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Ulcers|Definition|
Ulcers:Isthecompletelossofepithelium.
Erosion:isasuperficialdamageleadingtopartiallossofepithelium.
|Classification|
Accordingtoitspreceding,either:Primary
Ulcers
Secondary
Ulcers
Isntprecededbyavesiculobullous
lesion
Isprecededbyavesiculobullouslesion.Thesevesiclesmaybesubepithelialorintraepithelial(Acanth
Non acantholytic)
Traumatic
Infective
Neoplastic
SystemicGITorblooddisorders
Aphthous
Behcetssyndrome
ReitersSyndrome
Subepithelial Intraepithelial
BullousPemphigoid
MucousMembranePemphigoid
ErythemaMultiforme
BullousLichenPlanus
EpidermolysisBullosa
DrugEruption
Acantholytic Acantholytic
=Deathandruptureofgroups
ofepithelialcells.
=Destructionofintercel
attachments.
HerpesSimplex
HerpesZoster
Herpangina
Hand,footandmouthdisease
PemphiguVulgaris
DariersDisease
Accordingtoetiology:1. Physicalandchemical2. Microbial Bacterial NecrotizingulcerativeGingivitis,TB,Syphilis
Fungal HistoplasmosismBlastomycosis
Viral HerpesSimplex,HerpesZoster,Herpangina,Hand,footandmouthdisease
3. Neoplasm SquamousCellcarcinoma4. Immunologicalreactions Aphthousulcers,Behcetssyndrome,PemphigusVulgaris,MucousMembranePemphigoid,Lupu
Erythematosus,LichenPlanus,EpidermolysisBullosa,DrugEruption
5. Blooddisorders Aneamea,Leukemia,Neutropenia6. GastrointestinalDisease CoeliacDisease,UlcerativeColitis,CrohnsDiseases7. Drugs CytotoxisDrugs
erpes Viruses|Facts|
Effectsmostanimalsandhumans. AllHerpesareidenticalmorphologically. TheyareDNAvirus.(VIP) Abilitytoremainlatentinaviableformwithinthehostcellaftertheprimaryinfection,theymaybelatentandpersistforalo
time,andsomemaybecomeactive(reactive)toinfectagainproducingarecurrentformofinfection.
Thereareeighttypes:HerpesSimplexvirus1 (HSV1) Varicella ZosterVirus Epstenin BarVirus (EBV) HumanHerpesVirus6
HerpesSimplexvirus2 (HSV2) Cytomegalovirus HumanHerpesVirus7 HumanHerpesVirus8
|SummeryDiagram|
Herpes HSVVarcellaZosterVirusHSV1
HSV2
AnInfectioninnewborn,showsasage
infectionand/ordermatitisbelowthew
PrimaryHer
Gingivostom
RecurrentLesions
RecurrentintraoralLesionsRecurrentHerpesLabialis
HerpeticWithlow
Primary
Reactivity
ChickenPox
HerpesZoster
RamsyhuntSyndrome
Ifthe
effected
nerve
is
Facial
Nerve
(7th)
(Bells
Palsy)
Onthe
fingers
of
doctors
whose
fingers
are
injured
&
exposed
to
HSV
HerpesSineHerpes
Noclinical
Manifestations
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Herpes Simplex Infection
|Types|
HerpesSimplexVirus2
HerpesSimplexVirus1 HerpesSimplexVirus2
OralInfections:
Primary: PrimaryHerpeticGingivostomatitis.
Recurrent: RecurrentintraoralHerpes. RecurrentHerpesLabialis.
ExtraoralInfections:
Dermatitisabovewaist. PharyngealInfection. Meningoencephalitis
ExtraoralInfections:
Dermatitisabovewaist. GenitalInfections. Infectioninnewborn.
|Fact|
Incaseofnewborns,theinfectionsareduetothecontactoftheinfantduringdeliverywithavaginallesionofthemother.Minfantsareasymptomaticbutinsomeminoritymayshowmanifestationbythe4
thto7
thday(Jaundice,Hepatosplenomegaly
Thrombocytopeniaandlargevesicularlesionsontheskin)andwithahighmortalityratebythe9th
tothe12th
duetoviremia.
InCaseofAdults,PrimaryinfectionasGenitallesionsisrarebutmaystarttoincreaseaftertheageof14,duetoincreasesexactivity.
HerpesSimplexVirus1
PrimaryHerpetic
Infection
Recurrent
Lesion
HerpeticGingivostomatitis HerpesLabialis,IntraOralHerpes
OccursduetoPrimaryInfection OccursduetoActivationoflatentVirus
NopriorImmunity(ABraisebyconvalescenc) HighAntibodyTitre
LocalandsystemicManifestations LocalmanifestationswithNosystemicManifestations
|Primary(Acute)HerpeticGingivostomatitis|
|Facts|
Commoninchildren(110yearsold)andhighestpeakat23years. Uncommoninadultsandinfantsyoungerthan6months,why?BecausetheinfantacquirestheIgG(maternalAB)thatpassth
placentafromthemotherandlifespanoftheantibodyis6months.
AntibodyTitre:Beginningofthedisease 1weeklater 3weekslater Throughoutlife
NoraiseofABtitre Beginstoraisebyconvalescence (4folds)reachmaximumpeak Remainshigh
Incaseofchildren,9599%ofcasesrunSubclinicalandmaybemisdiagnosedasTeething;while15%ofcasesexhibittheclinicalcourseofthedisease.
