y vesicle, bulla, papule, nodule

Introduction

Definition

Terminology

History

Examination

Classification

Diagnosis

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Primary lesion –vesicle, bulla, papule, nodule.

Secondary lesion – erosion, ulcer, pseudo membrane,

desquamation.

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INTRODUCTION

Deep crater that extend through the entire thickness of the epithelium

and involve the underlying connective tissue.-Wood & Goaz.

Break in continuity of the epithelium.- Bailey & love’s

An ulcer is a excavation of surface of an organ or tissue resulting from

the sloughing of inflammatory necrotic tissue.- Robbins.

oral ulcer is characterized by complete loss of epithelium accompanied

by a variable loss of underlying connective tissue resulting in a

crateriform appearance which may be augmented by edema or

proliferation of surrounding tissue. J oral pathol med(2009) 38:241-253.

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Vesicle- small circumscribed elevated blister containing clear fluid that is 1 cm in diameter.

Bulla- circumscribed blister containing clear fluid that more than 1 cm in diameter

Papule- a small, solid well circumscribed lesion raised above the skin surface that are less than 1 cm in diameter.

Plaques- solid well circumscribed lesion raised above the skin surface that are more than 1 cm in diameter.

Nodule-the lesion is deep seated in the dermis, and the epidermis can be easily removed over them.

Erosion- moist red lesion often caused by the rupture of vesicle or bulla or as well as trauma.

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Mode of onset

Duration

Pain

Discharge

Associated disease

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Sudden-Traumatic ulcer heals when the traumatic agent is removed.

Ulcer which originates gradual may follow swelling, - matted tuberculosis lymph nodes or gumma or a rapidly growing malignant tumour(epithelioma or malignant melanoma).

Marjolin’s ulcer develop on the scar of a sun burn.

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Duration

An acute ulcer is present for a short period

Chronic ulcer will remain for a long period

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Pain Those ulcer associated with inflammation will be painful.

Syphilitic ulcer and tropic ulcer - painless.

Tuberculous ulcer are slightly painful.

Malignant ulcer like epithelioma or basal cell carcinoma are painless and never become painful unless they infilterate the surrounding structure

Discharge

If discharge enquiry must be made about its nature-serum,blood or pus.

Associated disease

Such as fever, tuberculosis may lead to ulcer formation. Syphilis at the primary stage give rise to chancre and in the tertiary stage give rise to a gummatous ulcer.

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Site

Size and shape

Number

Edges

Floor

Discharge

Surrounding area

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Position

Apthous ulcer – non keratinized mucosa.

HGS- keratinized

Herpangina- posterior palate.

Malignant ulcer are mostly seen on lip, tongue, breast and penis.

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Size and shape

The size of the ulcer is important in deciding the time which will be required for healing. A bigger ulcer will take a longer time to heal than smaller ulcer.

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Number

Single ulcer-traumatic, sq cell carcinoma.

Tuberculosis, gummatous, varicose, and soft chancre may be more than one in number.

Undetermined edges

ulcer spreads destroying the subcutaneous

tissue faster than it destroys the

skin.

EG-Tuberculosis ulcer

Punched out edges

The edge drops down

at right angle to the skin surface as if it has

been cut out with a punch.

EG-Gumma

Sloping edges

mostly seen in healing

traumatic or venous

ulcer, which is reddish purple in color and consist of

new healthy epithelium.

Raised and pearly-white

beaded edges

type of edges

develop in invasive cellular

disease and necrotic at the center.

Rolled out edges

fast growing cellular

disease, the growing

portion at the edge of the ulcer heaps up and spills

over the normal skin

to produce an everted edges.

Eg-SCC

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Floor – the exposed surface of the ulcer.

red granulation tissue- healthy and healing.

Pale and smooth granulation tissue - slow healing ulcer.

wash-leather slough on the floor - gummatous ulcer.

A black mass on the floor - malignant melanoma.

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Discharge

healing ulcer - serous discharge

Spreading and inflammed ulcer -purulent discharge

Sero-sanguineous discharge -tuberculosis or malignant ulcer.

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Tenderness

Edges and margin

Base

Depth

Bleeding

Relation to deeper structure

Surrounding skin

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Tenderness

An acutely inflamed ulcer is always tender.

Chronic ulcer – Are slightly tender like tuberculous, syphilitic ulcer.

Neoplastic ulcer – Are never tender.

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Margin - junction between normal epithelium and ulcer.

Edge – area between the margin and floor of the ulcer.

Base- on which the ulcer rest

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Depth – recorded using examination sheet in millimeter Bleeding – whether the ulcer bleeds on touch or not? It is a common feature of a malignant ulcer. Relation to deeper structure – the ulcer is made to move over the deeper structure to know whether it is fixed to any of these structure.

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Spreading ulcer

• T.B ulcer

Healing ulcer

• Traumatic ulcer.

