2. Macule: flat and well-demarcated lesion of any size, characterized by color change
in contrast to the surrounding skin. It is generally caused by alteration of melanin
pigment.
10. Herpes Simplex Virus Infection
Herpes simplex type 1: Causes
oral and pharyngeal infection,
meningeoencephalitis and
dermatitis above the waist.
Herpes simplex type 2: Causes
genital infection and dermatitis
below the waist.
11. Primary Herpetic Stomatitis
HSV type 1
Transmission by close contact
Most primary infections
In non-immune
Subclinical
acute vesiculating
stomatitis
12. Clinical Picture
Prodrome (1-2 days)
Early lesion
Vesicles (Any part (hard palate & dorsum of the tongue) – dome shaped 2-3
mm in diameter)
Rupture
Ulcers ( round, sharply defined, shallow, yellowish floor, red margins,
painful)
Gingival Margin
Swollen, red, Regional L.N. (swollen, tender)
Self limiting (week to 10 days)
18. Differential diagnosis
Aphthous ulcers
(prodrome of fever and malaise, ulcers preceded by vesicles,
pinpoint size, involve gingiva and a positive history of contact)
Hand-foot-and-mouth disease
(by absence of lesions on palms and soles)
Herpangina
(small vesicles limited to soft palate and oropharynx, while HSV
affects anterior palate)
19. Recurrent Herpes Simplex Lesion
Recurrent Herpes Libialis
Reactivation of latent virus (20-30 %) leading to cold sores.
Prodrome (burning sensation – Parsesthesia)
Erythema
1-2 hrs
Vesicles (Clusters at the mucocutaneous junction of the lips – can
extend)
Enlarge, Coalesce & weep exudates
2-3 days
Rupture & crust
23. Recurrent Herpes Simplex Lesion
Recurrent Herpes Libialis
Reactivation of latent virus (20-30 %)
leading to cold sores.
Recurrent Intra Oral Herpes
Clusters of small vesicles
Break into
Prodrome (burning sensation –
Parsesthesia)
Ulcers ( 1-2 mm – On keratinized
mucosa e.g. gingiva, hard palate)
Erythema
1-2 hrs
Vesicles (Clusters at the
mucocutaneous junction of the lips –
can extend)
Chronic Herpes Simplex
Immunocompromised patient
• Skin & mucosa
Enlarge, Coalesce & weep exudates
2-3 days
Rupture & crust
• As recurrent herpes but duration is
weeks to months and develop into large
ulcers (several Cm)
29. Varicella Zoster Infection
Primary Varicella Zoster infection
• Chicken pox
Reactivation of the latent virus
Herpes Zoster of the
Trigeminal area
Herpes Zoster of the
Geniculate ganglion
Herpes Zoster
(reactivation of virus –
adults)
Ramsay Hunt Syndrome
30. Chicken Pox
Mild systemic symptoms
Maculopapular lesions
(Generalized – Puritic)
Rapidly develop into
Vesicles (on erythematous base)
Rupture
Ulcers
35. Herpes Zoster
Prodrome (2-4 days)
Sharp shooting pain, Parsesthesia, burning and tenderness along
the course of the affected dermatome
Vesicles
Unilateral – often confluent
L.N. enlarged and tender
Pain continues until lesion crust over and
heals
42. Secondary Infection
Suppuration and scarring of skin
Malaise and fever
Herpes sine eruption
Pain without rash or oral eruptions
Post herpetic neuralgia
44. Ramsay Hunt Syndrome
Herpes Zoster of the Geniculate Ganglion
Affects Facial nerve
(motor and sensory fibers)
45. Prodrome
(Facial pain – may radiate to jaws and misdiagnosed as toothache)
Bell’s Palsy
Herpetic Oticus
(unilateral vesicles on the external ear)
Oral mucosa
(unilateral vesicles
(Chorda Tympani
ulcers on erythematous base)
ant. 2/3 of tongue & soft palate)
Complications
(Permanent facial paralysis)
46.