Incaseofadults,themanifestationsarenttypical:shorterduration,feweroralulcersandlesspronouncedsystemicmanifestations.
|Pathogenesis|
Intraepithelialvesiclesduetodestructionofthepricklecelllayer. PresenceofMultinucleatedGiantcellsintheepithelialcellsliningthevesicleduetofusionoftheinfectedcellswithnormalc
ordivision
of
the
infected
cells
nucleus
without
the
division
of
the
cytoplasm.
PresenceofnuclearInclusionbodiesintheinfectedepithelialcells(LipschutzBodies). TheNucleusappearshomogenouswithmigrationofchromatin(Ballooningdegeneration)|Duration|
SelfLimitinganddiseasecourseis1014days Diseasecourseislessinadults. DiseaseCourseismoreinimmunosuppressedpatients. Diseasecourseismoreseverein:o Prematureandnewbornsinfants.o Malnourishedandimmunecompromisedpatients(immunesuppressivedrugsormalignancyorsevereburns).
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|Clinicalfeatures|
Prodrome:o Precedesthelesionsby12daysandsubsideswithin3days.o Fever,headache,malaise,nausea,vomitingandrefusaloffeeding.o Lymphadenopathy(Tenderandpalpable):submandibularandupperdeepcervicallymphnodes.
AcuteMarginalGingivitis:o 1 2daysafterprodromeo Acuteinflammation ofthegingivawithbleedingandedemaandpersistduringthewholecourseofthedisease.o Theorallesionappearsasulcerationanderosionofthegingiva(duetotheruptureofthevesicles)BUTthereisnolosingo
marginalgingivaorInterdentalpapillae.DIFFRENTAILDIAGNOSISFROMACUTENECROTIZINGULCERS.
Vesiculareruptions:o Oncethefeversubsides,vesiclesstarttoeruptintheoralcavityandcircumoraltissue(vermillionboardofthelip)and
circumoralskin.
o Thesevesiclesappearonthebothkeratinizedandnonkeratinizedmucosa.o Thesevesiclesmaycoalescetoformabullaewithirregularoutline,thisisdueto: Humidity,mechanicalirritationandhightemperature.
VesicularRuptureandulcerformation:o Thesevesiclemayrupturegiving Ashallowerosionorulcer. Smallandround Surroundedbyaninflammation. Coveredbygrayishmembrane.
o Thisulcermaycoalescetoformalargerulcer.o ThesesUlcersarepainfulExcessiveSalivation(Painreflex)SalivaisfilledwithVirusesthesalivaisinfective
infectingthelipsorhandsandmayevenspreadtotheeye(Conjunctivitis)andgenitals(Vulvovaginitis).
|Diagnosis|
History:o Prodromeprecedingorallesions.o Historyofcontactoflesioneitherprimaryorrecurrentwithotherinfectedpeople.o Nohistoryofrecurrentlesionwithinthesameperson.
ClinicalExamination:o Gingivalinflammation.o Lymphadenopathy.o Ulcerformationaftervesiculareruption.
SpecialInvestigations:Onlypreformedwhenthepatienthasnoobviousclinicalmanifestations.
o CytologicalSmearfromunrupturedvesiclesnucleuswithGeimsaStainGiantcellsandInclusionbodies.o IsolationofHSVintissuecultures(e.g.RabbitsKidney).o Totalleukocyticcount(eithernormalorelevated)o AntibodyTitre:
Onsetofdisease Oneweeklater 3weekslater
NoAntibodies Beginstoraise Maximumpeak
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|Treatment|mainlySupportiveandsymptomatictreatment,why?Becauseitsaselflimitingdisease.
BedRest. Supportivetherapy(liquiddietwithpropercaloriesandhighnutritionalvaluetoraisethebodyresistence. Painreliefbyanalgesicsandtopicalanesthetics. Antipyretic.(Paracetamol) Orabasetoprotecttheulcerduringhealing(Sodiumcarboxymethylcellulose) Antibiotics,why?UseBroadspectrumtoprevent2ndbacterialinfections. Antiviraldrugs,onlyusedwhen:o Inseverecases.o Inimmunecompromisedpatients.o Ifthediseaseisdisseminated.
Drug Rifampicin Acyclovir
Action Antibacterial(Systemic)+Antiviral(Topical) Antiviral(InhibitionofDNAreplicationininfectedcells)
Dose 10mg/kgthreetimesaday(t.d.s.) Lessthan12yearsMorathan12years
ImmunecompromisedPatients
100mg/5timesdaily/forfivedays
200mg/5timesdaily/forfivedays
400mg/5timesdaily/tillhealing
How InAdultsUsedasamouthwash
InInfantsandchildrenAdropperisused(the
childsheadshouldbelowerthanthebodytoallow
thedrugtobeswallowed)
Mouthwashanddropper=topicalantiviral. Swallowing=Systemicantibacterial.
Shouldbeusedinearlystagesofthediseasetoinhibitthevirareplicationduringprodrome.
Ifusedlate,itwillhavelessvalueandeffect;itmayevenelicitresistanceinHSVwithoutanyclinicalvalue.
Itisinactiveinuninfectedcellsnontoxictonormalcells.
HerpeticWhitlow
|Info|
Aninfectiononthefingersofdoctors,dentistsandnurseswithHSV. AfingerinjuryisneededforthediseasetooccurandwithanexposuretooralorpharyngealHerpesinfection. RubberdamandGlovesareessentialasprotectivemeasures.|ClinicalFeatures|
LocalFeatures:Itchingandpainofinfectedfinger. Systemicfeatures:maymanifestifthepatientisseronegative(meansthataspecificABisntpresentandinourca
themissingABisagainstHerpes).