• pemphigus

• Erythema multiform

Chronic ulcer/callous

• SCC

clinically

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single

• Traumatic

• Histoplasmosis

• Blastomycosis

• Mucormycosis

multiple

• RAU

• EM

• Epidermolysis bullosa

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According to etiology and pathology:

Traumatic

• Mechanical irritant • Chemical irritant • Thermal burn • Radiation burn • Anesthetic necrosis • Oral trauma from

sexual practice

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Viral infection

• Herpes simplex

• Herpes zoster

• Hand-foot and mouth disease

• Herpangina

• Chickenpox

• Infectious mononucleosis.

Bacterial infection

• NUG

• Tuberculosis

• Syphilis

• Scarlet fever

Fungal infection

• Histoplasmosis

• Blastomycosis

• Mucormycosis

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Allergy

• Local

• Systemic

Neoplastic

• Squamous cell carcinoma

• Malignant melanoma

• Non- Hodgkin's lymphoma

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Blood disorder

• Cyclic neutropenia

• Leukemia

• Aplastic anemia

GIT

• Crohns disease.

• Malabsorption syndrome.

Auto immune

• Bullous pemphigoid

• Mucous membrane pemphigoid

• Pemphigus

• Systematis lupus erythematous

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dermatology

• Erosive lichen planus

Disease of unknown etiology

• Apthous ulcer


• Epidermolysis bullosa.

Syndrome

• Behcet’s syndrome

• Reiter’s syndrome

• Steven-johnson syndrome

miscellanious

• Necrotizing sialometaplasia

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Acute multiple ulcer

• Acute herpetic stomatitis


• Herpes zoster infection

• Cytomegalovirus infection

• Coxsackie virus infection

• NUG

• Allergic reaction

Chronic

• Pemphigus

• Pemphigoid

• Cicatrical pemphigoid

• Epidermolysis bullosa

• Para-neoplasia pemphigus

• Subepithelial bullous dermatoses

• Chronic bullous disease of childhood

Recurrent ulcer

• Recurrent aphthous stomatitis

• Behcet’s disease

Single ulcer

• Traumatiic ulcer

• Eosinophilic ulcer of tongue

• Histoplasmosis

• Blastomycosis

• Mucormycosis

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Mostly common ulcer.

History of trauma.

Acute – single-Painful

Surface – yellow pseudo membrane.

Usually heals with no scar formation.

Common – lateral border of tongue.

Ulcer associated with trauma

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Often in children.

Pain , difficulty upon swallowing.

Oral vesicles which may be widespread and breakdown to leave Oral ulcers that are initially pinpoint but fuse to produce irregular painful ulcer.

Acute marginal gingivitis - Gingival oedema, erythema and ulceration are prominent.

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RHL

Lip lesions at the mucocutaneous junction

Lesion begins as macules that rapidly turn papular, then vesicular For about 48 hrs, then become pustular, and finally scab and heal without scarring.

RIH • Vesicles break rapidly to form small red ulceration. •Occur only on the hard palate and gingiva.

• H/O recurrence • Lesion are preceded by itiching ,burning sensation

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Clinical diagnosis- along the distribution of nerve

Pain- unilateral, severe

Like chickenpox, it goes through macular, papular, vesicular and pustular stages before crusting and healing, sometimes with scars.

Maxillary nerve involved-rash and pain over ipsilateral cheek ,palate and maxillary teeth .

Mandibular nerve involved- face; lip; tongue and soft tissue.

Investigation- PCR; Biopsy, fluoresent antibody testing.

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Usually –children.

Skin vesicles that are small, painful and surrounded by inflammatory haloes, especially on the dorsum and lateral aspect of the fingers and toes.

Oral ulcers usually affect the tongue or buccal mucosa and are shallow, painful, very small and surrounded by inflammatory haloes .

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Children 3-10yr.

Commonly occur in posterior pharynx, tonsil and soft palate.

Vesicles mainly on the soft palate, which rupture to leave Ulcers round, shallow, painful.

Erythematous pharyngitis is commonly present.

Heals without any treatment within 1 week.

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First 2 decay of life.

A classic pattern of vesicle surrounded by zone of erythema.

Common -trunk and head and neck (i.e.centripetal).

The typical rash goes through macular, papular, vesicular and pustular stages before crusting

Vesicles, especially in the palate, which rupture to produce ulcers; painful, round or ovoid with an inflammatory halo.

resolve 2-3 week

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Young adults.

Sore throat, inflammation of the

tonsils , tonsils are covered by

white or grayish

pseudomembrane.

Palatal petechiae, especially at the

junction of the hard and soft

Paul-Bunnell test for

heterophilc antibodies (positive

in IM)

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common-young adult

Craterform painful

ulceration of the

interdental papillae.

