Ebook Concise oral medicine: Part 1

(BQ) Part 1 book “Concise oral medicine” has contents: Ulcerative and vesiculobullous lesions, red and white lesions, gingival enlargement, tongue lesions, granulomatous diseases and STDs, cross-infection control,… and other contents.

Concise Oral Medicine

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CBS Publishers & Distributors Pvt Ltd

New Delhi • Bengaluru • Chennai • Kochi • Kolkata • Mumbai • Pune

Hyderabad • Nagpur • Patna • Vijayawada

Professor and HeadDepartment of Oral Medicine and RadiologyGovernment Dental College and Hospital

Mumbai

Concise Oral Medicine

Science and technology are constantly changing fields New research and experience broaden the scope of information and knowledge The authors have tried their best in giving information available to them while preparing the material for this book Although, all efforts have been made to ensure optimum accuracy of the material, yet it is quite possible some errors might have been left uncorrected The publisher, the printer and the authors will not be held responsible for any inadvertent errors, omissions or inaccuracies

eISBN: 978-93-885-2793-4

Copyright © Authors and Publisher

First eBook Edition: 2018

All rights reserved No part of this eBook may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system without permission, in writing, from the authors and the publisher

Published by Satish Kumar Jain and produced by Varun Jain for

CBS Publishers & Distributors Pvt Ltd

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Kochi: 36/14 Kalluvilakam, Lissie Hospital Road, Kochi - 682018, Kerala

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Kolkata: No 6/B, Ground Floor, Rameswar Shaw Road, Kolkata - 700014

my wife, Vasu and

my daughters Medha and Anagha

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After Concise Oral Radiology was well-received by the undergraduate students, I had the

temptation of compiling a similar text on oral medicine and for this endeavor I was

encouraged and even goaded by many PG students and lecturers

The basic motive behind this venture is to present important aspects of oral medicine readily

available in various textbooks in a nutshell, to help the exam-going students too hard pressedfor time to refer to various books

Again I would make no claim regarding the originality of the text in Concise Oral Medicine,

on the other hand I may be guilty of ruthlessly cutting down on a lot of information with theprimary aim of keeping the text short and simple

During my tenure as a student and a teacher, I had the privilege of learning this subjectunder the erudite guidance of stalwarts of oral medicine in India namely Dr Girish Merchant,

Dr Aspi Surveyor, Dr Jakhi, Dr Ani John, Dr Bharati Parekh and Dr RN Mody I will foreverremain indebted to these dedicated teachers In fact this text has its roots in the notes madeduring their lectures

Compilation of this book, however, concise, was a challenge to my lazy nature and scepticalattitude and without the active participation of many individuals, it would have beenimpossible to accomplish this task Dr Eswaran Ramaswamy and Dr Akshay Chaturmohattaspearheaded the venture by compiling the first few chapters Dr Harsha Puri, Dr AmrutaBandal and Dr Ashish Talanje were lecturers in the department and of great help in this venture

I relied heavily on the selfless efforts provided by lecturers Dr Suvarna Sawant,

Dr Hasan Ali, Dr Prashant Salve, Dr Kavita Amale and postgraduate students Dr ManasiKajale, Dr Minakshi Hivarkar, Dr Priyanka Verma, Dr Pooja Jain, Dr Ajas Gogri, Dr DeepikaKhurana, Dr Sunita Kakade and I express my heartfelt gratitude to all of them and manyothers whom I might have failed to mention

I owe a debt of gratitude to Dr Smriti Khanna, Lecturer, Oral Pathology, for diligent proofreading of a few chapters and Dr Nitin with artistic talent for the line diagrams and also to

Mr Ashish Jalamkar and Mr Vikas Jadhav for converting old departmental slides into goodquality pictures

Dr Shruti Shah was ever helpful and efficiently completed the laborious task of adding thecolor pictures with legend and overall preparation of the manuscript

I am extremely grateful to Dr Nandita Gupta for the preparation of index and Dr VarunManek for providing constructive criticism which helped in improving the content of thebook

I consider myself blessed, that I am associated with Government Dental College and Hospital,Mumbai, a great institution which has always encouraged me and almost all the cases presented

in this text belong to the patients attending the heavy OPD of GDCH and obtained with courtesyfrom the ever helpful staff and PG students

Preface

Dr Sonali Kadam, Associate Professor, has always been co-operative and supportive and

I express my gratitude to her for all the help

With Dr Jagdish V Tupkari, HOD, Oral Pathology, I have always enjoyed good rapport andbenefited immensely by his knowledge, wisdom and wit and willingness to offer a helpinghand

I will always remain indebted to Dr Mansing G Pawar, Dean, GDCH, for constant supportand I always felt encouraged in this institution because of him

Mr YN Arjuna and Mr Ramesh Krishnammachari of CBS Publishers always provided allthe assistance and it was their enthusiasm which made this text a possibility I also wish toexpress my gratitude to CBS Publishers & Distributors as without their efforts this book wouldnot have been published

HR Umarji

Preface vii

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ORAL MEDICINE

Oral medicine may be defined as the branch

of dentistry that deals with the diagnosis and

management of diseases that are nonsurgical

in nature, that may occur only in the oral

cavity or may be oral manifestations of

systemic disease

Scope of oral medicine: It is a clinical discipline

that encompasses the following:

1 Diagnosis and medical management of

diseases of oral mucosa, jaws and the

salivary glands

2 Diagnosis and medical management of

oro-facial pain and TMJ disorders

3 Dental management of patients with

complicated medical diseases

CASE HISTORY

The first and the most important step in

evaluating a patient is obtaining a detailed

case history Case history means gathering

relevant information from the patient for the

purpose of establishing the diagnosis and

providing oral health care needs to them It

involves listening patiently to the patient’s

complaints and obtaining the necessary details

by asking him appropriate questions This is

followed by a thorough physical examination

with special attention to the area of chief

com-plaint so as to arrive at a provisional diagnosis

1

The case history includes the following parts:

1 Patient’s personal data

S—Subjective is recording the patient’s

chief complaint, symptoms and a briefreview of his medical history

O—Objective involves a brief physical

examination followed by detailed tion of the area of chief complaint

examina-1

Definition and Introduction

A—Assessment, which involves arriving at

the diagnosis

P—Plan, where the required treatment is

planned and executed

THE IMPORTANCE OF CASE HISTORY

As already mentioned above, case history is

the most integral part of patient assessment

Every detail recorded can be of enormous

importance and the time spent in obtaining

this vital information is worthwhile

1 Patient’s Personal Data

This part of the history includes recording the

patient’s name, age, gender, address, etc

i.Name: Apart from identification,

address-ing the patient by his name when he enters

the office and during the appointments

makes the patient feel important and at

home and helps in establishing a good

rapport with the patient

ii.Age: The patient’s age is a vital information

as it helps in diagnosis as well as treatment

planning Certain diseases have

predilec-tion to affect certain age groups, e.g

developmental anomalies, rampant caries

and lesions such as primary herpetic

gingivostomatitis, measles, chickenpox,

etc are more common in children, while

diseases such as root surface caries,

osteomyelitis, herpes zoster infection,

pemphigus, etc are common in the older

age group Another important matter that

requires consideration of the patient’s age

is dosage of drugs in prescriptions

Dosages should be reduced appropriately

for children Drugs such as tetracycline are

contraindicated in small children where

it can cause permanent discoloration of the

developing dentition Similarly aspirin is

contraindicated during viral infections in

the pediatric age group as this can result

in anicteric liver dysfunction called Reye’s

syndrome Drug dosage must be adjusted

for the elderly considering their general

health status The possibility of druginteractions must also be considered asmany senior individuals are undermedications for co-existing medicaldiseases

iii.Gender: Diseases are known to have dilection to certain genders, e.g diseasessuch as recurrent aphthous stomatitis,lichen planus, MPDS, iron deficiencyanemia, AOT, etc are more common in thefemales, while conditions such as leuko-plakia, squamous cell carcinoma, amelo-blastoma, hemophilia, etc are common inthe males

pre-iv.Address: Knowing the patient’s completeresidential address facilitates communi-cation With the advent of modern techno-logies, it is advisable to record the patient’smobile numbers and e-mail address also

so that information regarding ments and follow ups can be done veryeasily!