Deepvesiclesmycoaleseinthedistalsegmentofthefinger. SelfLimiting. Incisionofthevesiclemaycomplicateittoamoreseriousproblemincluding2ndbacterialinfectionorencephaliti Healswithin1820days.
|RecurrentHerpeticLesions|
|Info|
AfterPrimaryinfection,theVirustravelsfromtheoralsiteofinfectionviathePeriaxonsheathofthesensorynerto
the
trigeminal
ganglion
and
other
cranial
and
cervical
ganglia.
Thevirusremainslatentintheganglioninapotentiallyviablestatetillreactivatesbylocalorsystemicpredisposinfactors(Trauma,sunexposure,commoncold,fever,allergy,stress,menstruation,GITdisturbanceandimmunosuppression).
Theviruscanbeisolatedinthetrigeminalgangliaofbothpeoplewhosufferreactivationandthosewhodoesnt. Incaseofgenitalherpes,type2becomeslatentinthesacralganglia. Reactivationsofinfectiondosenotstimulateariseintitreofherpesantibody. LesionsareeitherRecurrentHerpesLabialis(ColdSore)orRecurrentintraOralHerpes.
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|RecurrentHerpesLabialis|
|Info|
Vesiclesatthemucocutaneousjunctionofthevermillionboarderofthelip. Thevirustravelsfromthetrigeminalgangliondownthemaxillaryormandibularbranchestoreachtheareasofsk
suppliedbythesenerves.
|ClinicalFeatures|
Prodrome:burningortinglingsensationandsorenessatthesiteofthedevelopingofthevesicle. Localedema,erythemaandvesicleformation:o vesiclesaresmallinsize(1mm)o Surroundedbyerythema.o Occursasclusterandmycoalescesformingalargerlesions(12cm).
Vesiclesmayrupture:o Ulcerateandcoveredbyacrustofpurulentexudatesdueto2ndinection.
Recurrence:o Mayoccurmonthly,every2months,everyyear,onceinalifetimeortwiceinthelifetime.
|Pathogenesis|
Identicaltoprimaryform.
|Duration|
o Selflimitingin714dayso Healswithoutscarformation.
|Treatment|
Sunexposureprevention:o Sunblocker(Zincoxide).o Sunscreenlotionorcream(ParaminobenzoicAcid).
Ifsunlightexposureisapredisposingfa
o AvoidSunExposure. Antiviral:o Acyclovirointment5timesdaily/forfivedays.o Treatmentbeginswithin24hoursafterlesionsonset.o Ifapplicationofointmentislate,thelesionwillrespondpoorly.
InimmunecompromisedPatients:o CuringDose: Acyclovir 400mg/5timesdaily/tillhealing.o ProphylacticDose: Acyclovir200mg/34timesdailyortopicalointment.
|RecurrentIntraoralHerpes|
|Info|
ThevesiclesappearonthekeratinizedMucosa(tongue,Palateandgingiva). Thevesiclesare1mminsizeandsurroundedbyerythema.TheyMayoccurinclusters. Vesiclesmaruptureformingmultipleulcers.TheseulcersarepinheadsizedandsurroundedbyErythema. Theseulcerstendtocouleesforminglargerulcerswhichare:o irregular,superficial,surrounded erythemaandareverypainful.
Healswithoutscarformation Healswithin714days.|Pathogenesis|
Identicaltoprimaryform.
|Treatment|
2%tetracyclinemouthwash RifamipicinElixirmouthbath.
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Varicella Zoster Virus Infection
|Info|
Varicella=Primaryinfection=Chickenpox Zoster=Reactivationof=Shingles.
Itneveroccursasaprimaryinfection
Thesameviruscausestwodifferentdiseases. InthePrimaryInfection(chickenPox)thevirusmigratesfromtheepidermisviathePeriaxonsheathofthesensor
nervesandremainslatentwithineither:
o Dorsalrootganglionofspinalcord.o ExtramedullaryGanglionofcranialnerves.
Oncetheyarereactivatedbypredisposingfactors(e.g.radiation,malignancyetc) ThelatentvirusistriggeredandspreadsfromtheGangliontothenervetrunktoinfectaspecificdermatom
resultinginherpeszoster.
|ChickenPox(Varicella)|
ACommonchildhoodfever(mildandfebrileillness)duetoprimaryinfectionwithVaricellaZostervirus.|Transmission|
Itinvadestheupperrespiratorytrackby:o ViaContaminatedDropletsintheair.o Viadirectcontactwithfreshskinlesionsofinfectedpersoneitherchickenpoxorshingles.
|IncubationPeriod|
About2weeks(1021days)duringwhichthevirusproliferateswithinthemacrophages. ThentheVirusspreadsanddisseminatesthroughblood(Viremia). ThenSpreadstotheskin,mucusmembraneandotherorgans.|Age|
Atanyagebutthepeakincidenceisat510years. Thediseaseismoresevereinolderchildrenanddebilitate(Weak)adults,whilemildinyoungerchildren. Mostcommoninspringandwinter.|ClinicalFeatures|
Prodrome:Mildfever,Headacheandmalaise. InGeneral:o Vesicularrashinsuccessivewavesfor36days,why?Duetorepeatedwavesofviremia.o Becauseofthesuccessivewavesthepatientwillhavemixedskinlesionsatthesametime(Papules,vesicles,
Pustulesorcrust).
o Feversubsidesandnewlesionswillstopdeveloping. ExtraoralLesions:o Appearsasaskinrash(Cropsofredpapulesonthetrunkspreadstotheface,Scalpandextremities).o ThesepapulesdevelopwithinhoursintovesicleswhichappearclearlikeTeardrops.o TheseVesiclescontentsbecomeCloudydevelopintopustules.o ThesePustulesrupturebecomescabbedandcrusted.
