecler in immunocompetent attachedmuege Herpetic HandFalate attached gingiva  are usually vesicles Herpetic ulcers preceded by TRAUMATIC ULCER and Biopsy centre 14 c u Seen secondary to acute and chronic injuries of the oral mucosa. In most cases, there is an adjacent source of irritation said fi u Simple chronic traumatic ulceration u Mostly found on tongue, lips, and buccal mucosa d u Lesions on gingiva, palate, and mucobuccal fold can occur from other irritants u Individual lesions display erythema around a central ulcer with a removable, yellow fibrinopurulent membrane. Often accompanied by a 00 rolled white border of hyperkeratosis near the ulcer u Remove identifiable sources of injury for ulcers u If the cause is unclear or patient doesn’t respond to therapy, consider biopsy oralbenedict chancet painterly syphilis rashaculopapular Lo rasher spit.IE ksat  nt nerosie necrotic Effie 3 June Cell carcinoma TRAUMATIC ULCER mimics sq I S c Iicentre elbow 8k low Fmnd surrounding whirin 10 d NDAC: Well-circumscribed ulceration of the posterior buccal mucosa on the left side. cell Carcinoma dorsalsurface is gap oftongue unlikely Hat most  gtinglikely so TRAUMATIC ULCER NDAC: Mucosal ulceration with a NDAC: Exophytic ulcerated mass on the hyperkeratotic collar located on the ventrolateral tongue associated with ventral surface of the tongue. multiple jagged teeth. fell carcinone sq of I lat bander desaluffled tongue hostled  l TRAUMATIC ULCER RSJ: Chronic traumatic ulcer from repeated RSJ: Chronic traumatic ulcer from sharp biting. teeth.  HVIGHs askffchornic ae HERPES SIMPLEX VIRUS miinFiam www.t u HSV-1: spreads primarily through infected saliva or active perioral lesions; pharynx, intraoral sites, lips, eyes and skin above the waist are most frequently involved; ask forblisters it may cause genital lesions askas popsup u HSV-2: transmitted predominantly through sexual contact; genitalia and skin below the waist are most frequently involved; one of the most common sexually transmitted infections worldwide bearexposed u Primary infection = occurs due to initial exposure of an never individual without antibodies to the virus; usually occurs vigffodice at a young age; often asymptomatic Trentsaskfn persistent blisters  Sanctifier affects asymp PETER T giggs 1 Primary HERPES SIMPLEX VIRUS V1 2 oral herpes Latent Seconday no go we u After primary infection is established, virus is taken up by sensory nerves and transported to associated sensory or Treat it in autonomic ganglia where the virus remains latent (most blish phase common site of latency for HSV-1 is the trigeminal not in ulcerated ganglion) u Secondary/recurrent infection = occurs when virus is phase reactivated and often symptomatic u Factors associated with reactivation include old age, UV light, stress, fatigue, heat, cold, pregnancy, allergy, mulities trauma, dental treatment, respiratory illness, fever, menstruation, systemic disease, malignancy Primaryherpetictrial acute multiple Ulcer tapangaine chidenpox iiii HMF soft plated fi taobao.es 1uin fi teeth letters t inblw  punched how layto oHYgn they hoethiff it aa a IEEE.ae ACUTE HERPETIC GINGIVOSTOMATITIS (PRIMARY HERPES) u Most cases are seen between ages of 6 months and 5 years (peak: 2-3 years) u It is often accompanied by anterior cervical lymphadenopathy, chills, fever u Mucosa u Initially numerous pinhead vesicles are seen that rapidly collapse to form small, red lesions u These enlarge and develop central areas of ulceration u Adjacent ulcers may coalesce to form large, shallow, irregular ulcerations u Seen on movable and attached mucosa 99 u Gingiva is enlarged, painful, and erythematous and often shows punched-out erosions along mid facial free gingival margins Trenchmouth Trepennapallida Newgrangepunched outler spirochete internal papilla youyadddf.si  s P.ILEL.in ACUTE HERPETIC GINGIVOSTOMATITIS (PRIMARY HERPES) u Management u Maintain