A pronounced tendency to

gingival bleeding.

Sever pain with Halitosis.

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H/o low graded fever, weigth loss. night sweet , cough with sputum, chest pain.

Common - dorsum of the tongue and palate.

Single painful chronic ulcer; undermined margin; minimal induration.sentinel tubercle.

Sputum sample

Staining method- ziehl-neelsen; carbol fucschin.

Tuberculin skin test- montoux test.

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Primary syphilis (Hunterian or

hard chancre).

regional lymphadenitis

a small papule which develops

into a large painless , indurated

ulcer (chancre),which heals

spontaneously in 1-2 months.

Rarely chancres are seen on the

lip(upper) or tongue.

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Secondary syphilis

Coppery coloured rash typically on

palms and soles.

Oral lesions (mucous patches, split

papules or snail-track ulcers) are

highly infectious and painful. They are

seen mainly on the tongue.

Multiple indurated and slightly

papillary nodule on the dorsal surface

of the tongue- condyloma lata.

Tertiary syphilis

Oral lesions, which are noninfectious and painless.

Gumma (usually midline in palate or tongue).

Investigation

Lesion biopsy

Treponemal antigen test

Non-Treponemal antigen test

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Common children.

H/o fever normal within 6 days.

Skin rash- a sunburn with goose pimples common - pressure and skin folds.

White strawberry tongue- white coating,fungiform papillae-edematous,hyperemic projecting above the surface as small red knobs

Red raspberry tongue – coating of tongue is lost soon from the tip followed by lateral margin expect for swollen, hyperemic papilla.

Culture of throat secretion .

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H/O chronic cough, low grade

fever, night sweet, weight loss.

Oral lesion secondary to

pulmonary infection.

Painful ulcerated granulomatous

mass common – tongue, palate,

gingiva, recent extracted site.

ulcer have rolled margin, firm

Biopsy, Serology test.

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Common in adult.

Mimic more of tuberculosis.

The lesion have an irregular, erythematous

or white intact surface or as ulceration with

irregular rolled borders and varying degree

of pain.

chest x-ray; Special stains - PAS method.

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Usually it rise from the lateral wall of the nose and maxillary sinus and rapidly spread by arterial invasion involve orbit, palate, maxillary alveolus.

Nose appear reddish black nasal turbinate and septum.

Ulcer on the palate appear black and necrotic.

CT – detecting of bone destruction.

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H /O – chronic ulcer, painless, habits.

Common site- lower lip, tongue , alveolar ridge.

Deep chronic ulcer, rolled out edges, indurated base, initially painless later painful, fixed to underlying structure, bleeds readily on palpation.

Lymph node-initially mobile, later fixed.

Biopsy.

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H/o recurrane with uniform

spaced episode for every 21 days;

Recurrent pyogenic infections;

mouth ulcers-painful and

chronic, deep, Punched out, with

grayish white necrotic base.

Advanced periodontitis.

Neutrophils count less than

500/cu mm for 3-5 days for at

least 3 successive cycle. 54

• gingiva firm on palpation. Spontaneous gingival haemorrhage (and prolonged post-extraction bleeding);

• Leukaemic deposits occasionally cause swelling; gingival swelling is a feature especially of myelomonocytic leukaemia.

• Candidiasis , Recurrent intraoral herpes simplex herpes labialis is common.

• Immature- WBC.

• Decrease platelet count.

• Prolonged bleeding and clotting time.

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Gingival hemorrhage, Oral mucosal petechiae,purpura and ecchymosis

Mucosa appear pale

Oral ulcer associated with infection particularly that involves the gingival tissue

Gingival hyperplasia.

RBC-low 1 million/cu mm

WBC- >2000/cu mm.

>2000platelet/cu mm.

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Early adulthood; males usually 2nd and 3rd decades.

Typically with abdominal pain, persistent diarrhoea with passage of blood and mucus, anaemia and weight loss.

Oral lesions are most likely in those who develop skin, eye or joint complications.

Folding of the oral mucosa may lead to a 'cobblestone' appearance.

Angular stomatitis; Persistent irregular linear ulcers –buccal mucosa; Mucosal tags.

Biopsy -granulomatous inflammation

Blood tests for full blood picture.

Intestinal radiology, endoscopy, and biopsy

Malabsorption syndrome/celiac disease

Intestinal disturbance- diarrhea,constipation.

Skin- brownish pigmentation face; neck; arm

Glossitis, painful burning sensation of tongue and mucosa.

Small projection which ar ered and erythematous swelling and palatal lession as multiple apthous ulcer.

Low blood calcium level.

Lesion is typically painful. Recurrent, often ovoid ulcer -

yellowish necrotic base with an inflammatory halo, are small, 2-4 mm in diameter.

Last 7-10 days; Heal with no obvious scarring Most patients develop not more

than six minor ulcers at any single episode.