Healing:o Healswithnoscarformationunless2ndinfection.
Intraorallesions:o Appearsasmultiplevesicles,shallow,notpainfululcers.o Nosymptomatic,diagnosticortreatmentproblems.
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|Treatment|
Healthychildren:noneedfortreatment,why?Becauseitsselflimitingdisease. Immunocompromised:o Acyclovir: Lessthan12yearsold: 5 mg/kg every8hours for7days Morethan12yearsold: 10mg/kg every8hours for7days
=Varicellaorzosterrespondswelltoacyclovirbutcomparedtoherpessimplexlesseffective.
=But
because
the
Drug
has
low
toxicity
the
dosage
can
be
increased
to
get
the
needed
effect.
o Prophylaxis: PassiveimmunizationbyZIG(VaricellaZosterImmunoglobulin)preparedfrompooledplasmawithhightitre
VaricellaZosterAntibody.
UsefulforprophylaxisandreducingtheseverityofthediseaseinvulnerablecontactsofchickenpoxorlessoftHerpesZoster.
o Vaccine: UsedincaseofchildrenwithLeukemiaorsolidtumorsasitprovidesgoodprotection. ItsdonebytheuseofanAliveAttenuatedVirusVaccine.
|HeroesZoster(Shingles)|
|Etiology|
Reactivationoflatentvaricellazostervirusisbymanypredisposingfactors,whichincludes: Trauma,Radiation,Surgery,Malignancy(Lymphoma,leukemiaortumorinthedorsalrootganglion),Immune
suppression.
Reactivationofthelatentvirus(whichwasprimarychickenpox)resultsininfectionoftheposteriorrootganglionspinalcordorextramedullaryganglionofthecranialnervethenspreadsdownthenervefibersoftheskinofthe
dermatomeleadingtovesiculareruption,unilateral,segmental,alongtheCutaneousdistributionofthenerve
|EffectedNerves|
C3,T5,L1,L2andOphtahlmtic(1stdivisionofthetrigeminalnerves)
Lesscommonthefacialnerve(withersensoryornerve)
|ClinicalFeatures|
Age:adultsandoldage.o Rareinchildrenexcept: Childhadchickenpoxinthefirstfewmonthsoflife. MotherhadchickenpoxduringearlypregnancytheinfantwillsufferfromCongenitalVaricellaSyndrome.
Limbdeformity,ocularlesion,Extensivescarring,Muscularatrophy,cerebralandpsychomotorretardation Course:3 4weeks. Prodrome:o 25days.o Fever,malaise,tendernessintheinvolvednerve.o Unilateralitchingandneuralgicpain(burningorstabbing/Constant,intermittentorradiating).
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SkinLesion:o Unilateralandlinerpapulesorvesiclesalongthedermatomicdistribution(skinandmucosamembrane)supplie
bytheaffectednerve.
o Thepapulesorvesiclesaresurroundedbyerythema.o TheycontainClearfluid.o Afterafewdaystheclearfluidbecomespurulent.o Oneweeklaterthevesiclesruptureformingacrust.o TheSkinlesionsaremixed(similartochickenpox)papules,veiclles,pustulesandcrustarepresenttogether,wh
becauseit
occurs
in
successive
waves.
Healing:o 34weeks.o Scarformation,why?Dueto2ndinfection. Scarsarepainlessandsometimesverypainfultotouch(Hyperalgesia). Scarsarediagnositicforpostherpeticneuralgia.
Oralmanifestations: Mayinvolveoneofmorebranchesoftrigeminalnerve. Vesiclesulcersscarring(Painfulandsurroundedbyerythema). MaybebilaterallesionsinViremia. Confluentandnecroticorallesionsinimmunesuppressedpatients.
1. Involvementofmandibulardivision. Unilaterallesions. Involvingcheek,tongue,vestibuleoflowerjawandCutaneouslesionsextendingfromthechintothevert
2. InvolvementofMaxillarydivision. Unilaterallesion. Involvinghardpalate,softpalate,vestibuleofupperjaw,skinofcheekandsidesofthenose.
3. InvolvementofOpthalmicdivision. Unilaterallesion. Involvingcornea,foreheadandeyelid Mostcommon(1520timesmorethanthemandibulardivision).
|Pathogenesis|
Identicaltoherpessimplexviralinfection.|Diagnosis|
Casehistory(Fever,Prodromeetc). Clinicalexamination(vesiclesandulcers=Unilateral,alongnervecourse,painful). Specialinvestigation(sameasherpesSimplex)
|Treatment|
Disseminatedherpeszosterandimmunesuppressedpatients Elderypatients
IVacyclovir10mg/kgevery8hoursfor10days Acyclovir
Prednisone4060mg/day
Decreaseover3weekstopreventpostherpeticneuralgia
HealthyPatients
Mildclinicalmanifestations Severeclinicalmanifestations
Sedation
Avoid2nd
infection
by
proper
hygiene
0.2%chlorhexidinemouthwash
Rifampicinelixirmouthbath4timesdaily.
5%Acyclovirointmentforskinandeyelesions. 800mgacyclovirtablets5timesdailyfor710days.
Topicalcapsaicin(hotpeppers),why?
Topicalanaethesiaarenteffectivesincepainarisefromthesensorynerve.
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|HeroessineHerpes(ZosterSineEruption)|
|Info|
PaincausedbyHerpeszostervirusalongthecourseofthenervewithoutanyclinicallesions. AdiagnosticProblemasitcanbemistaken,why?Becauseitmaybemistakenforappendicitis,cholecystitsorden
pulpitisleadingtounnecessarysurgery.