fluid intake u Antipyretics (no aspirin under 18 years) u 1st three symptomatic days- initiate for small children who have trouble swallowing a capsule u Acyclovir suspension 200mg/5mL u Disp: up to 125 mL (5mg/kg) u Sig: Use 0.25 to 1 teaspoonful (depending on pt’s weight) as a mouth rinse for 2 to 5 minutes and then swallow(5 times/day for 5 days u Tetracaine lollipops- for rapid numbing of affected mucosa u Popsicles or cold icy treats u Mild cases usually resolve in 5-7 days, severe cases may take 2 weeks to resolve ACUTE HERPETIC GINGIVOSTOMATITIS can take tablet (PRIMARY HERPES) Older child if they u Valacyclovir (Valtrex) tablets 1 g u Disp: 5 u Sig: Take two tablets initially, then two at 12 hours, initially and one at 24 hours 2 2 at me u Acyclovir (Zovirax) capsules 800 mg one of 24M u Disp: 7 4 intially u Sig: Take four capsules initially, then two at 12 2 at 12h25 hours and one at 24 hours 1 at 24hr ACUTE HERPETIC GINGIVOSTOMATITIS (PRIMARY HERPES) NDAC: Acute Herpetic Gingivostomatitis. NDAC: Acute Herpetic Gingivostomatitis. Widespread yellowish mucosal Numerous coalescing, irregular, and ulcerations. yellowish ulcerations of the dorsal surface of the tongue.  ACUTE HERPETIC GINGIVOSTOMATITIS (PRIMARY HERPES) NDAC: Acute Herpetic Gingivostomatitis. NDAC: Acute Herpetic Gingivostomatitis. Painful, enlarged, and erythematous palatal Painful, enlarged, and erythematous facial gingiva. gingiva. Note erosions of the free gingival margin. ACUTE HERPETIC GINGIVOSTOMATITIS (PRIMARY HERPES) f.in ciiiii vostomatitx RSJ: A and B, Primary herpes simplex infection. RECURRENT HERPES/SECONDARY they can move sure around which HERPES depending is on involved u Prodromal signs and symptoms: 6-24 hours before lesions develop there is pain, burning, itching, tingling, erythema of the involved epithelium u Most common site is the vermilion border and adjacent skin of lips = this is known as herpes labialis u Oral involvement (Recurrent intraoral herpes): in an immunocompetent patient, oral lesions are limited almost always to keratinized mucosa that is bound to bone (attached gingiva and hard palate) HE.fr Iai 1 heeper u Presents as small vesicles that rupture and form a cluster of erythematous macules with a central ulceration iumi FIificman u Most active viral replication is complete within 48 to 72 hours u Healing takes about 7-10 days Recurrent 12 heepee attached gingiva Ghydate RECURRENT HERPES/SECONDARY HERPES u Herpes labialis u Penciclovir cream – 1% preferred form u Reduces healing time and pain by one day u Greatest efficacy u Best 89 within results if initiated during the prodrome stage days u Acyclovir ointment – 5% u Limited benefits u OTC 10% docosanol cream u Least effective RECURRENT HERPES/SECONDARY HERPES has to be done u Penciclovir (Denavir) cream 1% most effective during prodromol u Disp: 1.5 g tube Phone u Sig: Apply a thin film to the lesion every 4 hours while awake, for 2 days u Acyclovir (Zovirax) cream 5% not effective u Disp: 2 g tube u Sig: Apply a thin film to the lesion every 4 hours while awake, for 2 days Pencidovin  RECURRENT HERPES/SECONDARY HERPES u Recurrent herpes infections (herpes labialis & intraoral secondary herpes) – start at the earliest prodromal symptom u Valacyclovir (Valtrex) tablets 1 g uDisp: 5 the mayor uSig: Take two tablets initially, two at 12 hours, at 21hm then one at 24 hours u Acyclovir (Zovirax) capsules 800 mg uDisp: 7 xyd uSig: Take four initially, then two at 12 hours and one at 24 hours YITY x RECURRENT HERPES/SECONDARY HERPES u For patients, whose recurrences appear to be associated with dental procedures: (may suppress or minimize any associated attack) Force u Valacyclovir – 2 gm twice on the day of the procedure and 1 gm taken twice the next day u Two most used diagnostic procedures are exfoliative cytology (cytologic smear-least invasive and cost effective) and tissue biopsy Dental Care