P3-OD-PRIMARY LESIONS BETTER

Primary lesion

These lesions that arise de novo and are therefore the most characteristic of the disease process

ERYTHEMATOUS MACULES

This type of macule is caused by localized congestion in the vascularized bed. It is also a first degree burn.

✓ Bullae/ blebs

✓ Macules

✓ Nodules

✓ Papules

✓ Pustules

✓ Tumescences

✓ Vesicles

"Baguio May Never Plant Purple Tulip Valleys."

Enumerate the 7 types of primary lesions that may occur in the oral cavity and skin as a disease.

✓ trauma

✓ mastication

✓ maceration (softening and breaking down of skin resulting from exposure to moisture)

✓ movement of tissues

✓ time

Primary lesions usually DO NOT retain their initial appearance because they are altered by _____________?

MACULES

Flat and well-circumscribed colored areas of tissue that vary in size, color, & shape.

pin head to several centimeters

Describe the SIZE of macules.

✓ Red

✓ Brown

✓ White

✓ Black

COLOR of Macules (give at least one)

1. Erythematous

2. Petechiae and Ecchymosis

3. Pigmentary Macules

"Egg, Pie and Egg, Pie Madness"

Three (3) TYPES of Macules

➢ Thermal (hot & cold beverages)

E.g. Extreme cold (frost bite) can cause vasoconstriction → low blood supply → first degree (erythematous) → black discoloration

➢ Chemical (caustic drugs)

E.g. Aspirin - do not place aspirin for too long in your mouth because it can cause a chemical burn (aspirin has acid in it and acid causes burning).

Enumerate the CAUSES of erythematous macules. (in the mouth)

✓ Red area : (tender & painful)

✓ Blanches on pressures (turns white)

✓ Size and shape: (depend on the caustic agent)

✓ Common sites: Buccal and Palatal mucosa

✓ Palatal burns: (ex. aspirin burns_

CLINICAL FEATURES of macules.

if pain is present, prescribe:

✓ Analgesic / Topical application of hydrocortisone emollient base (Kenalog in Orabase)

What is the management plan for Macules:

(Note: The majority of these cases are mild & painless.)

PETECHIAE and ECCHYMOSIS

This type of macule results from hemorrhages into the tissue / damage to the tissue.

When purpura spots are less than 4 mm in diameter, they are called petechiae. Purpura spots larger than 1 cm (centimeter) are called ecchymoses.

petechiae = < 4 mm

ecchymoses = 1 cm <

What is the difference between ecchymosis and petechiae?

Answer: TRUE

color of Petechiae and Ecchymosis = red. (The color red does not disappear on pressure.)

True or False:

Petechiae and Ecchymosis DO NOT blanch (color fades away when pressure is applied).

➢ Physical trauma or blunt traumatic insult to the tissue.

- If examined, it is red in color but when sufficient time has lapsed, it will permit the breakdown of the hemoglobin pigment, and turns bluish in color (bluish brown)

CAUSES of Petechiae and Ecchymosis.

The size varies according to the forces of the physical agents inflicting the damage.

✓ borders are poorly demarcated.

✓ does not blanch under pressure because the RBC is located within the tissue rather than in the vessel.

CLINICAL FEATURES of Petechiae and Ecchymosis.

external trauma on body surface → (blood vessels rupture → bleeding under the skin)

How does a hemorrhage occur?

✓ Self-limiting

✓ Removal of the cause

✓ Avoid trauma (usually persist 4 to 5 days)

✓ Palatal petechiae & ecchymosis patches deserve special attention when they occur as a solitary lesion at the junction of the hard & soft palate.

MANAGEMENT of Petechiae and Ecchymosis.

✓ Palate

✓ Buccal mucosa

✓ Floor of the mouth

COMMON SITES of Petechiae and Ecchymosis.

✓ 4-5 days

Duration of Petechiae and Ecchymosis.

✓ thrombocytopenia

✓ leukemia

✓ hemophilia

- affects clotting factors

Hemophilia A – factor VIII

Hemophilia B – factor IX

Hemophilia C – factor XI

✓ SBE

Note:

A complete blood workout should be done to be able to reach a diagnosis.

- CBC

- CT

– BT

- PT

- PTT

If continuous episodes of petechiae and ecchymosis happen, the patient must have a systemic problem and should be examined for the presence of hemostatic defects such as:

✓ Hemophilia A – factor VIII

✓ Hemophilia B – factor IX

✓ Hemophilia C – factor XI

What clotting factors are affected by hemophilia A, B and C?

a. Dengue Fever

b. Idiopathic Thrombocytopenic Purpura

c. Trauma from fellatio

d. Trauma from severe coughing & vomiting

e. Signs of infectious mononucleosis

f. Hemostatic diseases

What are OTHER POSSIBLE DIAGNOSES that can be rolled out based on the presence of petechiae and ecchymosis?

