Oral Pathology I Third Year

1. Vesiculo-Bullous Diseases
Aiman A. Ali DDS, PhD.

2. Vesiculo-Bullous Diseases



Viral
Associated with immunologic defects
Hereditary
Aiman A. Ali DDS, PhD.

3. Viral infections of significance
to clinical dentistry
Aiman A. Ali DDS, PhD.

4. Viral infections of significance
to clinical dentistry
 Herpes
Simplex Virus (HSV)
infection
 Varicella-Zoster infections
 Hand, Foot, and Mouth Disease
 Herpangina
 Measles (Rubeola)
Aiman A. Ali DDS, PhD.

5. Herpes Simplex Virus (HSV) infection
Pathogenesis
 DNA
virus.
 Two types HSV1 & HSV2
 Transmitted by physical contact with an infected
person
 Travel through the trigeminal nerve to the t. ganglion
 Become latent in the neural tissue
 With reactivation it travels to the epithelial surface
 Reactivation by exposure to sunlight [fever blister] or
exposure to cold [cold blister] or other factors.
Aiman A. Ali DDS, PhD.

6. Precipitating Factors
Stress
Nutrition
Trauma
Hormonal
Diet
Immunologic

8. Herpes Simplex Virus (HSV) infection
Clinical features (Primary)
 Primary herpetic gigivostomatitis
 Usually affects children
 Vesicular eruption may appear on the
skin vermilion
 In the oral cavity, lesions may appear
on any part of the oral mucosa
 Viremia symptoms: fever, arthralgia,
malaise, headache and cervical
lymphadenopathy
 After 7 to 10 days the lesions heal
without scar
Aiman A. Ali DDS, PhD.

9. Herpes Simplex Virus (HSV) infection
Clinical features (Secondary)
• Usually on the lip and rarely on gingiva
or palate
• Prodromal symptoms
• Within hours multiple fragile vesicles
appear
• Lesions ulcerate and coalesce
• Lesions heal without scaring in 1 to 2
weeks
• Rarely become secondarily infected
• Recurrence vary from 1 per year to 1
per month
Aiman A. Ali DDS, PhD.

10. Herpes Simplex Virus (HSV) infection
Clinical features (Whitlow)





Typically occur in dental
practitioners who don’t use
gloves
and had physical contact
with
infected individuals
Either primary or secondary HSVI
involving the fingers
Recurrent lesions if occurred, would
be expected on fingers
Pain, redness, vesicles that break to
become ulcers
Duration vary from 4 to 6 weeks
Aiman A. Ali DDS, PhD.

11. Herpes Simplex Virus (HSV) infection
Histopathology
 Vesicles are intraepithelial
 Some virus-infected epithelial cells
are seen
 After several days these features
disappear
Aiman A. Ali DDS, PhD.

13. Herpes Simplex Virus (HSV) infection
Differential Diagnosis
 Primary HSV infection
 Streptococcal pharyngitis
 Erythema multiform
 ANUG
 Secondary HSV infection
 Recurrent aphthous stomatitis
Aiman A. Ali DDS, PhD.
 Virus culture, monoclonal antibodies
or DNA hybridization

14. RIH
RAS
Appearance of primary
lesion
vesicle
ulcer
Appearance of mature
lesion
shallow, punctate ulcers
ulcer (with erythematous halo)
Common location
attached gingiva, hard
palate,vermillion border
buccal mucosa, floor of mouth, oropharynx,
vestibule, tongue
Number
few to several
one to few
Lesion duration
1-3 weeks
1-2 weeks
Etiology
Viral
Unclear; immunologically mediated
Prevalence (by
adulthood)
70-80% (HSV-1)
Possibly up to 66%

15. Herpes Simplex Virus (HSV) infection
Treatment
 Time
is very important
 Acyclovir
• Oint 5% 5t. daily when symptoms first appear
• Tab 200 to 400 mg 5t daily is effective
 Vidarabine
or Idoxuridine are effective on
ocular HS but not LHS.
 Primary
HSV infection is best managed
with supportive therapy [fluid, rest, oral
lavage and antipyretics]
Aiman A. Ali DDS, PhD.

16. Varicella-Zoster Infection
Etiology & Pathogenesis
 VZV
is one of the herpes virus
 Cause
primary infection (varicella or
chickenpox) and secondary disease
(herpes zoster or shingles)
 After
primary infection, virus remain latent
in a sensory ganglia
 Reactivation
of latent VZV usually follows
immunosuppressive status, drug
administration, irritation or local trauma
Aiman A. Ali DDS, PhD.

17. Varicella-Zoster Infection
Clinical features (Varicella)
 Common
 Fever,
among children
chills, malaise and headache
 Rash
involves the trunk, head & neck
including oral mucosa
 It
develops into vesicles
ulcerations
 Lesions
pustular
heal after several weeks
 Secondary
infection is common
Aiman A. Ali DDS, PhD.

18. Varicella-Zoster Infection
Clinical features (Herpes Zoster)
• Involvement of 5th nerve result in unilateral oral, facial,
and ocular lesions
• Prodromal symptoms of pain or paresthesia
maculo-papular rash
vesiculo-bullae
Ulcerations
heal after several weeks
• Complications include
• secondary infection
• Post-herpetic neuralgia
• Motor paralysis
• Ocular inflammation
Aiman A. Ali DDS, PhD.