for the Patient with an Oral Herpetic Lesion – AAOM Clinical Practice Statement u Viral infections in and around the oral cavity can serve as a source of contagion u Standard precautions should be implemented that protect the health care provider and patient from the spread of infection u PPE u Avoid manipulation of tissues infected with HSV u Minimize use of aerosolizing agents and devices around HSV lesions (e.g., E handpiece, ultrasonic scalers) u Avoid the use of petrolatum products on active HSV lesions that contain fluids or are emanating fluids (i.e., prior to the scab stage) u AAOM recognizes that delaying care until an HSV lesion is scabbed over or completely healed is prudent for minimizing recurrences and spread of the infection, and that the presence of an infectious HSV lesion orally or periorally can be a reason for deferral of care AAOM Clinical Practice Statement: Subject: Dental Care for the Patient with an Oral Herpetic Lesion,. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology, Volume 121, Issue 6, 2016. Pages 623-625. https://doi.org/10.1016/j.oooo.2016.02.015. HERPES LABIALIS NDAC: Herpes Labialis. NDAC: Herpes Labialis. Multiple fluid-filled vesicles on the lip Multiple sites of recurrent herpetic infection vermilion. secondary to spread of viral fluid over cracked lips. HERPES LABIALIS RSJ: A , Secondary herpes simplex RSJ: Herpes simplex infection. labialis. B , Two weeks later. Hard palate immunocompetent attached gingine it can be  compom Everywhere INTRAORAL RECURRENT HERPES/SECONDARY HERPES NDAC: Intraoral Recurrent Herpetic NDAC: Intraoral Recurrent Herpetic Infection. Infection. Early lesions exhibiting as multiple Multiple coalescing ulcerations on the erythematous macules on the hard palate. hard palate. Lesions appeared a few days after extraction of a tooth. digposterior mediangoing  Qr affair fwd palatea attachedmon INTRAORAL RECURRENT HERPES/SECONDARY HERPES RSJ: Secondary herpes simplex infection of RSJ: Secondary herpes simplex infection of the palate the palate. Hiv positi Exfoliative cytology Haydnp Do  Ion attacks precancerous 2 herpes Bushpiopsy Immunocompetent pt attathdadmfk fnomgfffs.ve 8 Immunocompromisedit it can beseen Everywhere in notablemucosa RECURRENT APHTHOUS STOMATITIS ulcers it theft has multiple Celiacdisease panataliadian u Etiopathogenesis u Cause appears to be “different things in different people” u Initiating causes in certain subgroups of patients aphthous D u Allergies Blockers trigger B alley f u Genetic predisposition of ÉÉÉ ff u Hematologic abnormalities gifff door seat it you État u Hormonal influences u Stress (mental and physical) ulcers AN ulcer send the Pt u Trauma torule to physiciandisease u u Nutritional deficiencies Infectious agents fight out celiac u Immunologic factors the Lesion is on mucosa labial upper unaffed mucosa  Herpes states I rearrant Aption Herpetifor Lafarge minor RECURRENT APHTHOUS STOMATITIS u Systemic Disorders Associated with Recurrent Aphthous Stomatitis u Behcet Syndrome u Celiac Disease BELIS u Cyclic Neutropenia u Nutritional Deficiencies (iron, folate, zinc, B1, B2, B6, B12) u IgA deficiency u Immunocompromised conditions, HIV etc. u Inflammatory bowel disease including Crohn’s and ulcerative colitis and u Systemic lupus erythematosus SE triggers soggy milk  RECURRENT APHTHOUS STOMATITIS u Minor Aphthous Ulcerations heals quickly u Most common (80%) minor u Fewest recurrences u Shortest duration of the three variants u Prodromal symptoms: burning, itching, stinging u Appears as ulceration covered by yellow white removable fibrinopurulent membrane encircled by erythematous halo exacerbated Size D8u 1 to 5 lesions per episode u Size is between 3 to 10 mm pain mum u Heal without scarring in 7-14 days entwined seen u Pain is often out of proportion to ulceration size more u Buccal mucosa and labial mucosa most often involved (nonkeratinized