Ans. trauma from fellatio

"..Seen mostly on the posterior palate - the bruise will disappear in a few days after passing the various colors of blue, green, and yellow"

3 multiple choice options

Color and shape:

linear red or bluish bruise

Location:

at the junction of the hard & soft palate

APPEARANCE of trauma from severe coughing & vomiting.

✓ Appears with 6 to 20 petechiae in the soft palate before the patient becomes ill

✓ This petechiae may also occur between the 5th & 12th days of illness. (in the middle of the duration)

✓ It goes along with malaise, enlarged nodes in the neck

Enumerate the SIGNS of infectious mononucleosis.

A macule can be a variety of colors based on the cause.

Ex. Macules can be moles (which are hyperpigmented, or darker, relative to the skin) or vitiligo lesions (which are hypopigmented, depigmented, or lighter, relative to the skin).

Describe the CONCEPT of pigmentary macules.

Ans. Brown to black (extrinsic pigmentation)

COLOR of pigmentary macules.

PHYSIOLOGIC

Also known as "genetic makeup"; this feature/characteristic of pigmentary macules is part of the person already.

Unknown, but has been postulated that macules maybe due to trauma or post inflammation.

ETIOLOGY of pigmentary macules

- Light Brown to Black

- The deeper & heavier the deposit of melanin, the darker it appears

- Light-tanned individuals have normally even coloration, but dark complexion frequently have macules of pigmentation.

CLINICAL FEATURES of pigmentary macules.

Other diagnosis:

a. Ephelis (Freckles)

b. Melanosis

c. Melanoplakia (Black pigmentation)

d. Albinism

e. McCune-Albright syndrome

f. Von Recklinghausen's Disease (Neurofibromatosis 1)

What are OTHER POSSIBLE DIAGNOSES that can be rolled out based on the presence of pigmentary macules?

MELANOSIS

(pigmentary macule)

An abnormal melanin pigmentation of oral mucosa

- usually occurs on the gums

- e.g. cigarette smoking

– stimulates melanocytes

MEALNOPLAKIA (Black pigmentation)

(pigmentary macule)

- People have discernible degree of melanin pigmentation distributed throughout the epidermis of the skin/mucosa

- Usually occurs on the lips

ALBINISM

It happens when melanin formation is impaired by congenital decrease in tyrosinase

McCune-Albright syndrome

- It is associated with mosaicism, meaning that the abnormal genes is present in a fraction, but not all, of the patient cells

- results from a change (mutation) in a gene that occurs by chance in the womb; mutations in the GNAS1 gene

Ans. Both statements are TRUE.

Rationale:

McCune-Albright syndrome is not inherited. Instead, it is caused by a random mutation in the GNAS gene that occurs very early in development.

As a result, some of the body's cells have a normal version of the GNAS gene, while other cells have the mutated version. This phenomenon is called mosaicism.

True or False:

Mc.Cune-Albright syndrome is not inherited and not contagious.

HYPEROCCLUSION

Definition: Whole biting pressure is focused on that area.

Premature contacts

This happens when there is not enough insulation of pulp; exposed dentin.

Sepsis

A serious condition in which the body responds improperly to an infection

Diazepam + Alcohol: Death

Give an example of POTENTIATION.

Antibiotics will have no effect because alcohol will compete and attach to the receptor that the antibiotic is supposed to attach to.

Antibiotics + Alcohol = ?

Antagonism Oplates + Naloxone = Narcotic

Antagonism Oplates + Naloxone = ?

Corticosteroids

Drugs that delay wound healing.

Antihistamine

Effect is for the lungs, causes drowsiness in the brain (Histamine recognizes irritant; causes bronchoconstriction. With antihistamine, it lower down your senses.)

Phenytoin

For gingival enlargement.

fibrous dysplasia of bone (FD)

Description:

- larger bone

- scar-like tissue

- happens with weight bearing bones such as legs causing limping, deformity & fracture.

- no treatment, but surgery may correct fractures and deformities

café-au-lait skin spots

skin; patches of increased or darker skin coloring

precocious puberty (PP)

In the endocrine system; irregular function of growth-regulating glands that produce hormones.

- early puberty like menstrual bleeding before 2 years of age

- boys shows less signs than girls

Thyroid Function - thyroid gland is small in the neck that affects the metabolism.

- majority have thyroid problem, like presence of enlargement or masses (nodules/cyst).