47. Hand Foot and Mouth Syndrome
Coxsackie A Virus
Epidemic among school
children
Incubation period 3-10
days
Causes oral ulcers and
rash on the extremities.
Highly infectious
48. Oral Ulcers
Small, scattered with little pain
Affect Ant. Part of oral cavity
Gingivitis is not a feature
Systemic upset Mild or absent
59. Differential diagnosis
Herpetiform ulcers - Aphthous ulcers
(Prodrome of systemic illness)
Primary herpes simplex infection
(small vesicles limited to soft palate and oropharynx,
while HSV affects anterior palate)
Hand-foot-and-mouth disease.
(by presence of lesions on soles and palms)
62. T.B
Ulcer on mid dorsum or
tip of tongue.
Less common on lips
and other parts
Angular or stellate
over-hanging edges &
pale floor.
Indurated base
Painless in early stages.
63.
64.
65. Syphilis
(Primary syphilis (Chancre
3-4 weeks after infection with Triponema Pallidum.
Affects lips and tip of the tongue.
Firm nodule (1 cm) within few days surface breaks
Round ulcer with raised indurated edges, painless.
LNs enlarged and rubbery.
Within 8-9 weeks healing with no scar.
66.
67.
68. Secondary syphilis
1-4 month after infection.
Mild fever, malaise, headache, sore throat & generalized
lymphadenopathy Followed by rash & stomatitis
Rash starts at trunk, asymptomatic pinkish macules,
symmetrical distribution, few hours to weeks.
Stomatitis lateral borders of the tongue, tonsils and lips.
ulcers are flat, covered with grayish membrane, snail tract,
may coalesce and form well defined round ulcer.
69.
70. (Tertiary syphilis (gumma
3 or more years after infection.
Insidious onset.
Affects palate, tongue, tonsils.
Swelling with yellowish center (several inches) Necrosis
painless deep ulcer
Ulcer is rounded, soft, punched out edges, floor is depressed
and pale.
Heals with sever scarring distort tongue and soft palate,
destroy uvula, perforate hard palate.
76. Traumatic ulcers
Obvious cause as sharp edge of denture or a broken tooth
cause traumatic ulcer on tongue and/or buccal mucosa.
Single
Acute onset and Short duration
No systemic features
Painful, yellowish floor, red margins
Removal of the cause healing within 7-10 days
If not Biopsy
77.
78.
79.
80.
81.
82. Recurrent Aphthous Stomatitis
Onset In childhood
Peak Adolescence
Recurrent
In healthy patient
Prodrome: Burning sensation 2-48 hrs with localized
erythema
83. Minor
Most common type
Non keratinized
mucosa
Shallow, rounded,
5-7 mm with red
margins and
yellowish floor
Can be one or many
Healing with no scar
formation in 7-14
days
Major
Herpetiform
Uncommon
Uncommon
Keratinized & non
keratinized mucosa
Non keratinized
mucosa
Several centimeters, deep
and sometimes with
indurated base & everted
edges
1-2 mm
Persistent for several month
Healing with scar formation
Dozens or hundreds (may
cluster Large ulcers).
Wide spread bright
erythema around the
ulcers.
94. Differential diagnosis
Pemphigus and mm pemphigoid
by absence of vesicles and healing in 7-14 days, and the
well defined appearance, absence of epithelial tags.
Erythema Multiforme
As above + uniform appearance and size, also no lip crusting.
Atrophic candidiasis
predisposing factors in candidiasis, most cases pass through
white necrotic phase or have a minor keratotic component.
95. Primary herpetic gingivostomatitis
Prodrome of fever and malaise, ulcers preceded
by vesicles, pinpoint size, involve gingiva and
a positive history of contact.
Recurrent Intra oral herpes
Involve keratinized mucosa, while RAU involves
non keratinized mucosa.