mucosa) death guitar erythematic attachedmeose m attachedggier 1 Hopes Handpalati Haper Aphthous  minor where Ruffians Butmose did RECURRENT APHTHOUS STOMATITIS u Major Aphthous Ulcerations Minor u 10% of patients u Larger than minor, longer duration u Measure 1 to 3 cm in diameter u Range in number from 1 to 10 Nudists u u 2-6 weeks to heal May cause scarring bordained u Any oral surface is affected - Labial mucosa, soft palate, tonsillar matin fauces are most commonly involved FIIIsitive u Onset after puberty 1 3mm in size 100 episode Size inis big test number  long Ks Centre Yellow white border red Be specific with subtype Major RECURRENT APHTHOUS STOMATITIS minor Herpetiform u Herpetiform Aphthous Ulcerations Pinpoint to larger u Weak evidence of viral cause ulcer u Greatest number of lesions u Most frequent recurrences u Small – 1 to 3 mm in size; Individual lesions can coalesce and form larger ulcers u As many as 100 per episode, small lesions (superficially resemble primary HSV) u Heal within 7-10 days u u Can affect any oral mucosa Female predominance u Onset in adulthood F y É É son fgy mugging mucosa II RECURRENT APHTHOUS STOMATITIS u Review medical history for signs and symptoms of any associated systemic disorder u Diffuse minor/herpetiform u Dexamethasone solution (0.5 mg/5 mL) (previously marketed as Decadron) u Disp: 240 mL u Sig: use 5 mL as a mouth rinse, then swallow, each morning for 2–4 days RECURRENT APHTHOUS STOMATITIS u Minor or Major aphthae u Localized minor: u 0.05% augmented betamethasone dipropionate bad gel or 0.05% fluocinonide gel u Major aphthae: u Covered with 0.05% clobetasol (temovate) propionate gel or 0.05% halobetasol propionate ointment u In hard-to-reach areas, you can use beclomethasone dipropionate aerosol spray RECURRENT APHTHOUS STOMATITIS u Minor or Major aphthae u Augmented betamethasone dipropionate gel 0.05% (previously marketed as Diprolene Gel) u Disp: 15 g u Sig: Apply a thin film to the lesion, four to six times daily, as early in the course of the process as possible u Fluocinonide gel 0.05% (previously marketed as Lidex Gel) u Disp: 15 g u Sig: Apply a thin film to the lesion, four to six times daily, as early in the course of the process as possible u Clobetasol (Temovate) gel 0.05% u Disp: 15 g u Sig: Apply a thin film to the lesion, four to six times daily, as early in the course of the process as possible RECURRENT APHTHOUS STOMATITIS u Recalcitrantcases uSystemic and topical corticosteroids uPrednisolone oral suspension, swish and swallow preferred to prednisone tablets as it provides both systemic and topical effects RECURRENT APHTHOUS STOMATITIS-MINOR it looks big NDAC: Minor Aphthous Ulceration. NDAC: Minor Aphthous Ulcerations. Erythematous halo encircling a yellowish Two ulcerations of different sizes located ulceration of the soft palate on the left on the maxillary labial mucosa. side. RECURRENT APHTHOUS STOMATITIS-MINOR NDAC: Minor Aphthous RSJ: Minor aphthous ulcers. Ulceration. Single ulceration of the anterior buccal mucosa. stiffs  cancerous Present Impeticlerian with Brightest positive pi HIV AIDS Buccalmycosal RECURRENT APHTHOUS tongue cytoin STOMATITIS-MINOR Exfoliative RSJ: Minor aphthous ulcer of RSJ: Minor aphthous ulcer of the floor of mouth. the lateral tongue. easier  parallelism upperlabial lesions mosaicist herpetic RECURRENT APHTHOUS STOMATITIS-MAJOR NDAC: Major Aphthous Ulceration. NDAC: Major Aphthous Ulceration. Large, deep, and irregular ulceration of the Large, irregular ulceration of the posterior buccal mucosa. Note extensive soft palate. scarring of the anterior buccal mucosa from previous ulcerations. RECURRENT APHTHOUS STOMATITIS-MAJOR RSJ: Major aphthous ulcer. RECURRENT APHTHOUS STOMATITIS-MAJOR NDAC: Major Aphthous Ulceration. A, Large ulceration of the left anterior buccal mucosa. B, Same lesion after 5 days of therapy with betamethasone syrup used in a