19. Aiman A. Ali DDS, PhD.

20. Hunt’s Syndrome
A
special type of herpes zoster
infection with involvement of the
external ear and oral mucosa
(facial and auditory nerves)

21. Varicella-Zoster Infection
Histopathology
 The
same as those seen in HSV
 Virus
infected epithelial cells
 Homogenous
 In
nuclei
uncomplicated cases, epithelium
regenerates with little or no scar
Aiman A. Ali DDS, PhD.

22. Varicella-Zoster Infection
Differential diagnosis
 HSV
infection:
• Clinical features
• Virus antigen typing using
immunologic tests
Aiman A. Ali DDS, PhD.

23. Varicella-Zoster Infection
Treatment
 Varicella:
• Supportive therapy
• In immunocompromised patients more
substantial measures are indicated
 Herpes
zoster:
• The same for HSV but in high dose
• Acyclovir 800 mg x 5 x 7 to 10 days
• Analgesics
 Corticosteroids
Aiman A. Ali DDS, PhD.
are contraindicated

24. Hand foot & mouth disease
Etiology & Pathogenesis
 Coxsackie
virus
• CV type A
• CV type B
 A16,
and occasionally A5, A9, A10, B2
and B5 cause HFM disease
 HFM is a highly contagious infection
 Virus transmission: through airborne
spread or oral-fecal contamination
Aiman A. Ali DDS, PhD.

25. Hand foot & mouth disease
Clinical Features
• Affect children under the age 5 years (epidemic)
• Resolve spontaneously after 1 to 2 weeks
• Signs and symptoms of viremia (low grade)
• Oral lesions: multiple vesicles
Ulcers
covered by yellow membrane surround by
erythema
• Occur anywhere of the oral cavity
• Hand and feet lesions are maculopapular
with or shortly after the oral lesions
vesicles
ulcers
Aiman A. Ali DDS, PhD.

26. Hand foot & mouth disease
Histopathology
 Vesicles
are intraepithelial
 The vesicle cavity filled with
proteinaceous debris and
inflammatory cells
Aiman A. Ali DDS, PhD.

27. Hand foot & mouth disease
Differential Diagnosis
 Primary
HSV infection and varicella:
• Milder symptoms
• Cutaneous distribution
• Virus culture or detection of antibodies

Recurrent Aphthous
Aiman A. Ali DDS, PhD.

28. Hand foot & mouth disease
Treatment
 Symptomatic
Aiman A. Ali DDS, PhD.
therapy

29. Herpangina
Etiology & Pathogenesis
 Coxsackie
type A (A1-6, A8, A10, A22,
B3 and possibly others)
 Transmission through contaminated
saliva
Aiman A. Ali DDS, PhD.

30. Herpangina
Clinical Features
 Common in summer and in children
 Pain, malaise, fever, dysphasia and sore throat
 Oral vesicular eruption on the soft palate, faucial
pillars and tonsils
 Pharyngitis
 Lesions last less than 1 week
Aiman A. Ali DDS, PhD.

31. Herpangina
Differential Diagnosis
 HSV
infection, HFM and varicella
• Clinically
• Short duration
 Streptococcal
Pharyngitis
• Vesicular eruption
• Summer presentation
• Mild symptoms
 Aphthous
stomatitis
• Systemic symptoms
Aiman A. Ali DDS, PhD.

32. Herpangina
Treatment
 Treatment
required
Aiman A. Ali DDS, PhD.
is usually not

33. Measles (Rubeola)
Etiology & Pathogenesis
 Highly
contagious
 Measles virus (DNA paramyxovirus)
Aiman A. Ali DDS, PhD.

34. Measles (Rubeola)
Clinical Features
 Commonly affect children in winter and spring
 incubation period of 7 to 10 days
 Fever, malaise, conjunctivitis and cough
 After 2 days small macules with white necrotic center
(Koplik’s spots) appear in the buccal mucosa
 After 2 days skin rash appear initially on the head and
neck followed by the trunk and then the extremities
Aiman A. Ali DDS, PhD.

35. Measles (Rubeola)
Histopathology
 Warthin-Frankeldey
giant cells are
seen in lymphoid tissue
 Infected epithelial cells which become
necrotic
Aiman A. Ali DDS, PhD.

36. Measles (Rubeola)
Diagnosis
 Usually
•
•
•
•
made on:
Clinical signs and symptoms
Prodromal symptoms
Koplik’s spots
If necessary, serologic test for
antibodies to measles virus
Aiman A. Ali DDS, PhD.

37. Measles (Rubeola)
Differential Diagnosis
M. Rubeola
Rubella (German M.)
• Paramyxovirus Family
• Togavirus Family
• Contagious
• Contagious
• (sever) Fever respiratory
symptoms and rash
• (mild) Fever, respiratory
symptoms and rash
• Koplik's spots
• no Koplik's spots
• Does not cause developmental abnormalities in
the fetus
• Cause developmental
abnormalities in the
fetus
Aiman A. Ali DDS, PhD.

38. Measles (Rubeola)
Treatment

Supportive treatment:
•
•
•
•
Bed rest
Fluids
Adequate diet
Analgesics
Aiman A. Ali DDS, PhD.

39. ‫حادي العيس‬