Vesicular stomatitis - erosions - ulcers in the oral cavity Differential diagnostic remarks MUDr. Hana Poskerová Ph.D. Stomatologická klinika FN u svaté Anny a LF MU v Brně C:\Users\ing. Radomil Novak\Desktop\ICRC\propagace a marketing\PPT prezentace\Background\budovajpeg.jpg C:\Users\ing. Radomil Novak\Desktop\ICRC\propagace a marketing\loga\FNUSA - NEW!!\FNUSA_logo.jpg VESICLE - small blister BULLA - blister larger than half cm •separation of tissue •intraepithelial •subepithelial • •contains fluid • (tissue fluid, haemorrhagic blister) • • puchýř EROSION ULCERATION •Ulcer – complete loss of epithelium, connective tissue is exposed at the base, scar is possible • •Erosion – surface layer is disturbed, healing without scar • vřed vřed Ulcerated lesion • superficial (aphtous ulcer) • deep - seated (squamous cell carcinoma) C:\Documents and Settings\Hanka\Plocha\HANA srpen 2011\A HANA STK\OBRÁZKY\SLIZ OBR\Afty\Afta malá vest.jpg C:\Documents and Settings\Hanka\Plocha\HANA srpen 2011\A HANA STK\OBRÁZKY\SLIZ OBR\Nádory maligní\Ca\Jaz Ca.3.jpg BLISTER EROSION ULCER EROSION ULCER blisters turn very quickly into erosions • lesions can pass from one form to another - depends on the development of disease Patient history Why is the patient comming? Who sent him? Type of trouble? Blister, Erosion, Ulcer - history •Age: child – adult – older person ? •Time: when the disease occurred, how long it has lasted, does it occur for the first time or repeatedly ? •Is it associated with external and internal factors (skin diseases, infectious diseases, allergies, drugs, smoking, alcohol…) ? •local symptoms ? - general symptoms ? •Clinical course of the lesion, speed of the development (acute – chronic) ? increase - decrease in size, remain stable ? Blister, Erosion, Ulcer - history •subjective complaints ? • - painful/painless • - bleeding • - intensity of symptoms • •are their aphtous ulcers in history ? • •previous treatment ? Blister, Erosion, Ulcer - examination •is it localized solitary lesion or multiple lesion • or diffused lesion ? •do lesions merge in greater lesion ? •is their symmetry of lesions ? •consistency • - size of formations • - the mobility and relationship to the surrounding tissues •serious ? – no serious ? malignant changes, systemic diseases ? • •oral mucosal ulcers can be associated with variety of systemic diseases (can be initial clinical manifestation) • •if oral mucosal ulcer persists for more than 2 weeks following appropriate treatment - biopsy is indicated • Blister, Erosion, Ulcer Blister, Erosion, Ulcer – history, examination •solitary - multiple? •merging - solitary lesions? •painful - painless? •acute - chronic? •children - adults - older age? •general symptoms? •skin lesions? •aphtous ulcers in history ? •consistency? size? localization? Rec Solitary - multiple? nik49748 Rec Merging - solitary lesions? pos4 Painful - painless? OLP SH 2 Syfilis prim nik17620 Acute – chronic? GSH nik30117 Child – adult – older person ? nik44829 nik34575 Systemic symptomes ? Nik_00001_16 Herpang Leukemie chr EEM jazyk Are skin lesions present? nik30123 nik30117 nik58632 nik58633 Are skin lesions present? Aphtous ulcers in history ? nik17619 What is the consistency of the lesions? Syfilis prim What is the size and location of the lesions? p19 Rec Erosion/ulcer non specific tool for distinguishing: •oval form – endogenous cause •irregular form – exogenous cause •multiple form – viral infection • Afta_23 •Solitary lip lesion or oral cavity is it also affected? • •Traumatic ulcer •Actinic cheilitis •Squamous cell carcinoma •Viral diseases •Group of „bullous diseases “ •Syphilis / TBC •Deep fungal infection DLE ret Lip red (lip vermilion) nik56127 F Pemfigus5 CarcinomaLip 1 6 5 4 3 2 prim lues F Pemfigus5 HerpesZoster2 Herpes ret 2b syphilis pemphigus HSV VZV Ca2 actinic Ch1 DLE ret DLE Ca Ca ACH Gingival lesions •Solitary gingival lesion or