swish-and-swallow method. The patient was free of pain by the second day of therapy. The ulceration healed completely during the next week. RECURRENT APHTHOUS STOMATITIS-HERPETIFORM ulcer multiple Herpetiform NDAC: Herpetiform Aphthous Ulcerations. Numerous pinhead ulcerations of the ventral surface of the tongue, several of which have coalesced into larger, more irregular areas of ulceration. EE rteee  Vit B def IFY.tamiic.de RECURRENT APHTHOUS STOMATITIS- HERPETIFORM subyp an 13mm notb main clusters RSJ: Herpetiform aphthous large ulcers. The patient also had RSJ: Herpetiform aphthae of numerous lesions of the lip sun the tongue. and buccal mucosa. sometimes weird  where purple multiple prioritic for 3Hperfstman polygonal you papules from LICHEN PLANUS u Relatively common Bilated month u Chronic, immunologically mediated mucocutaneous Mathare muy Ilitch disorder pemphigoid u Common in middle age pemphigus u Female predilection vulgaris u Cutaneous lesions: present as “purple pruritic polygonal papules” usually on flexor surfaces of extremities 480 u Wickham's striae: fine lacelike network of white lines on both skin and oral lesions for vesicles dFTTwgadprphigia.no peephonferae blisters Musousmembanepemphi.gr blister mad form below the Epithelium Sub ifis'initials  are aware of it wish blister don't last seen Iwww.fddtdfff s tEttn Ig us the within bias forms Epithelium blister is ORAL LICHEN PLANUS roof the in pemphigus very thin Ion resin u Oral lesions = 2 types u Reticular uMore common, usually asymptomatic uPosterior buccal mucosa (bilateral) is the most common location. May involve other surfaces uLesions wax and wane for weeks/months uDorsal tongue may have more keratotic polygonal plaque-like appearance with atrophy of papillae parasitic Purple papules Eiiiid lines lips on  Reticular panettone Tigranes ORAL LICHEN PLANUS shift Retaken u Erosive u Less common but more significant due to symptoms u Clinically present as atrophic erythematous areas with central ulceration u Periphery of atrophic regions is usually bordered by fine white radiating striae u Pain is worse during eating, especially hot/spicy foods and alcohol I u Desquamative gingivitis requires biopsy because it may be clinically similar to mucous membrane pemphigoid and pemphigus vulgaris ORAL LICHEN PLANUS hypothyroidism u Reticular lichen planus lichen planus u Typically, no treatment is needed nauseated u Antifungal treatment if there is superimposed candidiasis u Annual reevaluations of the reticular lesions mucositis may lichenoid Cbe due to amalgam ORAL LICHEN PLANUS u Erosive u Fluocinonide (Lidex), betamethasone or clobetasol gel (Temovate) applied several times/day-induces healing within 1-2 weeks u Monitor for iatrogenic candidiasis associated with corticosteroid use u 3-6-month recall ORAL LICHEN PLANUS u Correlation between oral lichen planus and increased risk of oral cancer is controversial. u A specific benign lichenoid lesion transforms into a malignant lesion 29 u OR wiffiani u Presence of dysplasia at the time of initial diagnosis of oral lichen planus lesion u OR u Risk is unrelated to a specific oral lichen planus lesion ORAL LICHEN PLANUS u Some studies suggest that patients with oral lichenoid lesions and the ulcerative or erosive form of oral lichen planus have a greater AA risk of oral cancer than other forms of oral lichen planus u Many reports have incomplete documentation of clinical or pathologic features u Retrospective studies u Inadequate sample size u Recent systematic review (Journal of the American Dental 0.7 0.194 Association) showed an overall rate of malignancy of 1.09% for oral lichenoid lesions ORAL LICHEN PLANUS u AAOM recommendations u Periodic monitoring of patients with diagnosis of oral lichen planus or oral lichenoid lesions for possible malignant and premalignant lesions and biopsy if needed u Patient counseling about the low but potential