appoint-Apart from that, the knowledge of thepatient’s place of residence can give a clueabout his social and cultural background andprevalence of certain habits and diseases inthat geographic location For example, thehabit of reverse smoking is common in thestate of Goa and coastal area of Kerala, wherepalatal changes could result in a premalignantchange Similarly enamel fluorosis is endemic

in areas where fluoride content in drinkingwater is high

2 Chief Complaint

Chief complaint is the problem for which thepatient approaches the doctor to seek

treatment “Listen to the patient, he is telling you

the diagnosis” is an age old adage that still holds

value The complaints mentioned by thepatients are called as symptoms and must betherefore listened to attentively Carefullyframed questions should be asked that wouldencourage the patient to reveal some vitalpiece of information which otherwise thepatient may not have expressed These

questions may be of two types, open-ended

questions and close questions Open questions

are those that will encourage the patient to

narrate in detail the information asked to him,

e.g ‘what kind of pain do you experience?’

Questions like these will make the patient

think and give a reply in a descriptive manner

Closed questions on the other hand are more

objective in nature for which the patient has

to choose just the right type of option given by

the doctor, e.g ‘is the pain continuous or

intermittent?’

The common chief complaints that can lead

the patient to a dentist are pain, swelling,

bleeding from the gums, difficulty in opening

the mouth, pain in the TMJ region, ulceration

or burning sensation in the mouth, etc Each

of the symptoms must be recorded in the

decreasing order of their severity The chief

complaint must be recorded in the patient’s

own words and technical terms must be best

avoided The onset, duration, progress,

aggravating and relieving factors must also be

recorded which are very useful in leading to

the correct diagnosis

Onset indicates the manner in which the

disease began It denotes the acute or chronic

nature of the disease, e.g lesions such as

erythema multiforme, allergic reactions, etc

have a sudden or acute onset On the other

hand, chronic lesions and conditions such as

pemphigus, lichen planus, MPDS, OSMF and

others have a gradual onset

Duration indicates the time for which the

symptoms last, e.g pain due to dental diseases

usually lasts for a longer period of time, while

pain in trigeminal neuralgia typically occurs

in episodes and lasts for just a few seconds

Similarly lesions such as lichen planus,

pemphigus, aphthous major, etc have a long

duration of history while conditions such as

aphthous minor, herpes labialis, etc have a

short duration

Progress indicates the manner in which the

disease process has advanced Rapid

fulminating infections such as Ludwig’sangina spread fast and increase suddenly insize, while pain associated with TMJ disease,MPDS, etc progress slowly in severity.Lesions such as aphthous stomatitis, benignmigratory glossitis, herpes labialis, etc charac-teristically show periods of remissions andexacerbations and recur periodically

Aggravating factors are those that cause thesymptoms to grow more severe For example,pain of acute pulpitis aggravates on lyingdown while neuralgic pain is aggravated

by smiling or even touching specific parts ofthe face lightly Many oral lesions such aslichen planus, aphthous stomatitis, herpesinfection, etc are known to be aggravated bystress

Relieving factors are those that help thepatient to get relief from the symptoms Forexample, pain of dental diseases is usuallyrelieved on taking some anti-inflammatory/analgesic drugs while that due to neuralgia isrefractory to analgesics Similarly muscularpain due to MPDS may be relieved by applica-tion of hot fomentation

3 Medical History

It is very important to know about the patient’sgeneral medical health status prior tobeginning any sort of dental treatment Theobjectives of knowing the medical history aretwofold First it helps us to understand thecompromised health status of the patient sothat necessary precautions can be taken toavoid any untoward complications Thus as

it is rightly said, ‘When you prepare for an

emer-gency, the emergency ceases to exist.’ A sound

knowledge of management of medically promised patient is important so as to avoidundesirable complications and embarrass-ment that accompanies it Secondly, thepatient may have certain oral lesions that may

com-be manifestation of systemic disease as oralphysicians it is our responsibility to managethese lesions effectively

A variety of medical problems are of

impor-tance to be considered by a dentist during

treatment planning This list can be easily

remembered by following the pnemonic

F — Fits and faints (epilepsy)

G — Gastroinestinal disorders such as

peptic ulcer, hyperacidity, etc

H — Hospitalization and blood

Asthma is a respiratory disorder characterized

by hyper-responsiveness of the bronchi to

stimuli resulting in wheezing and dyspnea

Asthma may be extrinsic or intrinsic Extrinsic

asthma is essentially allergic disorder seen

commonly in children, while intrinsic asthma

is nonallergic and caused due to mast cell

instability

Dental considerations:

i Anxiety due to dental treatment can

precipitate an asthma attack Hence these

patients must be reassured and handled

gently during treatment procedures

ii Local anesthesia is safe However, LA

con-taining adrenaline must be avoided as

sodium metabisulphite which is used to

preserve adrenaline from being oxidized

can trigger an allergic reaction in asthmatics

iii Patients should not forget to take their

medication and carry their inhaler pump

with them

iv Benzodiazepines and sedatives must beavoided as they too can precipitate anattack

v Drugs such as aspirin and NSAIDs likemefenamic acid may induce an attack.Nimesulide is safer in these patients.Similarly morphine, thiopentone andother opioids can stimulate histaminerelease and so should be avoided

vi Severely asthmatic patients may be understeroid therapy and hence necessaryadjustments of steroid dose may be requi-red to prevent adrenal crisis Long-termand frequent use of steroid inhalers pre-disposes these patients to oral candidiasis.vii Emergency medications such as adrena-line and hydrocortisone must be available

in the clinic to be used, should any suddenattack be precipitated

Anemia is a disorder characterized by

reduction in the hemoglobin levels in theblood Based on the cause, anemia may becategorized into iron deficiency anemia,hemolytic anemia, pernicious anemia, etc.Some of the common clinical presentationsinclude general lassitude, pallor of nails, con-junctiva and oral mucosa, bald depapillatedtongue, glossitis, angular chelitis, etc

Dental considerations:

i The patient’s hemoglobin level and RBCcount must be ascertained prior to anysurgical procedures It is advisable topostpone any surgical procedures if thehemoglobin levels are below 10 mg/dland the patient needs to be referred to ahematologist/physician for opinion GAmay not be safe in severe anemics

ii Oral manifestations of anemia includefrequent aphthous ulcerations, glossitis,angular chelitis, Plummer-Vinson syn-drome, candidiasis, etc Patients presentingwith burning mouth or bald tongue must

be investigated for anemia when there

is no other notable cause for thesesymptoms

B—Bleeding Disorders

Disorders of hemostasis can cause

manage-ment problems mainly due to excessive

post-operative bleeding The causes for prolonged

bleeding may be due to platelet disorders like

thrombocytopenia, idiopathic

thrombo-cytopenic purpura, drug such as aspirin, etc

Coagulation defects such as hemophilia,

von Willebrand’s disease, Bernard-Soulier

syndrome, etc can also result in abnormal

excessive bleeding

Dental considerations:

