1. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 11 Lesions That Have a Vesicular Appearance

2. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Vesiculobullous Disorders Grouped as −Inflammatory −Traumatic

3. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Names for the Mucocele The Mucocele Common names Mucous retention cyst (lined with epithelium) A true cyst sialolith or salivary gland stone is the cause. Mucous extravasation phenomenon (lined with granulation tissue). Histology of Mucocele

4. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Locations of the Mucocele May be found on −Lower lip −Palate −Retro molar area −Upper lip −Ventral tongue region −Lingual frenum −Buccal mucosa Most common sites −Lower lip—trauma −Floor of the mouth −Ventral tongue— trauma −Buccal mucosa −Palate

5. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epidemiology—Mucocele Younger age groups in second decade Equal sex predilection Most commonly caused by trauma Damage to the salivary duct Exhibits spilled mucin— lodges in tissues

6. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Traumatic Versus Inflammatory Traumatic Inflammatory Histology

7. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Clinical Characteristics of the Mucocele Moveable Soft Painless Soft blue opalescent hue Dome-shaped

8. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Mucocele Versus Mucous Retention Cyst

9. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ranula Found in the floor of the mouth Severed and damaged salivary duct in the floor of the mouth (discussed in Chapter 17)

10. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

11. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Treatment Removal of the damaged duct Removal of blockage when sialolith is involved Caution the patient to avoid trauma to the area

12. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

13. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

14. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Herpes Simplex

15. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

16. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

17. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Primary Herpetic Gingivostomatitis (cont.)

18. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

19. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Herpes Labialis

20. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

21. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Herpetic Lesions and Aphthous Lesions Herpetic Keratinized tissue Multiple vesicles Usually appear in groups of small lesions Painful Aphthous Ulcers Nonkeratinized tissue Single lesions Larger lesions with yellow center and a halo appearance May or may not be painful

22. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Varicella–Zoster Virus—HHV Type 3 Chickenpox Herpes zoster or shingles—caused by reactivation of the virus, usually occurs in later life

23. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Herpes–Zoster Infections Varicella is the original infection. Result: chickenpox Herpes zoster is the reactivation of the virus. Result: shingles

24. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Chickenpox Young children Two-week incubation Vesicles resolve in several weeks. Pruritus is complaint. Trunk lesions

25. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Herpes Zoster Varicella reactivated Adults 60+ (vaccine available) Painful vesicles May develop postherpetic neuralgia (PHN)

26. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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)

27. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Enterovirus 71 (Coxsackie Enterovirus) Hand-foot-and-mouth disease Herpangina Acute lymphonodular pharyngitis

28. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Hand-Foot-and-Mouth Disease Transmitted airborne, oral, fecal Viral shedding Usually children under 5 years old Rash orally, feet and hands

29. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Herpangina May contact various strains of coxsackievirus Sore throat, fever, abdominal pain, and vomiting Oral vesicles

30. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Acute Lymphonodular Pharyngitis Fever, sore throat, headache Lasts from several days to several weeks Lymphoid tissue is inflamed. Oral appearance may vary.

31. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Paramyxoviridae Virus (Rubeola— Measles) MMR vaccine has caused decline. Koplik spots—small bluish white spots Cutaneous rash

32. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

33. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Noninfective Vesiculobullous Diseases Pemphigus vulgaris Autoimmune Males = females Four to six decades— familial May affect nose, etc.

34. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pemphigus Vulgaris Begin with bullae Over 1 cm in size Quickly rupture Painful Nikolsky sign present

35. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pemphigus Vulgaris Histology Tzanck cells Acantholysis Immunofluorescence is needed in diagnosis along with histology diagnosis.

36. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins EBA Occurs in adults (has been reported in children) May mimic other blistering disease states Two forms are presented: −Inflammatory −Noninflammatory

37. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Pemphigoid Autoimmune May affect the eyes/skin Erythematous Gingiva is the target. Nikolsky sign

38. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Ocular Mucous Membrane Pemphigoid Eyes should be examined and the patient should be referred to an eye professional for evaluation.

39. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

40. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Bullous Pemphigoid Autoimmune Affects seven to eight decade of life Affects most oral tissues Usually affects skin first

41. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epidermolysis Bullosa EB Forms Four types −Simplex (mild form) −Junctional −Dystrophic (digital webbing mitten-like) −Mixed (Kindler syndrome) Mitten-Like Scarring

42. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Organs Affected by Epidermolysis Bullosa Ocular involvement Blood due to poor iron absorption Skin—nails Esophagus Intestinal Musculoskeletal

43. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

44. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Antiviral Medications Most effective in prodromal stage −Individual experiences tingling, burning, and pruritic sensations. −Localized

45. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epidermolysis Bullosa Acquisita

46. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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

47. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Epidermolysis Bullosa Acquisita (cont.) Correlated with onset of various systemic diseases Use of certain medications

48. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 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.

49. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins Conclusions Always ask good questions! Always listen to your patients!