- Hyperthyroidism

➢ Growth Hormone

- too much pit. growth hormone. resulting to coarse facial features like larger hands & feet & arthritis.

- Acromegaly

- Abnormal bone growth in the skull can lead to blindness or deafness due to pinched nerves

- Deformities may be seen in the frontal bone and can cause cosmetic problems

Other effects of McCune-Albright syndrome on the endocrine system:

Cushing Syndrome

- too much pituitary growth hormone resulting to coarse facial features, larger hands & feet & arthritis.

- Tx: medication & surgery

Von Recklinghausen's Disease (Neurofibromatosis 1)

- INHERITED autosomal dominant condition (difference with McCuneAlbright syndrome)

- It has eight (8) category but most common is NF1.

- NO prevalence for gender and race in NF1.

-also manifest café-au-lait spots

multiple fibromatosis that occurs in any part of the body

Von Recklinghausen's Disease: most common sign on the skin is?

lisch nodules

pigmented hemartomas of the iris; translucent brown pigmentation spots in the iris

crowe's sign

inguinal and axillary freckles is usually present in this sign

- bone lesion

- cardiovascular and neurological abnormalities

- mental deficiency

- seizures

- short statute

- scoliosis

MANIFESTATIONS of Von Recklinghausen's Disease (Neurofibromatosis 1).

- tongue and buccal mucosa are affected

- hemifacial disfigurement caused by plexiform neurofibroma of the trigeminal nerve

- presence of impacted, displaced or missing teeth in the mandible and overgrowth of the alveolar ridge

- may have severe periodontitis & calcular deposits.

ORAL MANIFESTATIONS of Von Recklinghausen's Disease (Neurofibromatosis 1).

-enlarged mandibular canal, mandibular foramen, mental foramen → displaced teeth

- Neurofibroma can develop intraosseously resulting to well demarcated unilocular & multilocular radiolucent lesion

RADIOGRAPHIC FINDINGS of Recklinghausen's Disease (Neurofibromatosis 1).

➢ Bilateral Adrenocortical Destruction after TB

➢ Idiopathic Atrophy

➢ Bilateral Tumor Metastasis

➢ Leukemic Infiltration

➢ Amyloidosis of Adrenal Cortex (adrenocortical insufficiency) Addisons disease

PATHOLOGIC causes of Pigmentary Macules

Weakness

- Weight loss

- Nausea

- Vomitting

- Hypotension

- The cheek is the most common site for pigmentation. Highly reliable sign in primary adrenal insufficiency.

Signs & Symptoms of Adrenocortical Insufficiency

- If suspected should not begin treatment, seek medical consultation first.

- Supplemental corticosteroids medication is always required prior to dental treatment to cope up with adrenal insufficiency during stressful treatment.

Management for adrenocortical insufficiency in the dental setting.

a. Addisons disease

b. Peutz Jegher syndrome

c. Systemic Lupus Erythematosus

Other diagnosis aside from Adrenocortical Insufficiency:

Peutz Jegher syndrome

Inherited autosomal dominant may be a causative factor

- similar to ephelides but distribution seen around the lips (peri-oral distribution)

- seen around the lips, buccal mucosa, gingiva, hands, and feet.

abdominal pain, rectal bleeding, and diarrhea

Subjective symptoms of intestinal polyps

Systemic Lupus Erythematosus

This is an autoimmune disease in which the immune system attacks its own tissues - supplemental corticosteroid is given to suppress the immune system.

TRUE: Intestinal polyposis found in the jejenum is a manifestation of the perioral pigmentation.

TRUE or FALSE:

Intestinal polyposis found in the jejenum is a manifestation of the perioral pigmentation.

Butterfly Rash

Common sign of SLE (SYstemic Lupus Erythematosus)

Give prophylactic antibiotic for 7 days

Tx. for SLE

PAPULES

- ELEVATED

- usually associated with stress

- Size = pinhead but measures greater than 0.5cm

- Shape = flat, conical, circular, pointed to umbilicated, has elevated and raised bumped.

Describe PAPULES.

a. pimples

b. lichen planus

EXAMPLES of papules.

➢ Unknown, maybe due to psychological problem like deep emotional strain and remission after a personal crisis personal crisis.

➢ Other causative factors:

- Diabetes Mellitus

- Mechanical Irritation

- Galvanic Currents

- dissimilar metal components (e.g. amalgam + stainless steel resto)

CAUSATIVE FACTORS of papules.