i The coagulation profile must be obtained

for these patients before beginning dental

procedure These include assessment of the

bleeding time (BT), clotting time (CT),

prothrombin time (PT), activated partial

thromboplastin time (aPTT), etc

ii Adequate factor replacements such as

factor VII for hemophilia A, factor IX for

hemophilia B, etc must be given and their

levels must be maintained during and after

the surgery to prevent excessive bleeding

iii Preventive dental care must be

empha-sized for these patients so that serious

consequences of dental neglect that result

in the need for surgeries can be avoided

iv Endodontics is safer than exodontia

v Nerve block anesthesia such as

pterygo-mandibular block, etc must be avoided as

these techniques are blind procedures and

can result in extensive bleeding into the

deeper planes of the tissues Infiltration

anesthesia may be given but with caution

for they too can lead to extensive bleeding

However, lingual infiltrations must be

avoided as the bleeding may track down

and posteriorly into the parapharyngeal

spaces causing air space compression and

respiratory distress Intraligamentary

injections are safer in these patients

vi Surgical procedures must be carried out

with minimal trauma and antifibrinolytic

drugs such as tranexamic acid can be used

to arrest uncontrolled bleeding

vii It is ideal to carry out surgical procedures

in a hospital setting so that emergenciescan be immediately handled

C—Cardiovascular Diseases

Cardiovascular diseases such as hypertension,ischemic heart diseases, etc are becomingincreasingly common in the modern days.Hypertension may be defined as a persistentrise in the arterial blood pressure Ischemicheart disease such as angina pectoris, myo-cardial infarction, etc result in a compromisedstate of health that these patients requirespecial care during dental treatment proce-dures

reduc-ii It is advisable to check the patient’s bloodpressure before any surgical procedure isattempted In patients who have sufferedfrom myocardial infarction, dental treat-ment may be postponed until completerecovery has taken place, i.e for a period

of 6 months after the attack

iii Many patients with cardiac disease take alow dose of aspirin daily As aspirin hasantiplatelet effects, it may result inprolonged bleeding after extractions orother surgical procedures Hence, it isrecommended that aspirin be stopped atleast 7 days before the surgery with thephysicians consent However, recentstudies indicate that patients may beallowed to continue aspirin if the bleedingtime and clotting time are within normallimits

iv Antihypertensive agents such as pine can induce gingival hyperplasia

nifedi-v Local anesthesia can be used safely.

Adrenaline containing solutions may be

avoided as adrenaline being a

vaso-constrictor can raise the blood pressure

However, the low concentration of

adrenaline (1:80000) that is used in LA

solutions is considered safe, and advisable

as anesthetic effect is longer lasting, but

not more than 4 ml of such LA solution

must be used It is more likely that the

release of endogenous catecholamines

[associated with stress in HT patients] can

suddenly shoot up the blood pressure

Patients on antihypertensive beta blockers,

for example, propranolol—if these

patients are given adrenaline there will be

an un-opposed action of alpha receptors

which leads to exaggerated

vasoconstric-tion and will precipitate anginal attack

vi Emergency drugs including nifedipine,

isosorbitrate, etc must be readily available

while treating unstable hypertensive and

angina patients

vii Referral to the physician is an essential

prerequisite for reassurance and also

immediate hospital support if warranted

Rheumatic heart disease is another

condi-tion affecting the CVS that requires special

considerations These patients require

anti-biotic prophylaxis prior to dental treatment

procedures such as extraction, scaling,

curett-age or even deep periodontal probing and

placement of wedges or rubber dam

Bacte-remia caused due to these procedures can affect

the heart valves and result in subacute bacterial

endocarditis Antibiotic prophylaxis is also

required for patients with valvular heart disease

or prosthetic heart valves The recommended

antibiotic prophylaxis is as follows:

i Adults who are not allergic to penicillin: 2 gm

amoxycillin to be taken 1 hour before the

procedure

ii Adults who are allergic to penicillin: 600 mg

clindamycin to be taken 1 hour before the

procedure

iii Children between 5 and 10 years who are not

allergic to penicillin: 500 mg amoxycillin

1 hour prior to the procedure

iv Children between 5 and 10 years who are

allergic to penicillin: 300 mg clindamycin

1 hour prior to the procedure

v Children less than 5 years who are not allergic

to penicillin: 250 mg amoxycillin 1 hour

prior to the procedure

vi Children less than 5 years who are allergic to

penicillin: 150 mg clindamycin 1 hour prior

to the procedure

Procedures such as radiography, routinedental examination, endodontics (confined tothe apex), exfoliation of primary teeth, sutureremoval, etc do not require antibiotic coverage

D—Diabetes

Diabetes is a condition in which there isimpaired carbohydrate metabolism caused byinsulin resistance or deficiency The commonsymptoms of diabetes are polyphagia(increased appetite), polyuria (increasedurination) and polydipsia (increased thirst).Diabetic patients are under antidiabetictherapy and sometimes pose difficulty inmanagement They may frequently slip intohypoglycemic coma and fall unconsciousduring treatment Further as dental treatmentcan impose restrictions on their dietary intake,this may affect their glycemic balance that iscritically maintained by drug therapy

Dental considerations:

i Routine dental therapy can be carried outwithout any special considerations.However, when major therapy or surgeriessuch as even extractions are planned, thepatient’s blood sugar level must beevaluated before beginning the treatment

as hyperglycemia may predispose toinfection and delayed wound healing.Changes in the vessel wall such as micro-angiopathy leading to luminal narrowingalso causes delayed wound healing Treat-ment is best carried out in the morningafter the patient has had his breakfast and

a regular dose of antidiabetic medicines

ii Infections must be treated aggressively

with suitable antibiotics as they may

precipitate ketosis

iii Local anesthesia is safe and the low dose

and concentration of adrenaline does not

seem to affect much

iv Diabetic patients may also present with

oral manifestations such as burning

mouth, multiple periodontal abscesses,

aggressive periodontal disease,

non-healing wound, candidiasis, etc These

conditions must me recognized early and

managed effectively Antidiabetic drugs

can cause oral side effects such as lichenoid

reaction or even xerostomia

v Emergency medicines such as iv dextrose,

glucose, glucagon, etc must be readily

avai-lable to manage unexpected complications

E—Endocrine Disorders

The term endocrine disorders encompass

various diseases such as hyperthyroidism,

hypothyroidism, Addison’s disease, Cushing’s

syndrome, etc Although these conditions are

rare in practice, the clinicians must have a brief

knowledge of these conditions as they may

alter the dental treatment plan

Dental considerations:

i Patient’s with adrenal insufficiency

(Addison’s disease) often receive

exo-genous steroids for treatment This further

suppresses the hypophyseal axis and

inhibits the release of endogenous steroids

that is required during periods of stress

This can precipitate hypotensive collapse

during stressful dental procedures Hence

high doses of corticosteroids were

advo-cated in the past before and after dental

procedures or during events like trauma

or infection However, according to the

recent literature, the patient’s steroid dose

may be increased prior to the treatment

only if patient is taking more than 50 mg

iv Hypothyroid patients may precipitatemyxedema when drugs such as opioids,diazepam or GA are given to them LA issafer in these patients

v Similarly, pain, anxiety or trauma can cipitate thyroid crisis in hyperthyroidismthat is untreated

pre-vi Hyperparathyroidism may cause lized rarefaction of the jaw bone andoccasionally cause giant cell lesions calledBrown’s tumor

genera-F—Fits and Faints

Epilepsy is a central nervous system disorderwhich causes episodic disturbances ofconsciousness and is often accompanied byseizures Sometimes these patients may sufferfrom prolonged uncontrolled seizures that arereferred to as status epilepticus