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Recurrent, often ovoid ulcers

with an inflammatory halo, but are less common, much larger and more persistent than minor aphthae, and can affect the soft palate and dorsum of tongue as well as other sites.

Can be well over 1 cm in diameter.

Can take several months to heal

May leave obvious scars on healing

At any one episode there are usually fewer than six ulcers present.

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HU are more common in females. • lacking the associated fever, gingivitis and lymph. • Start as multiple pinpoint aphthae; • Enlarge and fuse to produce irregular ulcers • Can be seen on any mucosa, but especially on the ventral of the tongue.

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Young adults males.

Acute onset.

Common site- lip-lesion are extensive with presence of hemorrhagic crusting.

Oral lesions - macules to blisters and irregular ulceration.

Erythematous skin lesion appear on extremities .

Last for 2-6 week

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•Adult women less than 40. •h/o burning sensation, xerostomia •Skin; the characteristic rash is a 'butterfly rash' over the nose; • Kidneys; CNS; heart. • central area composed of red atrophic surrounded by 2-4 mm elevated keratotic zone that dissolve into small white line. lupus band test- immunoglobulin deposits at the basement membrane zone in epithelium. Serum: anti nuclear antibodies - antinuclear antibodies, are present in SLE, not DLE or LP

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More common - adults

Initially affects the respiratory tract; and renal damage.

Persistent oral ulceration, especially buccally or on tongue;Painless.

Progressive gingival enlargement that may have a fairly characteristic 'strawberry-like' appearance.

Lesional biopsy; Serology; antineutrophil cytoplasmic antibodies (ANCA); Chest radiograph.

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5th-6th decades;

Pressure on the blister may cause it to spread (Nikolsky sign).

Bullae, which rapidly break down to produce persistent irregular ragged-edged erosions or ulcers .

Associated with sever discomfort.

Lesions - trauma, such as on the palate , buccal mucosa, and gingiva.

A biopsy (with immuno staining) is essential.

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Age : < 50; 2:1.

The oral lesions of MMP affect especially the gingivae and palate.

Desquamative gingivitis- main manifestations.

Bullae or vesicles which are tense may be blood-filled and remain intact for several days. Pressure on the blister may cause it to spread;

Persistent irregular erosions or ulcers after the blisters burst .Heals with scars.

Conjunctival scarring. (entropion, symblepharon or ankyloblepharon; or glaucoma leading to impaired sight.

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Age : 60-80; 2:1.

Pruritis followed by multiple bullae remains locally and heals with out scar.

Oral lesion show large shallow ulceration with smooth, distinct margin are present after the bullae rupture.

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•Oral lesions are most common in the junctional types of EB. •Enamel hypoplasia may be seen in some subtypes. •Bullae appear early in life in some subtypes, often precipitated by suckling; •Blisters break down to persistent ulcers that eventually heal with scarring. • The tongue becomes depapillated . •Scarring in the dystrophic form affects the extremities including the nails

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Common – middle aged

women c/o- burning sensation. Presence of vesicle and bullae

or irregular shallow ulcer. Accompanied by

characteristic wickham’s striae.

Common- posterior buccal mucosa and lateral margin of tongue.

Biopsy, immunofluoresent study.

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Young adult.

Erythema multiform

skin, oral cavity, eye and genital lesion.

Oral lesion- extremely painful,mucous vesicle rupture and leave surface covered with thick whit or yellow exudate.

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• Recurrent oral ulceration (more than 2 episodes in 12 months). • Plus two or more of the following. • Recurrent genital ulceration. • Eye lesions. • Skin lesions-erythema

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Oral manifestation-

Lesion- painless red slightly elevated areas

Site- buccal mucosa, tongue, palate.

Consist of tetrad of

urethritis

arthritis

conjunctivitis

mucocutaneous lesion

77

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Common in male.

4th-5th decade.

Site – palate .

Initially an asymptomatic swelling;

Followed by painful solitary ulceration In the palate, though any oral tissue may be affected; deep, crater like non draining ulcer of 1-3cm .

Self-limiting, healing over 5 to 8 weeks.

S. Das,A manual on clinical surgery,7th edition.

Gary c- coleman,John.F.Nelson-Principle of oral diagnosis.

Edward.V.Zegarelli,Oral disease of mouth and jaw.

J.Robert Newland Oral soft tissue diseases a reference manual for

diagnosis and management 3rd edition .

Kerr.D.A.,Oral diagnosis,6th edition.

Neville .Damm.Allen,Bouquot,oral maxillofacial pathology, 3rd edition,

Elsevier publishers.

Bailey & love’s, short practice of surgery,24th edition, international

students edition .

Ghoms .A.G., Textbook of oral medicine 2nd edition,2010,Jaypee

publishers. 80

y vesicle, bulla, papule, nodule

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