increased risk of oral cancer LICHEN PLANUS NDAC: Closer view of a skin lesion of NDAC: The cutaneous lesions on the lichen planus. Careful examination papules. prurities wrist appear as purple, polygonal shows a network of fine white lines (Wickham striae) on the surface of the pruritic papules. polygnappulet purple Wickham striae LICHEN PLANUS NDAC: In persons of color who develop lichen NDAC: The interlacing white lines and planus, it is not unusual to see patchy areas of papules are typical of reticular lichen reactive (benign) melanosis develop in the planus involving the buccal mucosa, the lesions, presumably due to stimulation of the most common site of oral involvement. melanocytes in this area by the inflammatory cells that cause this condition. LICHEN PLANUS NDAC: With involvement of the dorsal tongue by NDAC: Reticular lesions of the lower lip reticular lichen planus, the characteristic vermilion. interlacing striae seen in the buccal mucosal lesions are usually not present. Instead, smooth white plaques are typically observed replacing A the normal papillary surface of the tongue. LICHEN PLANUS NDAC: A, A middle-aged woman with mild reticular lichen planus of the left buccal mucosa. B, Same patient 2 weeks later, showing exacerbation of the lesions. Such waxing and waning is characteristic of lichen planus. LICHEN PLANUS erosie NDAC: Ulceration of the buccal mucosa NDAC: Erosive lichen planus often appears shows peripheral radiating keratotic striae, as a desquamative gingivitis, producing characteristic of oral erosive lichen planus. gingival erythema and tenderness. LICHEN PLANUS epore NDAC: A, The dorsal surface of the tongue shows extensive ulceration caused by erosive lichen planus. Note the fine white streaks at the periphery of the ulcerations. B, Same patient after systemic corticosteroid therapy. Much of the mucosa has reepithelialized, with only focal ulcerations remaining. LICHEN PLANUS RSJ: A through C, Oral lichen planus, reticular form. LICHEN PLANUS RSJ: Oral lichen planus, erosive RSJ: Erosive lichen planus of the form. lip. LICHEN PLANUS RSJ: Oral lichen planus, plaque RSJ: Erythematous lichen planus of form. the gingiva. LICHEN PLANUS RSJ: Cutaneous lichen planus of the ankle. LICHEN PLANUS NDAC: A, This patient was diagnosed with erosive lichen planus affecting the buccal mucosa and was treated with topical corticosteroids. B, Same patient 2 weeks later. The creamy- white plaques of pseudomembranous candidiasis have developed as a result of the corticosteroid therapy. C, Same patient after antifungal therapy. At this point, he was asymptomatic.  MUCOUS MEMBRANE PEMPHIGOID § Etiopathogenesis changes § Group of chronic, blistering, Eye mucocutaneous autoimmune diseases multiple charges in which tissue-bound autoantibodies are directed against one or more components of the basement membrane blister  desquammative dingetm.PEefhe gingivitis Erosive lichplane DID I Mmp Pemphigusvulgaris MUCOUS MEMBRANE PEMPHIGOID u Average age: 50-60 years u Females are more frequently affected than males (2:1) u Oral lesions are seen in most patients Encoded red u Begin as vesicles or bullae which rupture leaving large, painful superficial, ulcerated areas. Vesicles or bullae may be identified clinically in contrast with pemphigus due to their thick, strong roof (although they last longer than pemphigus, they still rupture) u The ulcerated lesions persist for weeks to months if untreated gingiva will u They usually don’t scar be affected u Positive Nikolsky sign Mmp go_ u Gingival involvement produces a pattern termed desquamative gingivitis IPM  rupturing 9 mp MUCOUS MEMBRANE PEMPHIGOID u Other sites may be involved – conjunctival, nasal, esophageal, laryngeal, and vaginal mucosa; skin u Ocular lesions u Up to 25% of patients with oral lesions may eventually develop ocular disease u Earliest change is subconjunctival fibrosis u u I As it