Dental considerations:

i Epileptic patients have a greater chance

of injuring their tongue, lip or buccalmucosa during the attacks Occasionally,they may also sustain dental or jawfractures

ii Antiepileptic drugs such as phenytoinsodium can cause gingival enlargement,folate deficiency and hence aphthousstomatitis Sodium valproate can result inincreased bleeding tendencies

iii The clinician should be ready to manage

an emergency situation created by the

onset of epileptic attack All procedures

must be stopped immediately and the

patient must be put in a lateral position

with a soft mouth gag inserted between

the teeth to prevent the tongue from being

bitten If the seizures do not stop, diazepam

injections may be given intramuscularly

and medical help must be sought

G—Gastrointestinal Disorders

Gastrointestinal disorders include an array of

diseases affecting any part of the system from

the mouth to the rectum Of particular interest

to the dentist are, however, common conditions

such as peptic ulceration, liver disorders, etc

Dental considerations:

i Drugs such as aspirin and other NSAIDs

must be used cautiously in patients with

history of peptic ulcerations as they can

aggravate the existing condition Selective

COX2 inhibitors like nimesulide, pofecoxib,

etc are less harmful to the gastric mucosa

The patients must be instructed to have

the medications with a glass of milk or

plenty of water If required tablets of

ranitidine (150 mg BD) or omeprazole

(20 mg BD) can be added to the patient’s

prescription These drugs help to reduce

the acidity in the stomach Also use of

systemic steroids is contraindicated for

they too can inhibit prostaglandin

synthe-sis and thus aggravate peptic ulceration

ii Use of broad-spectrum antibiotics such as

amoxycillin can lead to diarrhea as they

suppress the normal intestinal microflora

Combinations with lactobacillus spores are

available which prevent such complications

iii Severe liver disease can inhibit the

produc-tion of clotting factors and hence these

patients are at a greater risk of bleeding

during or after dental surgeries Patients

with hepatitis have reduced secretion of

Bile so that fats are not emulsified and

fat-soluble vitamins such as vitamin K is not

absorbed from the intestine causing ciency and consequent chances of bleeding.Drug dosage must be reduced and hepato-toxic drugs must be avoided in thesepatients Patients with hepatitis B infec-tion have to be managed more cautiously[universal precautions to prevent cross-infection]

defi-iv Patients with history of gastroesophagealreflux disease suffer from frequent regurgi-tation of stomach acids that can lead toerosion of the lingual surfaces of theirteeth

H—Hospitalization and Blood Transfusion

Patients having a frequent history of zation usually have some of the medicalproblems mentioned above Causes of hospitali-zation and medication must be ascertainedand necessary precautions must be taken toavoid complications Similarly patients whohave received frequent blood transfusion mayrun a high risk of contracting blood-borneinfections such as HIV or hepatitis B, etc Alsothey may be suffering from conditions such

hospitali-as thalhospitali-assemia or hemophilia for which theyhave received many transfusions

I—Infections

Such as tuberculosis, HIV, hepatitis, etc arehighly communicable and the dentist musttake adequate precautions to protect himselffrom getting infected as well as spreading thedisease to other patients visiting his clinic.Proper cross-infection control protocol andaseptic precautions must be followed andinstruments used for these patients must besterilized thoroughly before they are used forthe next patients Also patients with HIV mayhave many oral manifestations which shall bediscussed in the appropriate sections Thedentist must also be immunized againsthepatitis B virus

J—Jaundice

Jaundice refers to the rise in the serum rubin level which in turn results in yellowish

bili-discoloration of the sclera, skin and the mucous

membrane Jaundice may be categorized into

three main types, i.e hemolytic, infective and

obstructive jaundice The liver functions are

affected in jaundice and the patients must be

tested for blood levels of bilirubin, SGOT,

SGPT, HbS antigen, etc

Dental treatment procedures may be

post-poned until the patient completely recovers

and drug prescription should be kept at

mini-mum Patients with advanced liver diseases

may exhibit a greater tendency of bleeding

after surgical procedures as vitamin K

absorption is low and coagulation factors

production which takes place in the liver is

affected

Patients who are HbsAg positive, i.e with

hepatitis B infection are a potential source of

cross-infection and need to be handled

cautiously in addition to following the

universal precautions All dental clinicians

including the paramedical staff should be

vaccinated against the hepatitis B virus

K—Kidney Disorders

Kidney disorders such as renal failure,

nephrotic syndrome, etc are commonly

encountered in practice Some of these patients

may be receiving dialysis or may have even

undergone renal transplants Many of these

patients thus require modifications in their

dental treatment plan

i Nephrotoxic drugs such as tetracycline,

aminoglycosides must be avoided

Anti-biotics like cloxacillin, doxycycline,

metronidazole are safe and can be

prescri-bed in their usual doses Ampicillin,

amoxicillin, benzylpenicillin,

erythro-mycin are fairly safe, but their dosages

must be reduced in severe renal disease

NSAIDs including aspirin are less safe and

their doses need to be reduced even in

patient’s with mild renal disease Safer

analgesics include paracetamol and

codeine Lignocaine and diazepam are

safe for use

ii Patients with severe uremia may presentwith oral ulceration due to uremicstomatitis

iii Dental treatment for patients undergoinghemodialysis may be carried out on thenext day after the dialysis when there ismaximum benefit of the dialysis and theeffect of heparin which is given duringhemodialysis has also worn off

iv Patients who require dental extractions,scaling or periodontal surgeries must beprovided antibiotic prophylaxis asbacteremia can result in peritonitis inpatients undergoing peritoneal dialysis

L—Lactation and Pregnancy

i Dental treatment during pregnancyrequires special consideration Pregnancymay predispose to gingivitis and localizedgingival enlargements called as pregnancytumor

ii Injudicious prescription of drugs must beavoided as there is a risk of fetal damage.Tetracyclines must be avoided as they cancause irreversible staining of teeth in thechild Drugs such as thalidomide, aspirin,etc must not be prescribed due to theirteratogenic side effects

iii Penicillins, erythromycin and paracetamolare safe during pregnancy, but drugprescription should be kept to minimumespecially during the first trimester Localanesthetic lignocaine is safe but must beused only when necessary

iv Extensive dental treatment should beavoided during the first and last trimester.The second trimester is comparatively safefor treatment

v Exposure to X-rays must be strictlyavoided in the first trimester If radio-graphs are unavoidable during pregnancy,the patient must be adequately protectedwith a lead apron, as otherwise, X-rays arepotentially dangerous to the fetus

10-day rule: The basis of this rule was

to do X-ray examinations only during the

10 days following the onset of

menstrua-tion as ovulamenstrua-tion and fertilizamenstrua-tion of the

ovum is least likely during this period and

hence no chances of radiation hazard to

the foetus

Now it is understood that the

organo-genesis starts 3–5 weeks after conception

and the focus is now shifted to missed

period and possibility of pregnancy

vi If a pregnant patient develops syncope

which is more common in the third

tri-mester, the patient must not be put in a

head low position as this may result in

compression of the inferior vena cava by

the gravid uterus thereby reducing venous

return to the heart and consequent supine

hypotensive failure Instead the patient

must be made to remain supine in the left

lateral position

vii A lactating mother should be prescribed

drugs with caution as some of the drugs

can be transferred to the child through

breast milk

4 Past Dental History

A brief record of the patient’s past dental visits

must be noted including the frequency of need

for dental treatment, nature of any treatment

received Particular attention must be given

to any untoward reactions that the patient may

have experienced such as drug allergy or any

complications such as excessive bleeding, etc

so that such events can be safely avoided The

information obtained can also provide an

insight towards the patient’s level of

aware-ness about dental procedures and expectations

from the dentist

5 Personal History

Personal history includes information about

habits such as paan, supari (areca nut), tobacco

chewing or smoking, clenching, bruxism, teeth

cleaning habits, etc Lesions such as

leuko-plakia, OSMF, oral squamous cell carcinoma

are found with higher frequency in people

with tobacco-related habits Stress and anxiety

may be a contributing factor for conditions

such as aphthous stomatitis, MPDS, etc.Stoppage of such habits plays a crucial role inthe treatment of these conditions Patientswith the habit of bruxism and/or of clenchinghave increased chances of attrition of teeth andtenderness of masseter