97. It has Four patterns
1. Mucocutaneous (oral & genital ulcers)
2. Arthritic (joint involvement with or without 1)
3. Neurological (with or without 1 & 2)
4. Ocular (with or without 1,2 & 3)
105. Reiter’s Syndrome
Triad of uritheritis, arthritis, conjunctivitis
Oral manifestations
Painless white lesions which may ulcerate Aphthous like ulcer
Geographic tongue like lesion
Purpuric rash on palate
Self limiting
106.
107. Geographic tongue
Characteristically, the lesions
persist for a short time in one area, then disappear completely and
reappear in another area. The condition is usually asymptomatic
110. Squamous cell carcinoma
Deep & large
Indurated base
Raised everted edge
Necrotic fetid floor
Painless unless invade nerve
Metastatic L.N:
Large
Painless
Hard
Fixed to underlying tissues
111.
112.
113.
114. A.N.U.G
Painful gingivitis
Redness
Swelling
Gingival bleeding
Punched out lesion on
interdental papillae
M.m covered with greyish
necrotic membrane
Bad breath(foetid oris)
Bad taste
lymphadenopathy
120. E.M. Minor
)(80% of cases
Skin lesions
Maculopapular lesion (dull red – flat or slightly raised)
Remains small or reach 1-3 cm within 48 hrs
Often involve the hands selectively
Kobner phenomenon
Target (iris) lesions:
Typical: Less than 3 cm in diameter.
Consist of 3 zones.
Atypical: Consist of only 2 zones.
121. Central zone of
erythema
Middle zone of
edema (paler)
Outer ring
of erythema
(well
defined)
Typical target- or iris-like lesions of the skin.
126. Oral manifestations of EM
Mucous membrane
Extensive bullae formation Followed by
Erosions
and a grayish white membrane.
Lips
Show characteristic hemorrhagic crusting.
127.
128.
129.
130.
131.
132. EM Major
((Steven Johnson Syndrome
Onset :sudden, may be preceded by a prodrome 1-13 days.
Organs involved
Mouth (100%)
Eye Bullae formation may occur – corneal ulceration is frequent –
these changes often regress completely, rarely cause blindness.
Skin variable – typical maculopapular lesion – bullous lesions –
rarely pustular.
Male genitalia
Anal MM
Bronchitis.
134. Differential diagnosis
Primary herpetic gingivostomatitis.
Involve gingiva
Aphthous ulcers.
By absence of vesicles and healing in 7-14 days, and the well
defined appearance, uniform appearance and size, also no
lip crusting.
Pemphigus vulgaris.
Ulcers lacking erythema, Positive Nikolsky’s sign, flaccid
bullae.
136. Oral manifestations
Appears first in mouth
spread to skin.
Vesicles (fragile)
Erosions
(superficial, ragged, painful, tender)
Peeling off of oral epithelium due to lateral movement.
Desquamative gingivitis
Positive Nikolsky’s sign
143. Skin Lesions
Vesicles or flaccid bullae
Ruptures
Erosions
(painful, ragged)
Positive Nikolsky’s sign
Death due to electrolyte imbalance and secondary infection.
148. :Diagnosis confirmed by
Smear taken from base of vesicle (tzank
smear) show tzank cells (acantholytic cells)
High titre of circulating antibodies(IGg4)
against intracellular cementing substance
Direct immunoflouresence
150. Differential diagnosis
Cicatricial pemphigoid & Viral diseases
o Bullae in pemphigus is smaller than mm pemphigoid
and considerably larger than viral diseases such as
herpes and hand-foot-and-mouth disease.
o By immunoflorescence
Erythema Multiforme.
Aphthous ulcers.
152. (b.m.m.pemphigoid (autoimmune
Old age
Oral lesion:
Non keratinized mucosa
Desquamative gingivitis
vesicles that rupture leaving
erosions that spread
peripherally more slowly and
self limited than pemphigus.
Skin lesion:
Large tense bullae
Stay long time rupture
leaving eroded area
Nikolsky’s sign is +ve