Diagnosisisbasedontheincreaseintheantibodytitre(besidestheclinicalsymptoms).|Complications|
Commoninimmunecompromisedpatientsandoldpatients.
Complication1:postherpeticneuralgia:
o Painpersistsafterhealingandresolutionofherpeszosterlesion.o Painmaylastweeks,monthsoryears.o Reason:duetoinflammationandfibrosisoftheaffectednerveo Scars: arediagnostic.
|Treatment|
Antidepressants,carbamzepineandchlorpramzine. Spontaneousimprovementsafter24months.Complication2:GeneralizedHerpeszoster:
Involvingtheinternalorgansleadingtopneumonia,meningoencephalitisandhepatitis.Complication3:Herpeszosteraffectingthemotornerveleadingtopralysis:
E.g.Herpeszosteraffectingthesacralregioncausingparalysisofthebladderanddiaphragm.Complication4:Secondaryinfection.
Complication5:BlindnessmayoccuriftheOphthalmicdivisionisinvolved.
|RamsyhuntSyndrome|
|Fact|
Anexampleofherpeszosteraffectingthemotornerveofthefacialnerve7thviainfectionofgeniculateganglion. Thefacialnerveisamixednerve.|Clinicalpicture|
Courseofthediseaseisrapid(resolutionwithin710days),butparalysismaybepermanent. Prodrome:o Sometimespainlocalizedtotheearorradiatestothejawsandneck.o Thisisshortlyfollowedbyherpeticoticus.
Herpeticoticus:o Smallcropsofvesiclesonthetragusoftheearortheexternalauditorycanalandmayreachthetympanic
membrane.
o Maysufferfromtinnitus,vertigoanddeafnessintheaffectedside.o Maysufferfromlossofhighpitchsound,why?Duetoinvolvementofthestapidiusnerve.
Oralmanifestations:o Vesiculareruptionulcersunilateralpainonsoftpalate,faucesandanterior2/3oftongue.o Lossoftastesensation.o Xerostomia,why? Duetodisturbanceintheparotidglandsecretion.o Facialplasy(Bellspalsy).
|Treatment|
Prednisone60mg/dayOR Tailandreducetillzerowithin10days
ACTH100unitsinthefirstday
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Recap on some points of herpes
Round1:Local Vs Systemic
RecurrentHerpesLabialis
RecurrentIntraoralHerpes
Primary(Acute)HerpeticGingivostomatitis
HerpeticWhitlowifseropostive HerpeticWhitlowifseroneagtive
Shingles(alongthenerve)
RamsyhuntSydromeandherpessineherpes(Alongthenervecourse)
ChickenPox
Round2:NoScarformation Vs Scarformation
Ifthereisno2nd
infectionChickenPox
Primary(Acute)HerpeticGingivostomatitis
RecurrentHerpesLabialis
RecurrentIntraoralHerpes
HerpeticWhitlow
By2nd
infectioninChickenPox
Shingles
Round3: AllHerpeshavethesamePathogenesis. Allulcersareprecededbyvesicobullouslesion.
Round4: Diseaseisselflimiting(exceptinherpeszoster,herpessineherpesandRamsyhuntsyndrome)andnoneedfor
interventionexceptinelderlyandimmunocompromisedpatients.
Coxsackieviruses
Name Herpangina Hand,Footandmouthdisease
Types A1,A6,A8,A10,A15,A22.(MostcommonA10)Contagious
A16
Contagious
Time Seasonalcommoninsummerandmayoccurseveraltimesbydifferentstrains.
Transmission EpidemicContaminatedsaliva
Epidemic
Airbornspread
Oral
fecal
contamination
Age Children.Notuncommoninadult
Children(5months 6years)
Occasionallyinyoungadults
ClinicalFeatures
Prodrome Lowgradefever,anorexiaHeadache
Sorethroatanddysphasia
Lowgradefever,anorexia
Coryza(symptomsofaheadcold),diarrhea,vomi
Lymphadenopahathy.
ExtraoralNONE!
Macule,popularandvesicularlesiononthe:
Extensorsurfaceofskinonhands,fingers,feet,to
andsometimesbuttocks.
Intraoral PharyngitisSoftpalate,uvula,anteriorfaucialpillarsand
Pharynx
Pharyngitis
Hardpalate,tongue,cheekmucosa,tonsilsand
Pharynx
Vesicles Bilateraltinyvesicles(12mm)thatrupturetoformulcers
Bilateralvesicles(110mm)thatrupturetoform
ulcers
Ulcers NotverypainfulSmall(12mm)
Shallow
Coveredbygrayishpseudomembrane
Onerythematousbase
Multiple
Largerthanherpangina
Shallow
CoveredbyYellowpseudomembrane
Onerythematousbase
Chiefcomplain Dysphasia Soremouthandrefusaltoeat
Fate Selflimitingandfewdays(notmorethanaweek)
Treatment Notreatmentneeded.Topicalanaestheisaandantisepticinseverecases
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11|
|Def
Is
|Eti
IDepoofski
|Trig
oo
oo
|Clin
|Clin
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)skinappea
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Treatment
|Mildcase|BysymptomaticTreatment:
Topicalanesthesia. Softorliquiddiet.|Moderatetoseverecase|
Systemiccorticosteroids,thedosagevariesdependingontheseverity. Prednisone3050mg/dayforseveraldaysandthentaper.(higherdosageincaseofseverecases).
|DifferentialDiagnosis|
ErythemaMultiforme AcuteHerpeticgingivostomatitis
Acutemultipleulcers
Larger
Oftenbleeds
Irregulardeeper
Acutemultipleulcers
Smaller
Coveredwithapseudomembrane
RoundShallow
Gingivaisntofteninvolvedoreffected Gingivaismainlyinvolvedoreffected
TreatmentbyCorticosteroids TreatmentbycorticosteroidsareCONTRAINDCAITED
Erythema Multiforme Major (StevenJohnsonSyndrome)
|ClinicalPicture|
Age:Anyage.
