PRIMARY LESION

primary lesion

are those lesions that arise de novo

the most characteristic of the disease process

changes in your skin that aren't associated with other conditions

7 most common types of primary lesions

macules

papules

nodules

pustules

bullae

tumescence

vesicles

wheal (mosquito bite size; skin test)

macules

size of a pin head to several centimeters

flat well circumscribed colored area of tissue that varies in size color & shape

example of macules

freckles

flat moles

petechiae

measles

color of macules

red-brown-white- black

3 types of macules

pigmentary

erythematous

petechia & ecchymosis

erythematous

its color fades away when pressure is applied

simple erythema caused by localized congestion in the vascularized bed

cause of erythematous

chemical (caustic drugs)

thermal (hot & cold beverages)

clinical features of erythematous

red area is tender & painful

blanches on pressures (turns white)

it’s size & shape depends on the caustic agent

aspirin burns

good examples of caustic drugs causing palatal burns which can lead to erythematous macule

common sites of erythematous

buccal & palatal mucosa

management of erythematous

if pain is present prescribe:

• analgesic

• topical application of hydrocortisone emollient base (kenalog in orabase)

[ majority of these cases are mild & painless ]

petechia & ecchymosis

the red color does not disappear on pressure

they are considered as subcutaneous or submucosal hemorrhages

palatal patches deserve special attention when it occurs as a solitary lesion at the junction of the hard and soft palate

if examined, it’s immediately 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)

color of petechia & ecchymosis

red-brown → results from hemorrhages into the tissue

cause of petechia & ecchymosis

results from hemorrhages into the tissue

due to physical trauma or blunt traumatic insult to the tissue

clinical features of petechia & ecchymosis

borders are poorly demarcated

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

does not blanch under pressure bc the RBC is located within the tissue rather than in the vessels

common sites of petechia & ecchymosis

palate

buccal mucosa

floor of the mouth

management of petechia & ecchymosis

self-limiting and removal of the cause

avoid trauma, usually persist 4-5 days

if continuous episodes, must have a systemic problem and should be examined for presence of hemostatic defects such as thrombocytopenia, leukemia, hemophelia, SBE therefore refer!

other diagnosis for petechiae & ecchymosis

trauma from fellatio

signs of hemostatic disease

signs of infectious monoculeosis

trauma from severe coughing & vomiting

signs of hemostatic disease

blood testing required to identify the disease or blood dyscrasia

signs of infectious mononucleosis

caused by the epstein-barr virus (EBV)

kissing disease, is transmitted through saliva

glandular fever, malaise, enlarged nodes in the neck

often appears early, sometimes before the patient feels ill

sometimes appears between the 5th or 12th day of illness

small red or purple spots (6-20 petechiae) in the soft palate

have the same clinical features but differ in size

purpura → 4mm, 10mm

ecchymosis → larger than 1cm

petechiae → pinpoint, less than 4mm

color of pigmentary macules

brown to black extrinsic pigmentation

2 types of pigmentary macules

physiologic pigmentary macules

pathologic pigmentary macules

2 types of physiologic pigmentary macules

mccune albright syndrome

von recklinghausen syndrome

2 types of pathologic pigmentary macules

addison’s disease

peutz jegher syndrome

examples of physiologic pigmentary macules

albinism

melanosis

ephelis (freckles)

smokers melanosis

labial melanotic macule

melanoplakia (black pigmentation)

cause of physiologic pigmentary macules

unknown, but has been postulated that maybe due to trauma or post inflammation

if unusual sign is seen, biopsy test is required to confirm diagnosis

clinical features of physiologic pigmentary macules

light brown to black

deeper & heavier the deposit of melanin, the more darker it appears

lightly tanned individuals → even coloration but dark complexion frequently have macules of pigmentation

melanoplakia

aka: black pigmentation

dark pigmented plaques in the oral cavity

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

melanosis

ex: cigarette smoking → stimulates melanocytes

increased / abnormal melanin pigmentation in tissues

albinism

melanin formation is impaired by congenital decrease in tyrosinase

mccune albright syndrome

a disease that affects the bones, skin, endocrine system

it is not inherited & passed down from generation to the next

due to a change (mutation) in a gene that occurs by chance in the womb

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

cause of mccune albright syndrome

it is caused by mutations in the GNAS1 gene

the mutation is sporadic (occurs in the womb during fetal development)