A history of exposure to commercial sexworkers or multiple partners may be asked incertain cases where oral lesions associatedwith sexually transmitted diseases such asHIV, syphilis, etc are suspected

6 General Examination

General examination should include tion of the patient’s general health and vitalsigns ‘A good clinical examination beginsfrom the moment the patient enters the clinic.’The patient’s general body composition, built,gait, etc must be observed as he walks intothe clinic While evaluating cases of trauma,

examina-it is imperative to assess the patient’s level ofconsciousness and orientation to space andtime Partial or complete loss of consciousnessafter trauma may be sign of CNS involvementand should immediately receive the attention

of neurosurgeon Vital statistics such as thepatient’s blood pressure, pulse, etc must berecorded, particularly if the patient has anymedical history or signs of an underlyingsystemic disease

The exposed parts of the skin should beexamined for any lesions, scars or pigmen-tation Many oral lesions such as lichen planus,erythema multiforme, etc may also show skininvolvement Pigmentation of the skin may beobserved in lichen planus, Addison’s disease,Peutz-Jegher’s syndrome, Albright’s syn-drome, neurofibromatosis, etc Occasionally,sinus tract opening may be seen on the skin

in chronic infections such as osteomyelitis,tuberculosis, chronic periapical infection, etc.Nails should be checked for pallor, clubbing

or other deformities Pallor of nails meanspaleness or lack of the normal pink color ofthe nails and could indicate anemia Spoon-shaped nails (koilonychias) and cracking of

nails may be also seen in anemia Such

patient’s should be referred for suitable

investigations such as complete blood count,

hemoglobin level estimation, etc Clubbing

indicates alteration in the shape of the nails

The nail bed swells up and the nails become

convex Clubbing may be of varying grades

and is seen in conditions such as alcoholic liver

disease, cardiac ailments, bronchiectasis, lung

abscess, etc Grooving or ridging of nails may

be a feature in lichen planus

Conjunctiva which is the mucosal lining of

the eyeball (bulbar conjunctiva) and the eyelid

(palpebral conjunctiva) should be examined

for ecchymosis, ulceration and pallor The

normal colour of the palpebral conjunctiva is

pink Pallor of palpebral conjunctiva may be

sign of anemia Ecchymosis of the conjunctiva

may indicate fracture of the zygoma or the

infraorbital bone Ulcerations of the

conjunc-tiva may be noted in Stevens-Johnson

syndrome, herpes zoster, etc Symblepharon

refers to the fusion of the palpebral and bulbar

conjunctiva that is a complication of cicatricial

pemphigoid

The sclera which is the white portion of the

eye should be examined for icterus, yellowish

discoloration that is seen in jaundice

Appro-priate investigations may be ordered and

the patient must be sent to a physician for

complete evaluation if needed

7 Extraoral Examination

Extraoral examination includes the

examina-tion of the face, jaws, neck and the TMJ

Observe keenly for any swellings or facial

asymmetry If a swelling is present, its

loca-tion, size, shape, margins must be inspected

The swelling must be palpated to study its

consistency, and presence of tenderness

Presence of any ulcer or draining sinus tract

must be noted

Lymph nodes must be palpated to study

their location, number, consistency and fixity

to the underlying tissues The submandibular,

submental and cervical group of lymph nodes

must be checked thoroughly Tender, firmlymph nodes are usually seen in infections,while hard, fixed lymph nodes may be due tometastasis from malignant tumor Multiplelymph nodes may be present in tuberculosis,lymphomas, HIV, etc For examining thesubmandibular nodes, the operator muststand behind the patient The patient is asked

to look slightly downwards and the operatormust palpate the nodes with the tip of his firsttwo fingers placing them medial to the body

of the mandible Similarly the cervical group

of lymph nodes must be palpated anterior andposterior to the sternocleidomastoid muscle.The common causes of lymphadenopathyinclude, dental infections, metastatic malig-nancies, lymphomas, tuberculosis, etc

The TMJ must be examined for any ness, restricted mouth opening, deviation,clicking, etc which indicate pathology Inorder to check for tenderness and clicking, theoperator must stand behind the patient andplace a finger over the joint bilaterally andinstruct the patient to open and close themouth The joint may be auscultated with astethoscope to detect clicking sound whichmay indicate disc derangement Suitableinvestigations may be then ordered to confirmthe diagnosis after clinical examination

be examined carefully depapillation oftongue may be noted in geographic tongue,median rhomboid glossitis, anemia, OSMF,etc The gingiva should be examined toindentify the presence of inflammation,enlargements or pocket formation The

floor of the mouth should also be inspected

carefully If any growth or ulceration or

white lesion is present, it must be thoroughly

checked Openings of Wharton’s duct in the

floor of mouth and of Stensen’s duct in

cheek mucosa opposite the upper molars

should be checked for normal secretions,

inflammation, etc

b Hard tissue examination includes inspecting

the overall status of the patient’s dentition

The teeth should be examined for their total

number, presence of any developmental

anomalies, hypoplasia, caries,

discolora-tion, wasting diseases such as attridiscolora-tion,

abrasion, erosion and abfraction

9 Examination of the Area

of Chief Complaint

The area of chief complaint must be examined

in detail Presence of any soft tissue swelling,

pus discharge, bony expansion must be noted

The teeth in the area must be evaluated for

dental caries and periodontal disease The

teeth may be gently percussed by tapping the

occlusal surface lightly with the blunt end of

the probe Pain elicited on percussion indicates

tenderness which may be a sign of periapical

disease The teeth should be checked for

abnormal mobility and vitality

10 Provisional Diagnosis and Investigations

After taking a good history and performing

the clinical examination, the clinician must

arrive at a provisional diagnosis Also the

possible differential diagnosis should be

charted so that appropriate investigations can

be advised to the patient Commonly advised

investigations are an IOPA radiograph,

occlusal or extraoral radiographs, blood

investigations such as CBC, etc Advanced

investigations such as CT, MRI, scintigraphy

may be required in certain cases Tests which

are not likely to yield any diagnostic

information for that particular case must not

be advised to the patient

11 Final Diagnosis

Once the reports of the investigations areavailable, the case should be reviewed tocorrelate the clinical and investigatoryfindings to arrive at a final diagnosis When atumor or cyst is suspected, biopsy may berequired to arrive at the final diagnosis

12 Treatment Plan

Once a case has been diagnosed, the nextcrucial step is to chalk out a treatment planfor the patient If the patient is suffering frompain or has signs of infection, antibiotic andanti-inflammatory drugs must be prescribed

as an emergency measure Appropriatetreatment must then be planned for the patientafter obtaining necessary consultation fromthe other specialists While treating patientswho are medically compromised, the nece-ssary precautions and treatment modificationmust be incorporated in the treatment plan.TERMINOLOGIES USED IN CLINICAL

EXAMINATION OF LESIONSClinical examination is by far the most impor-tant step in the Diagnostic sequence It isessential to identify various lesions which can

be manifested clinically and further analyzeand correlate their significance

Terminologies

• Lesion may be described as a visible change

in the normal anatomical structure caused

by a pathological process

• Primary lesion is the first pathologicalchange manifested clinically, e.g vesicle inherpes simplex

• Secondary lesion is the altered primarylesion, e.g ulceration caused by the rupture

of the vesicle in herpes simplex

Lesions may be flat such as a macule, raisedsuch as vesicle or depressed such as anulcer