oral cavity is it also affected? •External causes - traumatic ulcer (denture , related, OH,...) •Primary herpetic gingivostomatitis •Mononucleosis •Necrotizing ulcerative gingivitis •Desquamative gingivitis (OLP, P-P) •Agranulocytosis •Leukemia, lymphoma •Squamous cell carcinoma • GSH Ulcerosa 2 Agranulocytóza 1 2 3 4 5 Ulcerosa poanug nik3844 nik3843 Dorsum of the tongue Solitary lesion or oral cavity is it also affected? •External causes – trauma, burning •Infection •Group of „bullous diseases “, EEM •Oral lichen planus – bulous, erosive •Syphilis / TBC •Squamous cell carcinoma nik34575 1 2 3 4 5 Diff. dg .: large/extensive erosions covered by fibrin pseoudomembranes •Erythema multiforme •Pemfigus/pemfigoid •Oral lichen planus – bulous, erosive •Alergic/toxic reaction •Drug reaction •Burns • EEM rty EEM buk EEM jazyk EEM ging Erythema multiforme nik34580 nik34574 nik34575 nik34578 Oral lichen planus Pemfigus nik16585 nik16592 nik16759 Drug reaction- MTX nik40801 nik40805 nik40806 nik40808 Drug reaction- MTX Red lesions - the epithelium is thinner than normal - atrophy • - epithelial damage - erosion (ruptured blister) • - inflammation (more blood vessels in the submucosa), burning discomfort • - bleeding into the submucosal tissues •Atrophic glossitis -dietary deficiency or poor absorption of nutritional components (Fe, vit B12, folic acid) wich are essential for the normal maturation of oral epithelium -Sjögren‘s syndrome B12 deficiency •Lingua geographica -etiology is unknown -hypersensitivity, hormonal imbalance, emotional stess may predispose -may be associated with fissured tonque •Median rhomboid glossitis -developmental defect of the dorsal tonque -clinical manifestation of chronic erythematous candidiasis -erythematous rhomboid-shaped of paplillary atrophy on the midline -associated with intermitent burning discomfort •Erythematous candidiasis (acute, chronic) -infection of Candida species -systemic broad spectrum antibiotics -ill-fitting dentures -systemic predisposing factors -mucosal erythema -burning dicomfort -dorsal tongue and palate •Angular cheilitis -infection of the mucosa at the corners of the mouth by C. albicans -bacterial infection -nutritional deficiency (Fe, vit B) -chronic irritation from habitual licking of the corners of the mouth -loss if vertical dimension (associated with ill-fitting dentures) Plummer - Vinson sy Pemfigus – Pemfigoid - Lichen nik44829 Lichen planus - atrophic, erosive type nik34580 Drug reactions (EEM) - methotrexat •Toxic/allergic reaction -allergic contact stomatis (IV. type) (circumscribed erythematous patches at the site of contact with allergen) -drug stomatitis (I. type) -toxic reaction NSAID Amoxycilin Eugenol MMA Allergic contact stomatitis Latex •Erythroplakia - rare, premalignant process •Submucosal hemorhages - injury, hemorhagic diatheses •Petechiae – multiple, small, red spots •Ecchymosis – lager, more diffuse, red macules with irregular margins •Hematoma – circumscribed red nodule Drug reactions - toxic reaction Ca jaz Ca tvář Ca pod jazykem Ca GSH2 GSH Gingivostom pemfigus Pemphigus Pemfigus jazyk pos3 pos4 pos2 Herpes3 EEM tvář EEM ret2 erythema_multiforme_kůže2 PEM kuze Pemphigus tvář Pemfigus rty neonatal_varicella Herpes_Zoster_záda Herpang Herpangina2 Herpes ret 2a Pepfigus ret Pemfigus jazyk Herpes7B herpes GSH hor Stom Zooster HerpesZoster3 St Stom Rec pos Koag Herpes ret 2b HFM 3 hand_foot_mouth HFMD handfootmouth HFM 2 traumatic-ulcer GSHjazyk2 GSHza řezáky GSH jazyk Pemfigoid 3 Pemfigoid jizvící oko Traum HSVkoutek Ppemfigoid Pemfigus ging2 Pemfigus ging Pemfigoid bul fluor IgG Acylpirin Tox-alerg-Pastwa2 Pemfigoid pemfigoid2 Ppemfigoid Trauma jazyk Afta_25 actinic Ch1 Solární ch Tox Leuko nehomo Koag Afta26 Lupus eratematodes sys Dišková patro Stom Afta_23 Alerg Inf Mononukl EEM oko EEMkůže EEM tvář HerpesZoster2 Herpes zoster nik67207 PEM hist 2 PEM obr pem mikr 2