progresses, leads to scarring and formation of adhesions called symblepharon May eventually lead to blindness due to scarring and adhesions ymmn subonjunctival fibrosis Talented progrement String formats i inoffffit  Take airwater syringe direct tentrop the air directly on the gingival mucosa peels off seperath front 9 blow aircan skin be seen below the Epithelium that lichen planus typicallysee with myff.it MUCOUS MEMBRANE PEMPHIGOID u Topical steroid: clobetasol gel/augmented betamethasone dipropionate gel/fluocinonide gel/dexamethasone elixir u Gingival lesions: a flexible mouth guard may be used as a carrier for corticosteroids u Gingival lesions benefit from good oral hygiene u Systemic agents (if topical agents are unsuccessful)- dapsone; IV IgG; tetracycline or minocycline and niacinamide (nicotinamide) u All patients should be referred to an ophthalmologist for baseline exam of the conjunctiva MUCOUS MEMBRANE PEMPHIGOID NDAC: One or more intraoral vesicles, as seen NDAC: Although cutaneous lesions are not on the soft palate, may be detected in patients common, tense bullae such as these may with cicatricial pemphigoid. Usually, ulcerations develop on the skin of 20% of affected of the oral mucosa are also present. Étricial patients. MUCOUS MEMBRANE PEMPHIGOID NDAC: Often the gingival tissues are the NDAC: Large, irregular oral ulcerations only affected site, resulting in a clinical characterize the lesions after the initial pattern known as desquamative gingivitis. bullae rupture. Such a pattern may also be seen with lichen planus and pemphigus vulgaris. desquamate Defamationgingivitis MMP  lichenP MUCOUS MEMBRANE PEMPHIGOID RSJ: A, Mucous membrane pemphigoid of the gingiva. B, After control with corticosteroids, mandibular gingiva remains red and friable. Easily crumbled MUCOUS MEMBRANE PEMPHIGOID RSJ: Mucous membrane pemphigoid. MUCOUS MEMBRANE PEMPHIGOID RSJ: Ocular pemphigoid. RSJ: Ocular pemphigoid; symblepharon resulting from chronicity. i MUCOUS MEMBRANE PEMPHIGOID Bulbar palpebral conjunctiva NDAC: Although the earliest ocular NDAC: The disease has caused the changes are difficult to identify, patients upper eyelid of this patient to turn with ocular involvement may show inward (entropion), resulting in the adhesions (symblepharons) between the eyelashes rubbing against the eye itself bulbar and palpebral conjunctivae before (trichiasis). Also note the obliteration of severe ocular damage occurs. the lower fornix of the eye. Entropion trichiasis MUCOUS MEMBRANE PEMPHIGOID NDAC: A patient with ocular NDAC: In this patient, the ocular involvement shows severe conjunctival involvement has resulted in nearly inflammation. An ophthalmologist complete scarring between the removed the lower eyelashes because conjunctival mucosa and the eyelids of trichiasis associated with entropion. themselves, producing blindness. REFERENCES 1. Mucous Membrane Pemphigoid. Hong-Hui Xu, MD, PhD, Victoria P. Werth, MD, Ernesta Parisi, DMD, Thomas P. Sollecito, DMD, FDS RCSE. Dent Clin N Am 57 (2013) 611–630. 2. Clinical manifestations and treatment considerations of herpes simplex virus infection. J Infect Dis. 2002 Oct 15;186 Suppl 1: S71 3. AAOM Clinical Practice Statement: Vol. 122 No. 4 October 2016 4. Fitzpatrick SG, Hirsh SA, Gordon SC. The malignant transformation of oral lichen planus and oral lichenoid lesion: a systematic review. JADA. 2014;145:45-56. 5. Human herpes simplex virus infections: Epidemiology, pathogenesis, symptomatology, diagnosis, and management. Mahnaz Fatahzadeh, DMD, and Robert A. Schwartz, MD, MPH. J Am Acad Dermatol. November 2007 6. Recurrent Aphthous Stomatitis. Sunday O. Akintoye, BDS, DDS, MS, Martin S. Greenberg, DDS, FDSRCS. Dent Clin N Am 58 (2014) 281–297. 7. Fitzpatrick, S.G., Cohen, D.M. & Clark, A.N. Ulcerated Lesions of the Oral Mucosa: Clinical and Histologic Review. 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