• Vesicle is a circumscribed elevated serousfluid filled blister not more than 1 cm indiameter with a thin covering of epithelium,e.g HSV infection, herpes zoster (Fig 1.1)

• Bullae are circumscribed elevated serous

fluid filled blister more than 1 cm in

diameter The epithelial covering may be

thin if the lesion is intraepithelial as in

pemphigus and thick if the lesion is

subepithelial as in cicatricial pemphigoid

(Fig 1.2)

• Pustule is a circumscribed elevated lesionwhich is filled with purulent fluid or pus,e.g chickenpox (Fig 1.3)

• Papule is a circumscribed elevated solid(not fluid filled) lesion less than 1 cm indiameter, e.g primary lesion of aphthous,lichen planus (Fig 1.4)

Fig 1.1: Line diagram and picture of vesicle

Fig 1.2: Line diagram and picture of bullous lesion

Fig 1.3: Pustule

• Plaque is a slightly raised clearly

demar-cated area of gray or white discoloration,

surface of which may be smooth, cracked

or fissured, e.g leukoplakia, plaque type of

lichen planus (Fig 1.5)

• Macule is a circumscribed flat (nonraised)

area of altered coloration varying in size

from a pin head to several cms, e.g ephelis

(freckles) (Fig 1.6)

• Petechiae are pin head size (1–2 mm)discolored spots caused by extravasation ofblood, e.g scurvy, thrombocytopenicpurpura (Fig 1.7)

• Ecchymoses refer to larger areas of coloration caused by extravasation ofblood, e.g subconjunctival ecchymoses inzygomatic arch fracture (Fig 1.8)

dis-Fig 1.5: Line diagram and picture of plaque

Fig 1.4: Line diagram and picture of papules

Fig 1.6: Line diagram and picture of macule

• Erosion is a shallow defect in the mucosa

representing a loss of epithelial coverage,

e.g erosive lichen planus (Fig 1.9)

• Ulcer is a breach in the continuity of the skin

or mucous membrane caused by pathological

processes resulting in molecular death of

Fig 1.7: Petechial spots on the palate Fig 1.8: Subconjunctival and periorbital ecchymosis

tissue, e.g tuberculous ulcer, aphthous ulcer(Fig 1.10)

• Wound is a breach in the continuity of skin

or mucous membrane caused by trauma

• Nodule is a well-circumscribed tion of tissue that may project from the

condensa-Fig 1.10: Line diagram and picture of ulcer

Fig 1.9: Line diagram and picture of erosive lesion (lichen planus)

Fig 1.11: An example of nodule—fibroma

surface as a polyp It may be present in theepidermis or dermis, e.g small fibroma,irritational fibroma (Fig 1.11)

Ulcerative and vesiculobullous lesions are by

far the most commonly manifested oral

mucosal lesions It is very important to

differentially diagnose these lesions which

closely resemble each other as the treatment

for these lesions will be different and at times

wrong diagnosis and treatment can lead to

un-desirable consequences

Whenever a patient presents with ulcerative

lesion as a routine 3 questions are asked:

1 How many lesions are present—single/

multiple?

2 How long are these lesions present—acute/

chronic?

3 Has the patient suffered from similar

lesions in the past, i.e history of recurrence?

Depending on the answers received, the

patients are classified as follows:

• Patients with acute multiple lesions:

1 Acute viral stomatitis (HSV, Coxsackie,

• Patients with recurring oral ulcers:

1 Recurrent aphthous stomatitis (RAS)

2 Behçet’s disease, Reiter’s syndrome

3 RHL and RIOH

17

2

Ulcerative and Vesiculobullous Lesions

• Patients with chronic multiple lesions:

5 Erosive and bullous lichen planus

• Patients with single ulcers:

Herpes Simplex Virus (HSV)

Nine types of HSV have been reported to bepathogenic in human beings—HSV1, HSV 2,VZV, EBV, CMV, HHV6, HHV7, HHV8,Simian herpes virus B

Primary Herpetic Gingivostomatitis

3 To begin with there are prodromal

symptoms—headache, bodyache, nausea,

vomiting, malaise After 1–2 days, multiple

vesicles appear within the oral cavity They

resemble ‘drops of dew’

4 These vesicles (circular, dome-shaped,

2–3 mm) rupture immediately giving rise to

small shallow discrete round ulcers These

may coalesce to form a large ulcer They are

sharply defined, shallow with yellowish

grey floor and red margin

5 Each ulcer is surrounded by an tory halo and is slightly raised At margins

inflamma-of the ulcer ‘tissue tags’ are seen as aresult of rupture of the vesicle The appea-rance of the ulcer has been described as

‘moon crater’ (Fig 2.1)

6 There is generalized acute marginal vitis and the color of gingiva is dark red.Several small gingival ulcers often presentwith inflammation and edema of the entiregingiva

gingi-7 Herpetic involvement of the tongue showsmultiple vesicles and ulcers on the dorsalsurface and has been described as geometricglossitis by Neville (Fig 2.2)

8 Lymphadenopathy (submandibular andcervical) and pharyngitis present PrimaryHSV may have labial and facial skin lesionswithout intraoral lesions

9 It is considered important to differentiateherpetic lesions from those of erythemamultiforme as these lesions resemble eachother and corticosteroids which are consi-dered drug of choice in EM is contra-indicated in primary HSV In HSV infection,the ulcerative lesions are small, round,symmetrical and shallow and those oferythema multiforme are large, irregular,deep and bleeding The vesicles andconsequently the ulcers in HSV are intra-epithelial, i.e superficial and in EM thevesicles and consequently the ulcers aredeeper and involve subepithelial capillariesleading to bleeding and crustations.Corticosteroids are contraindicated in viralinfections as they suppress antibody

Type of virus

HSV 1 Stomatitis, pharyngitis,

meningitis, encephalitis and dermatitis (above the waist)

transmitted from mother to newborn infant or may be

of close personal contact (venereal origin)

HSV 1 and HSV 2 Carcinoma cervix

and is considered a possible factor in HIV infection HHV 6A—Causes Roseola infantum (exanthema subitum), manifested as fever and rash (mononucleosis like syndrome) HHV 6B—immunocompro- mised patient, interstitial pneumonitis and bone marrow suppression HHV 7 Found in saliva, no disease

patients, lymphoma and Castleman’s disease

Fig 2.1: Multiple vesicles and ulcerations in primary HSV infection

formation and there is always a danger of

viral infections spreading rapidly when the

immune reaction is suppressed Currently

HSV associated erythema multiforme cases

have been reported and in such cases

suppression of erythema multiforme can be

achieved with the help of acyclovir and

steroids will be contraindicated in such

cases

Diagnosis

1 Clinical picture—classically a young patient

presenting with H/o fever, malaise

multiple vesicles, acute marginal gingivitis

and lymphadenopathy gives a clue

• Cytologic smear from the base of freshly

opened vesicle stained with Giemsa stain

(also Wright and Papanicolau’s stain)

shows multinucleated giant cells or

intranuclear inclusion bodies (Lipschultz

bodies) with ballooning degeneration

of nuclei and syncytium formation

(Syncytium—multinucleated

proto-plasmic aggregation of cells without

apparent cell outlines) Ballooning

degeneration is absent in RAS, EM and

allergic stomatitis

2 Fluorescent staining of cytological smear

3 Conclusive evidence of primary HSV

includes testing for complement fixing or

neutralizing antibody in acute and

convale-scent sera—4 fold increase in convaleconvale-scent

Fig 2.2:Primary HSV infection—geometric glossitis and palatal lesions

serum is diagnostic in primary HSVisolation can be done on chorioallantoidmembrane of chick embryo or kidney ofrabbit