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

symptoms of mccune albright syndrome

range from mild to severe

related to bones, endocrine system & skin

physical examination findings of mccune albright syndrome

acromegaly

hyperthyroidism

precocious puberty

adrenal abnormalities

may experience kidney issues

café-au-lait (birthmark) spots/patches

skeletal deformities and fibrous dysplasia

renal involvement —> up to 50% of patients

mccune albright syndrome in endocrine system

precocious or very early puberty

• boys → less noticeable symptoms

• girls → early puberty with menstrual bleeding before age 2

mccune albright syndrome in thyroid function

thyroid gland is small in the neck that affects the metabolism

majority have a thyroid problem (presence of enlarge mass nodules/cyst)

mccune albright syndrome in growth hormone (skeleton)

treatment: surgery & medication

excess pituitary growth hormone resulting to:

• coarse facial features

• larger hands, feet, arthritis

von recklinghausen syndrome

no prevalence for gender and race in NF1

it is an inherited autosomal dominant trait, therefore it is hereditary condition

neurofibromatosis type 1 (NF1)

the most common form of von recklinghausen syndrome.

primary adrenal insufficiency

highly reliable sign of von recklinghausen syndrome (butterfly rash)

skin manifestations of von recklinghausen syndrome

multiple neurofibromas

café-au-lait pigmentation

cardiovascular abnormalities

bone lesions (short statute, scoliosis)

neurological issues (seizures, mental deficiency)

lisch nodules → pigmented hemartomas of the iris (translucent brown spots)

common skin manifestation of von recklinghausen syndrome

multiple neurofibromatosis

oral manifestation of von recklinghausen syndrome

overgrowth of the alveolar ridge

severe periodontitis & calcular deposits

presence of impacted displaced or missing teeth in the mandible

hemifacial disfigurement → caused by plexiform neurofibroma of the trigeminal nerve

common site of von recklinghausen syndrome

tongue, buccal mucosa

radiographic findings of von recklinghausen syndrome

enlarged mandibular canal, mandibular foramen, mental foramen

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

management of pathologic pigmentary macules

if suspected, should not begin treatments seek medical consultation

addisons disease

caused by adrenocortical insufficiency due to immune attack

adrenal glands don’t produce enough of the hormones cortisol and aldosterone.

cause of pigmentation in addisons disease

bilateral tumor metastasis

amyloidosis (protein buildup)

idiopathic atrophy of adrenal glands

leukemic infiltration of the adrenal glands

bilateral adrenocortical destruction (after TB)

S/S of adrenocortical insufficiency

nausea

weakness

weight loss

hypotension

cheek

the most common site for pigmentation → also evident systemic lupus erythematosus SLE (butterfly rash)

management of adrenocortical insufficiency

supplemental corticosteroids medication

—always required prior to dental treatment to cope up with adrenal insufficiency during stressful treatment

peutz jegher syndrome

an autosomal dominant condition

characterized by:

• mucocutaneous freckling

• hamartomatous polyps of the GI tract (intestinal polyposis found in the jejenum)

common sites of peutz jegher syndrome

buccal mucosa, gingiva, hands, feet

similar to ephelides (freckles) but with a peri-oral distribution (around the lips)

subjective symptoms of peutz jegher syndrome

diarrhea

abdominal pain

rectal bleeding

papules

size of a pin head to about 5mm

solid elevation less than 0.5cm in diameter

shape is round to more or less polygonal

circumscribed superficial elevated areas varying in size

eroded or overlaid surface or moist epithelial desquamation

example of papules

wart

lichen planus

elevated moles

allergic eczema

colors of papules

red-yellow-white- bluish red

cause of papules

unknown, maybe due to psychologic problem like deep emotional strain and remission after a personal crisis

other causes of papules

diabetes mellitus

mechanical irritation

galvanic currents (unlike metals)

characteristics of papules

flat, conical, circular

pointed to umbilicate

elevated and raised bumps

common sites of papules

vermillon border

floor of the mouth

buccal mucosa (85%)

gingiva, tongue, palate

management of papules

topical application of cortisone (3x/day)

lichenoid drug reaction

has a clinical feature of lichen planus

caused by:

• drugs like beta blockers

• antibiotics (tetracycline, streptomycin)

• metallic drugs (gold, salts, arsenical, mercury)

• anti-inflammatory or nonsteriodal (indomethacin)

management:

• removal of causative factor

5 forms of papules

reticular

papular

erosive

atrophic

bullous

reticular papules

ex: striae of wickham

type of papules that has lacework of intersecting white lines

papular papules

type of papules that acne is an example

erosive papules

type of papules that has presence of squamous cells

atrophic papules

type of papules that has presence of carcinoma

bullous papules

type of papules that has malignant lesion

nodules

no pathological reactions

solid elevation 0.5-1cm in diameter

larger than papules, deep seated in submucosa

cause of nodules

may be of traumatic origin

associated with rheumatoid arthritis, leprosy and syphilis

no pathological reactions (not associated with infection, malignancy, or pathological conditions)

examples of nodules

epstein pearls

tonsil nodules

moles, lipoma

bohn’s nodules

erythema nodosum

tonsil nodules

an example of nodules that is seen on the lingual tonsils in lateral base of the tonguefoliate papilla

epstein pearls

due to arises from the mucosa gland elements

an example of nodules that is seen on palates of new born infants. (palatine cyst)

bohn’s nodules

due to remnants of dental lamina, will exfoliate on its own

an example of nodules that is seen on the buccal alveolar ridge of newborn infants

pustules

contains pus, serum fluid surrounded by area of erythema

vesicles but differs from it’s location → infrequent in oral mucosa

considered cutaneous lesion (skin) seen as superficial elevated lesions

example of pustules

acne

impetigo

psoriasis

superficial bacterial disease

psoriasis (pustular)

chronic inflammatory skin condition (itchy, scaly patches)

treatment of pustules

antibiotics

cause of pustules

staphylococci, streptococci

source of infection of pustules

pets

turkish bath

beauty parlor

swimming pool

dirty fingernails

bullae or blebs

has a roof cavity more resistant to rupture

deep seated, larger than vesicles greater than 0.5cm

rubbing of non-vesiculated area may result in a formation to a vesicles or denudation of the mucosa or epidermis. (nikolsky sign) + to stippling off epithelium

examples of bullae or blebs

burn, ranula

pemphigus

behcets syndrome

steven johnson syndrome

ranula

mucous retention cyst on the floor of the mouth

treatment of bullae or blebs

corticosteroid therapy

cause of bullae or blebs

autoimmune mucocutaneous disease → characterized by intra-epithelial blister formation

tumescence

these lesion maybe reactive (non-cancerous) or neoplastic (tumor-related) in character unless confirmed by biopsy

examples of tumescence

papilloma

cyst, torus

tumor, epulis

polyps, exostosis

cyst

fluid-filled sac that can develop in various tissues, often benign

torus

bony growth in the oral cavity, especially in the palate or mandible

tumor

means swelling

solid mass larger than 1cm

abnormal growth of tissue, can be benign or malignant.

an example of tumor

squamous cell carcinoma

epulis

benign growth in the gum tissue, often caused by irritation or trauma.

polyps

abnormal tissue growth, can be benign or precancerous

exostosis

bony overgrowth on the surface of bones, typically benign

papilloma

benign growth caused by the human papillomavirus (HPV)

refers to a small nipple shaped epithelial tumor which cells are covered with finger like process of stroma neoplastic lesion

vesicles

small blister consist of fluid, serum, plasma, blood

flat, globoid or umbilicate, tense or flaccid in character

examples of vesicles

chicken pox

herpetic gingivostomatitis