SystemicFeatures:suddensetoffeverandmalaiseorthepatientmaybeasymptomaticandwithin24hourshave
extensiveoralandskinlesions.
SkinLesions:generalizedVesiculobullouslesionsandatypicaltargetlesion.
EyeLesions:ConjunctivitisorCornealulcerationwhichmayleadtoblindness.
GenitalLesions:
InMales: Balanitis. InFemales:Ulcerinvaginaorvulva.Oral
Lesions:
more
sever
and
extensive
than
Erythema
Mutliforme
minor.
Treatment
SystemicSteroids. Ophthalmicconsultationiscritical,why?o Incaseofocularinvolvementwhichmaytoleadblindness.(themostcommoncomplication)
Toxic Epidermal Necrolysis (LyellsDisease)
|ClinicalPicture|
SkinLesion:largebullaeresultsindetachmentofepidermisinlargesheetsleavingascaled(burn)skin
appearance.
OralLesion:1/3ofcasehasorallesionsandconsideredaminorproblem.
Complications:Ithashighincidenceofdeathdueto2ndbacterialinfectionand/orfluid+electrolyteimbalance.
Treatment
Mangedinaburncenterto:
Removethenecroticskin. Graftplacement.
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Diagnosis of Erythema MultiformeA. Casehistory
a. Historyofdrugintake(Sulfonamide)b. Historyofviralinfection(HerpesSimplex)
B. ClinicalExaminationa. ThehallmarkofErythemaMultiforme:(VIP)
1.TargetLesions(Bulleyeoriris).2.BloodyCrustedLip.3.Oral,skin,eyeandgenitalinvolvement(inStevenJohnsonsyndrome)
C. Libratoryinvestigations: histologicalexaminationshows:a. EpithelialEdema.b. Necrosisofkeratocytes.c. Subepithelialvesicles.d. Perivascularlymphocyticinfiltration.
Ulcers 2ndto Chemotherapy (Anticancercytotoxic)
|Etiology|TheulcersbybeduetodirectorindirecteffectofChemotherapy.
Direct:o Itinterfereswithreplicationandgrowthoftheoralepithelium.
Indirect:o DepressedbonemarrowformationLeukopenialiabilityforbacterial,viralandfungalinfectionOralulce
|ClinicalPicture|
Ulcersarelarge,deep,andirregular. Necroticandfoalodor. Notsurroundedbyinflammatoryhalo.|Treatment|
HealswithintwoweeksafterstoppingChemotherapy.Revise on Ulcers
Ulcers
Multiforme erythematouslesion EMMinor
EMMajor(StevenJohnsonSyndrome)
Reiters
Syndrome
Bechets
Syndrome
(LyellsDisease)
ToxicEpidermalNecrolysusHerpesAssociated
ErythemaMultiforme
Mucocutaneousoccluarsyndroms
(oral,skinandeyelesions)ViralInfections
RecurrentLesions
HerpesCoxsackieviruses
SingleOralUlcers
Chemotherapy
TraumaticUlcer
2nd
tochemotherapy
RecurrentUlcers
ChronicMultiple
MinorUlcers MajorUlcer HerpetiformUlcer
AphthousUlcerPemphigusVulgaris
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Traumatic Ulcer (single Oral Ulcer)|Fact|
Mostcommonsingleulcer.|Etiology|
ByPatient:o Checkbiting,denturessoreness,irritation(fromroughtoothrestoration),lipbiting(afterL.A.orduringan
epilepticattack)
Bydentist(Iatrogenic):o Mechanical:improperuseofdentalinstruments,forcefulremovalof
cottonetc.
o Chemical:silvernitrate,eugenol.o Thermal:hotdentalinstruments,impressioncompound.
|ClinicalFeatures|
Single. Coveredbywhitefibrinclot. Locatednearoratthesitesubjectedtoinjury. Painful(assoonastheinjuryoccurs). Iftheulcerissubjectedtorepeadtedtrumamaybefirmonpalpation+elevatedborder. Ulcerresolveswithin12weekafterremovalofthecause.|Diagnosis|
Byhistoryandclinicalexamination. Siteandshapeoftheulcerisrelatedtothesourceoftrauma. MostdefinitivediagnosticfeatureResolutionofthelesionafterremovalofthecause.
Differential
diagnosis
must
differentiate
from
other
single
ulcers
of
bacterial
origin
or
syphilitic
chancre.
|Treatment|
Removethecause. Drug:o Prevent2ndinfectionby Tetracyclinemouthbath.o Symptomatictreatment Benzdaminehydrochloridemouthswash.
Reevaluateafterremovalofthecause,ifpersistenceoftheulcer12weeksaftereliminationofthecausetheulceisindicatedforbiopsy(toruleoutmalignancy).