4 Antibody titre is raised To differentiatebetween recurrent and primary attack,acute and convalescent serum is collected

In primary attack, only the convalescentserum shows raised titre, as during theactive stage antibodies are not formed Inthe recurrent attack, both the active andconvalescent serums show raised titre, asthe defense mechanism has been previouslyexposed to the virus and produces largenumber of antibodies

Differential Diagnosis

Other conditions presenting as acute multipleulcers are included in the d/d The ulcersassociated with primary HSV are seen inyounger patients and are small roundsymmetrical and shallow with associatedmarginal gingivitis and H/o prodromalsymptoms

1 ANUG older patients, punched out necroticulcers on interdental papilla and marginalgingiva, tender submandibular lymphnodes and H/o fever

2 Erythema multiforme older patients withallergic background, acute explosive onsetwith no H/o prodromal symptoms and

Fig 2.3: Multiple vesicles on soft palate—herpangina

Coxsackie B4 virus is believed to causeaseptic meningitis and encephalitis and has arole to play in the pathogenesis of IDDM andprimary Sjögren’s syndrome

Herpangina

Patient gives history of fever with rigors,anorexia, followed by dysphagia and sorethroat

Intraoral examination shows multiple smallvesicular eruptions in the posterior half of oralcavity

June to October: Increased incidence Incubation period: 2–10 days

Age: 3–10 yrs but not uncommon in

adole-scents and adults

Lesions start as punctate macules, whichquickly change to papules and vesiclesinvolving posterior pharynx, tonsils, faucialpillars and soft palate Vesicles rupture within24–48 hrs to form 1–2 mm ulcers (Fig 2.3) Thedisease is mild and heals without treatment

in one week

Treatment: Control of fever and mouth pain,

isolation Effective antiviral agent againstCoxsackie virus is not available

It is self-limiting Treatment is justsupportive—analgesics, anesthetic mouth-wash and lots of fluids

fever and no lymph nodes, bloody

crusta-tions present on the lips, marginal gingivitis

absent

3 Herpangina occurs in epidemics and

pre-sents milder symptoms, smaller lesions

involving posterior part of oral cavity, no

gingivitis

4 Varicella zoster unilateral distribution of

multiple vesicles/ulcers, lesions abruptly

stop at midline, severe pain, symptoms of

pre- and post-herpetic neuralgia

Treatment

1 Primary HSV in otherwise healthy children

is self-limiting Lesions heal in 7–10 days

2 Tab Acyclovir 200 mg five times a day

(inhibits viral replication in HSV infected

cells without any effect on normal cells),

IUDR—idoxuridine, cytosine arabinoside,

adinide arabinoside These are antivirals

and known to cause hepatotoxicity and

renal toxicity

3 Corticosteroids contraindicated

4 Antibiotics given to prevent secondary

infection

5 Dyclonine hydrochloride 0.5% and Benadryl

with milk of magnesia—topical rinse before

meal

6 Paracetamol for fever (avoid aspirin

because of possibility of Reye’s syndrome)

7 Fluids to maintain hydration and electrolyte

balance

COXSACKIE VIRUS INFECTION

It is named after town in New York where the

virus was found It is an RNA enterovirus and

can cause:

i Herpangina (Coxsackie A4),

ii Hand, foot and mouth disease,

iii Acute lymphonodular pharyngitis and

mumps-like parotitis (rare)

Hand, Foot and Mouth Disease

Coxsackie A16

1 Fever, non-pruritic rashes of papular and

vesicular type on hands and feet

2 Oral lesions are more extensive than

herpangina

3 Patient has fever and stomatitis

4 Treatment same as herpangina when

patients present with an acute stomatitis

and fever

5 Because of more frequent oral involvement,

dentists are more likely to see patients with

this disease than herpangina and they

should remember to check hands and feet

for macules and vesicles

Acute Lymphonodular Pharyngitis

Coxsackie A10

1 Common in children

2 History of fever, anorexia, sore throat,

lymphadenopathy

3 Raised yellowish white nodules on an

erythematous base (do not progress to

vesicles and ulcers) are seen on posterior

wall of pharynx (Fig 2.4)

Does not occur in

epi-demics

Affects anterior part of

the oral cavity

Generalized marginal

gingivitis is present

Lesions are larger in

size, i.e vesicles and

ulcers

May not be self-limiting

Shows ballooning

Absent Lesions are smaller in size

Self-limiting Giemsa stain does not show ballooning degenera- tion of the nucleus Caused by Coxsackie virus

Treatment: Effective viral against Coxsackie virus not available

anti-4 Histologically lesions are composed ofdensely packed lymphocytes

5 Disease is self-limiting and patient recoversafter 1–2 weeks

6 Treatment is symptomatic

VARICELLA ZOSTER VIRUS (VZV)VZV is a DNA virus and the infection isfirst manifested as chickenpox, which is anexanthematous fever [term exanthematousimplies skin eruptions] commonly seen inchildren

After an attack of chickenpox, the VZVwhich has an affinity for the nervous tissueremains latent in the dorsal root ganglion ofspinal nerves and extramedullary ganglion ofcranial nerves V1, C3, T5, L1, L2 are the nervescommonly affected by VZV Herpes zosteraffecting the spinal nerves is called as

‘Shingles’ meaning ‘belt like’ because of itsdistribution V1 15–20 times more commonthan V2 and V3

V1 (ophthalmic division of trigeminalnerve) lesions appear on upper eyelid, fore-head, and scalp

V2 (maxillary division) lesions appear onmidface, upper lip and palate (Fig 2.5)

Fig 2.4: Lymphonodular pharyngitis

V3 (mandibular division) lesions appear on

lower face, lower lip, mandibular gingiva and

tongue (Fig 2.6)

The VZV can be reactivated in some

indivi-duals causing lesions of localized herpes

zoster, pathogenesis of which is similar to RHL

Patients with HIV infection, leukemia,

lymphoma and on immunosuppressant drugs

and cancer chemotherapy are more

suscep-tible to severe form of herpes zoster

Fig 2.5: Herpes zoster involving the maxillary division

of trigeminal nerve

HZ infection may be deep seated and getdisseminated causing pneumonia, meningo-encephalitis and hepatitis

Clinical Features

1 Prodromal phase—shooting pain, thesia, burning and tenderness along thecourse of nerve Lasts for 2–4 days

pares-2 Unilateral multiple vesicles appear on anerythematous base showing singledermatome involvement [Some lesionsspread by viremia and may appearbeyond dermatome.]

3 Vesicles weep serum, scab and heal within2–4 weeks

4 Intraoral lesions are seen as unilaterallydistributed multiple ulcerative lesionswhich are extremely painful Cases ofsevere odontalgia, exfoliation of teeth andosteonecrosis have been reported

5 Herpes zoster of geniculate ganglion isknown as Ramsay Hunt syndrome It israre and causes Bell’s palsy, unilateralvesicles of external ear and intraorally onpalate, uvula and anterior tongue