1) Reticular - lacework of intersecting white lines (striae of Wickham – in cheek biting)

2) Papular – looks like pimples

3) Erosive - presence of squamous cells

4) Atrophic - presence of carcinoma

5) Bullous – malignant in nature

BREAP - Bullous, Reticular, Erosive, Atrophic, Papular

CLINICAL FEATURES of papules.

- Buccal Mucosa (85%)

- Gingiva

- Tongue

- Palate

- Floor of the Mouth

- Vermillon Border

SITES where papules are seen.

✓ topical application of cortisone (3x/day)

MANAGEMENT for papules.

This has clinical features of lichen planus.

- drugs like

• beta blockers,

• metallic drugs (gold, salts, arsenical, mercury, • anti-inflammatory (non-steroidal like indomethacin)

• and antibiotics (tetracycline and streptomycin)

describe Lichenoid Drug Reaction

Remove the causative factor

MANAGEMENT for Lichenoid Drug Reactions

➢ macules - flat and have causative factors

➢ papules - elevated and no causative factors

DIFFERENTIAL DIAGNOSIS for macules and papules.

no pathological reactions.

- these are elevated circumscribed solid lesion.

- It is enlarged papules deep seated which involves the submucosa or lower dermis of the skin

describe NODULES

a. Bohn's Nodule

b. Epstein Pearls

c. Tonsil nodules

d. Rheumatoid nodules

EXAMPLES of nodules.

Bohn's Nodules

-seen on buccal ridge; alveolar ridge of new born infants

- multiple white nodules and will be exfoliated by itself.

Remnants of the dental lamina

CAUSE of Bohn's Nodule

Epstein Pearls

seen on palates of newborn infants. (palatine cyst)

cause : arises from the mucosa gland elements

Tonsil nodules

This is seen on the lingual tonsils in lateral base of the tongue-foliate papilla

Rheumatoid nodules

This is common in rheumatoid arthritis and appear in approximately 25% of patients.

VESICLES

circumscribed single or group elevations of the epithelium of the skin or mucous membrane which consist of serum, plasma, and blood.

- 2nd degree burns

e.g. Herpetic gingivostomatitis – from painful vesicles → ulcers

Viral infection - chicken pox (varicella)

CAUSES of VESICLES

PUSTULES

-have pus (usually caused by infection; bacteria)

- considered cutaneous lesion (skin)

- seen as superficial elevations which contains pus, serum, and fluid surrounded by area of erythema.

- like vesicles, but differs in location and infrequent in oral mucosa.

➢ Psoriasis

➢ Impetigo

➢ Superficial Bacterial Disease

- All three are caused by staphylococci & streptococci

- Usually occurs during summer or hot months, humid weather and commonly seen in children.

✓ Tx: antibiotics

EXAMPLES of pustules.

- Pets,

- Dirty Fingernails,

- Beauty Parlor,

- Swimming Pool,

- Turkish Bath

Sources of infection for pustules.

Bullae or Blebs

- larger than vesicles and deep seated and has a roof cavity

- more resistant to rupture

- rubbing of non-vesiculated area may result in a formation to a vesicle

- denudation of the mucosa or epidermis -

Nikolsky sign

- positive to stippling of epithelium.

➢ Autoimmune Mucocutaneous Disease characterized by Intraepithelial Blister

CAUSES of Bullae/ Blebs

➢ Pemphigus

➢ Behcets Syndrome,

➢ Steven Johnson syndrome

➢ Ranula

EXAMPLES of Bullae/ Blebs

✓ Corticosteroid Therapy

- immunosuppressive drug

- will not recognize good and bad bacteria

MANAGEMENT for Bullae/Blebs

TUMENSCENCES

-these lesion maybe reactive or neoplastic in character.

- non-neoplastic lesions, unless confirmed by biopsy.

- Tumor

- is not synonymous with cancer, it simply refers to a a swelling (e.g. dental abscess)

- Cyst (e.g. eruption cyst)

- Epulis (e.g. epulis fissuratum

- surgically remove the lesion and remove denture)

- Exostosis,

- Torus

- Papilloma

- Polyps (e.g. pulp polyp)

EXAMPLES of Tumenscences

This is caused by both hot and cold (frost bite)

1st degree – ERYTHEMATOUS MACULES

- tender (painful on palpation), and painful even if not palpated

2nd degree – VESICLES / BLEB

Describe the concept

Oral Lesion

focal hyperkeratosis, nicotine stomatitis, lichen planus, leukoplakia, cheek biting

Keratosis

abnormal thickening of the outer layer of the epith. Of the mucous membrane or the skin. Ex. Actinic keratosis (solar keratosis)

Papillometoid

refers to nonneoplastic lesion.

• Keratosis - abnormal