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Mucocutaneous-ocular syndrome
BechetsSyndrome ReitersSyndromeEtiology Immunologicfactor
(immunecomplexformationleadingtovasculitis)
Similarto
Aphthous
ulcer
Unknownfactor
MayberelatedtoChlamydiainfection
ClinicalTriadAphthousulcer
Genitallesion
Occularlesion
Pathergytest*
Triad= Aphthousulcer+2oftheothersigns
Genitallesion
Occularlesion
Jointlesion
Pathergytest(Itisasimpletestinwhichtheforearmisprickedwithasmall,sterileneedle.Occurrenceofasmallredbumpustuleatthesiteofneedleinsertion,1to2daysafterthetest,constitutesapositivetest.)
ClinicalPictureOral
Aphthous
ulcers
Minorormajoratleast3timesyearly Shallow
ulcers
Psorisifomlesions(circinateLesion)
=redlesionwithslightlyraisedwhiteborde
Eye Retinalvasculitisblindness Conjunctivitis
Skin Pustuleformationontrauma.
Acneiformnodules
Keratodermablennorrhagica
(WhichisKeratoiclesionon
thesolesoffeetandpalmsof
hands)
Genital Males:ulcersonscrotumandpenis
Females:ulcersonlabia
CircinateBalanitis=Circinatelesionsontheglans
Urtheritis
Joint
Arthritis
TreatmentSteroids
Others
Corticosteroids
CorticosteroidsCombinedwithImmunosuppressers
(azathioprine,cyclosporine)
Corticosteroids
NSAID
Mucocutaneousoccluarsyndroms
(oral,skinandeyelesions)
EMMajor(StevenJohnsonSyndrome)
Reiters
Syndrome
Bechets
Syndrome
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Chronic Multiple UlcersAnautoantibodyisanantibody(a
typeofprotein)manufacturedby
theimmunesystemthatisdirecte
againstoneormoreofthe
individual'sownproteins.
Source:wiki edia
Pemphigus Vulgaris|Facts|
Itsautoimmunediseaseinvolvingskin,mucousmembraneshowingvesiclesandbullae. Uncommonandfatal.
|Etiologyand
Pathogenesis|
CharacterizedbycirculatingIgGautoantibodiesagainstintercellularcementingsubstancesintheepithelium.(Desmoglein) OncetheautoantibodiesattachestotheAntigen(cementingsubstance)releaseofproteolyticenzmesfromepithelialcel
destructionoftheintercellularcementseparationoftheepithelialcellfromeachother(acantholysis).
Presenceoftheweakestjunctionsuprabasalsplitbetweenthebasalandpricklelayer(suprabasalcleft)accumulationfluidinthesuprabasalcleftsformationofepithelialvesicleandbullae.
Suprabasalcleft|ClinicalPicture|
Age:4060yearsold.
Sex:female.
Site:skinandmucousmembrane.
Acanthosis
Oralfeatures:
Site:Buccalmucosa,palate,gingival,lip.o Morecommononthebuccalside,why?Becauseitssecondarytotrumaoppositetotheocclusalplane.o Theorallesionisbeforetheskinlesionin60%ofcases,why?Becausetheorallesioncontainslessintercellularcementing
substance.
PositiveNikolskySign:o Onintactoralmucosa: Lateralpressure mayleadtopeelingofepitheliumleavingalargedenudedarea(DesquamatedGingivitis). Lateralpressure mayleadtoformationofvesicleorbullae.
oOn
vesicle:
Verticalpressureextensionoflesiontoadjacenttissueincreaseinsizeofvesicle. TheBullae/vesicle:o Thinwalledonanon erythematousbase.o Thebullarapidlyrupturesandbreaksgivingashallowulcer.o Theulcerisirregularwithdetachedmarginsontheperipheral,why? Theedgesoftheulcercontinuetoextendperipherallyincreasinginsize(extendtolipcrustforming)+(extendtoth
throatleadstodifficultyinswallowing) detachedepitheliumatthemarginsirregularmargins.
o Theulcersare: Big,irregular,shallowandbleeding,why?Becausetheulcershasepitheliumdetachmentsontheperipheral.
SkinFeatures:
Site:Groin,Axilla,faceandneck. TheBullae/Vesicle:o ThinwalledonanonerythematousBase.o Shallowulcers.o ContainsclearorHemorrhagicorseropuruelntfluid.o Thebullaerupturesulcers+bleeding+easydetachmentofepitheliumontheperipheryulcersirregularmargino Whyirregularmarginsoftheulcers?Becauseofeasydetachmentofepitheliumontheperipheryoftheulcer.
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PositiveNikolskySign:
Bypressure theupper(outer)layerofepitheliumcanbeeasilyremovedandslipped. Bypressureonskin formationofbullaeorvesicle. Bypressureonintactbullae forcethefluidintosurroundingunaffected
tissue.
|Diagnosis|
Casehistory. ClinicalexaminationPositiveNikolskysSign. LaboratoryInvestigations:I. Biopsy: Intraepithelialbullae.
II. immunofluorescence: DirectandindirectimmunofluorescenceIgGintheintercellularattachmentzone.
Directshows: detectstissuewithAutoantibodyattachedtothem Indriectshows: detectstheCirculatingAutoantibody.
III. Cytologicsmear: DefinitionofTZankCells:
Acantholyticcells+whichshowsignsofdegeneration.ral.
.
.
Thenucleiarelarge,surroundingbyalightstaininghaloofcytoplasmthenadarkstainingattheperiphe
TZankcellsarepresentin Theliningofthebullae Inthefluidofthebullae
|Treatment|
Earlydiagnosisimprovesoutcomeoftreatment,why?o Atlatestagesseverskininvolvement2ndinfection+severeimbalanceoffluidelectrolytemaybefatal.o Atlatestages: Highdosageofcorticosteroidtocontrolthedieses.
Theamountofcorticosteroidsusedshouldbemonitored,why? becauseriskofdeathduetohighdosageocorticosteroidsishigherthandeathduetothedisease.
Topical
Drugs
for
the
oral
lesions:
o TopicalAnesthesia.o Antiseptics.o Corticosteroids.
Systemiccorticosteroids:o Usedaloneorcombinedwithimmunesuppressivedrugs,whycombined? Toreducethedosage,e.g.Azathioprine,Cyclosphosphamide.
Directimmunofluorescence
TZank
PositiveNikolskySign
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Recurrent Oral Ulcer|Fact|
Severaldiseaseshouldalsobeincludedinthedifferentialdiagnosiswithhistoryofrecurringulcers:
RecurrentUlcers CyclicNeutropeniaBehcetsSyndrome
RecurrentErythema
MultiformRecurrent
Herpes
Simplex
Virus
RecurrentAphthousUlcer
MajorUlcer HerpetiformUlcerMinorUlcers
Recurrent Aphthous Ulcer
|Definition|
Recurringulcersconfinedtooralmucosawithnootheroralsignsorlesions.|Etiology|
1) Hereditaryfactors.2) Hematologicfactors. Irondeficiency. Vit.B12deficiency. FolicAciddeficiency. CyclicNeutropenia.
3) ImmunologicFactors. Crossreactiontooralorganism. DisturbanceinlymphocyteCellproliferation. AntibodydependentCellmediatedcytotoxicty.
4) Hormonalfactor. Thuscommonwithfemalesduringmenstruationorpregnancy.
5) Hypersensitivitytocertainfoods.6) PsychologicalStress.7) Cessationofsmoking.8) Trauma.9) RelatedtoothersyndromesMucocutaneousocularsyndrome(behcetsSyndrome).10)GastrointestinalDisease: CaeliacDisease.
|GeneralClinicalPicture|
Age:beginsinthe2nddecadeoflife(Mayhappeninchildhood)
Sex:Morecommoninfemales.
|Types|
MinorAphthousUlcer MajorAphthousulcer Herpetiformulcer.
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Minor Aphthous Ulcer
|ClinicalPicture|
Prodrome burningsensation24/48hoursbeforeulceration. Shape localizedareaofErythema+centralsmallwhitepapule. Healing healsbyepithelizationfromtheboardertothecenter. Healing 714days. Healing withoutscarformation. Reccurenceemayoccurseveraltimesayear. Ulcer: Graduallyenlargeoverthenext48hours. Number: 1to6. Site: MostcommonlythenonkeratinizedMucosa. Shape: Symmetrical(Roundoroval). Depth: Shallow. Size: lessthan1centimeterindiameter. Floor: byFibrinExudates. Base: Notindurated. Margins: byErythema. Sensation: Painful. Regional: Onlylocalwithnoregionalaffections.
Major Aphthous Ulcer
|ClinicalPicture|
Passesthesamestagesasminortype. Healing withinafewmonths.Itcanbeconfusedwithsquamouscellcarcinoma,why?
Becausethelesionisinduratedandcanlastformonths.
Healing
withscar
Formation.
Site: mostcommonlyontheoropharyngealregionsmainlyontheglandbearingmucosa. Size: largerthen1centimeterindiameter. Depth: Deep. Floor: necrotic. Base: indurated Margins: byErythemaandraisedborders(duetoedema). Sensation: ExtremelyPainful. Regional: Associatedsometimeswithfeverandregionallymphadenopathy.
MinorAphthousUlcer MajorAphthousUlcer
Non
keratinized
Mucosa.
Less
than
1
cm
in
diameter More
than
1
cm
in
diameter
Oro
pharyngeal
regioMarginserythematous Margins erythematous+edematous
Shallow Notindurated Indurated Deep
Coveredbyfibrinexudate CoveredNecrotic
Healswithin714days Healswithoutscarformation Healswithscarformation Healswithinafewmon
RecurrentIntraoralherpes RecurrentAphthousU
Keratinizedmucosa NonkeratinizedMuc
SurrounedbyTissuetags Notissuetags,why
Thereisnovesicularl
DifferentialDiagnosis
Herpitform Ulcer
|ClinicalPicture|
Smallcropsofmultipleshallowulcers. Theulcersarescatteredoveralargeareaoftheoralmucousmembrane.
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|Diagnosis|
Itsmainlybasedonexclusion,why?Becausethereisnospecifictestforit.1) CaseHistory: Historyofrecurrence.(rememberthatitsnottheonlydiesesthatshowrecurrence).
2) ClinicalExamination.3) Laboratoryinvestigations: Toidentifyanypossiblesystemicdiserase:
Gastrointestinaldieses..
.
.
.
asone.
lone.
.
.
.
.
Cyclicneutropenia Nutritionaldeficiency:Iron,Vit.b12,folicacid BehcetsSyndrom Allergy
|Treatment|
Evaluationandelevationofanypossiblesystemicdiseasethatcauseit. Medications:
A. Mildcases: Topicalanesthesia. Topicalorabase(adhesivepastetocoverit). TopicalJojobagel.B. Severecases: Topicalcorticosteroidspreparations(4timesdaily),dependingonthelocationofthesite.
Lozengespreparations Hydrocortisone,Betameth Ointmentpreparations Triamcino
C. Resistantcases: Intralesionalinjectionofcorticosteroids(Tramcinolone).D. ResistantcasesinAIDSpatients: Thalidomide.
|Recommendations|
Do
not
apply
caustic
agent
or
cauterization
to
the
lesion,
why?
Destroyssensitivenerveendingsoffersshorttermreliefofpain Tissuedamage Delayofhealing Increaseinscarformation