Fig 2.6: Herpes zoster involving mandibular division of trigeminal nerve

6 Healing of HZ lesions occurs with scarring

and depigmentation of the skin

Serious and occasional side effect in

ophthalmic division involvement—acute

retinal necrosis, corneal scarring leading

to blindness in the affected eye It is

impor-tant to refer the patient to ophthalmologist

as soon as HZ lesions of V1 is spotted

7 After healing of ulcers, patients may suffer

from the agonising complication of

post-herpetic neuralgia, which is due to

inflammation and fibrosis of the affected

nerve This condition is severe in old age,

immunocompromised patients and can

involve motor nerves also

8 HZ can be associated with dental

ano-malies, scarring of facial skin if HZ occurs

in formative years It can lead to pulpal

necrosis and internal root resorption

9 Diagnosis is difficult during prodromal

stage when pain is present without lesions

Unnecessary surgeries have been reportedly

done with mistaken diagnosis of acute

appendicitis, cholecystitis, pulpitis, etc

10 Herpes sine herpes: Zoster sine eruption—

[sine = without] peculiar condition

diffi-cult to diagnose because patients present

with severe unilateral burning pain

without clinically visible lesions Should

be considered in the differential diagnosis

of orofacial pain

Besides the clinical symptom of severe pain

only evidence is the increased antibody

titre

11 Of special importance is the fact that 1st

division trigeminal zoster may involve

nasociliary branches resulting in herpetic

keratitis and ciliary ganglion involvement

may cause an Argyll Robertson pupil

[Prabhu Daftary]

Lab Findings

i Multinucleated giant cells with ballooning

degeneration of nucleus, intranuclear

eosinophilic inclusion bodies, virus

isolation

ii Fluorescent antibody stained smears usingfluorescein conjugated monoclonal anti-bodies is more reliable

iii Antibody titre rarely necessary except incases of herpes sine eruption

Treatment

Adequate and timely treatment [ideally within

72 hours of onset of disease] is essential toreduce the pain, duration of lesions andavoiding the postherpetic neuralgia in olderpatients and preventing dissemination inimmunocompromised patients

1 Acyclovir—decreases pain, accelerateshealing, minimizes ocular complication ofcorneal scarring and blindness Dose is

800 mg 5 times a day for 7 days (400 mgthree times a day for HSV)

3 In the past, corticosteroids [tab prednisolone,40–60 mg for 1–2 weeks] were prescribed

to prevent postherpetic neuralgia in olderindividuals, however, presently it is consi-dered controversial

4 Treatment of postherpetic neuralgia:

6 Alcohol block—sympathetic nerve block

7 Topical capsaicin (hot pepper) depletes thesubstance P formed in the nerve endings

8 Live attenuated vaccine—decreases theseverity of post herpetic neuralgia

9 Chemical/surgical neurolysis may benecessary in refractory cases

a Mild systemic symptoms

b Generalized intensely pruritic eruption of

maculopapular lesions that rapidly develop

into vesicles on an erythematous base

c The vesicles turn cloudy and pustular They

burst and scar The crusts then fall off after

1–2 weeks

d Lesions are present on trunk and face and

spread centrifugally Oral lesions are ulcers

Infectious mononucleosis: Caused by epstein

barr virus which may be transmitted due to

close personal contact, direct salivary transfer

during intimate oral kissing hence also known

as kissing disease Incubation period is 33–49

days

Clinical Features

i Fever, fatigue, malaise sometimes

morbili-form rash

ii Some cases have circumscribed mucosal

petechiae symmetrically distributed at the

junction of hard and soft palate seen

between 5th and 17th day of sickness

Ulcerative lesions may also be seen—

could represent immune induced reaction

to virus rather than direct effect of viral

infection

iii Sore throat, enlarged tonsils with copious

amount of cheesy yellow exudates filling

the tonsillar crypts, cervical

lymphadeno-pathy also evident, hence called glandular

fever

iv Hepatosplenomegaly

v Transient atypical lymphocytosis

Clinical diagnosis is difficult

Lab Diagnosis

Positive Paul-Bunnell reaction which detects

the heterophile antibody that agglutinates

sheep RBC The test is also positive in

leukemia, serum sickness and reticulosis

Therefore, Paul-Bunnell-Davidson test is more

specific

Large atypical lymphocytes 20–80% ofdifferential WBC count with pseudopodia thatproject from the cell outline in 3–4 directions.Mono-spot test—detects the heterophileantibody if the test is positive, it is most likelythat the patient is suffering from infectiousmononucleosis, however, false positive test isseen in hepatitis, SLE and other conditions

immunocompro-Oral Manifestations

In immunocompromised patients—singlelarge necrotic ulcer seen, less often multipleulcers which are painful and lasting for weeks

or months are also seen Patients of CMVand VZV infection have occasional reports

of mandibular osteomyelitis and toothexfoliation Both viruses are associated withvasculopathy and thrombosis which may bethe underlying pathogenesis

CMV has feature of latency within tive tissue cells such as endothelium andwithin endothelial cells, it contributes tovascular inflammation, vascular occlusion andend organ damage

• DNA hybrid capture.

• Biopsy for microscopic examination and/or

to obtain for tissue culture CMV produces

large intranuclear inclusions within

endo-thelial cells and monocytes within CT with

associated nonspecific inflammation

Management

Topical anesthetics and systemic analgesics for

pain control

Antiviral agents ganciclovir, valganciclovir

(tenfold bioavailability of ganciclovir),

cidofovir

Erythema Multiforme

Erythema multiforme—is a hypersensitivity

reaction It is an acute self-limiting disease of

unknown etiology affecting skin and mucous

membrane As the name “multiforme” suggests

the lesions present multiple forms, viz

macules, papules, vesicles, etc

Various clinical types have been recognized:

1 Simplex

2 Severe form: (a) Stevens-Johnson syndrome,

(b) TEN (toxic epidermal necrolysis/Lyell

disease)

3 Also rare chronic form

4 Herpes associated erythema multiforme

2 Deposition of immune complex-IgM C3:

Deposition of immune complexes in

super-ficial microvasculature of skin and mucosa

can be considered as a cause

3 Cell-mediated immunity/vaccination

4 Micro-organisms: Mycoplasma pneumoniae,

HSV

Association between HSV and EM has been

reported, as cases once thought to be

idio-pathic are infact cell-mediated immunologic

reaction to HSV infection and prophylactic

acyclovir prevented recurrent EM in HSVpositive patients

5 BT, MT, leiomyoma of stomach, ovary

6 Crohn’s disease, sarcoidosis, histoplasmosisand infectious mononucleosis

be the prodromal symptoms)

2 Adults (between 20 and 40 years age) andchildren are usually affected and commonlygive history of drug or food allergy

3 In EM simplex which is the least severeform, symmetric maculopapular rash 0.5

to 2 cm in diameter is seen on the skin.Skin and mucous membrane involvement

is seen in severe form

4 Skin lesions appear classically on hands,feet, extensor surfaces of elbows andknees, face and neck rarely involved.The lesions are nonspecific and can occur

as macules, papules or vesicles withpetechiae in the centre of the lesion Theselesions spread centripetally towards thetrunk in a symmetric distribution

5 Typical skin lesions has been described asiris, target or bulls eye lesions characterized

by central bulla/blister with concentricrings of erythema and are consideredpathognomonic for EM (Fig 2.7)

6 Oral lesions appear in anterior part ofmouth, especially vermilion border of lips,tongue, buccal mucosa, labial mucosa

7 Formation of bullae and vesicles whichrupture and coalesce to form ulcerscharacterised by deep, irregular bleedinglesions Typical presentation is bloodycrustations on the lips Tissue tags presentperipheral to the ulcers (Fig 2.8)

8 Increased salivation (may be blood-tinged)

9 Gingiva rarely affected.

10 Stevens-Johnson syndrome [SJS]—Severe

form of EM affecting skin, oral mucous

membrane, eyes (keratoconjunctivitis,

corneal ulcerations) (Fig 2.9), genitalia

(balanitis, urethritis, vaginitis) In the

severe form, Nikolsky’s sign may be

positive This condition, if untreated, may

lead to infection, electrolyte imbalance and

death

11 TEN is the most severe form of EM,

secondary to drug reaction, it results in

sloughing of skin and mucosa in large

sheets Death may be due to secondary

infection; fluid, electrolyte imbalance or

involvement of lungs, liver or kidneys.Patients are best managed in burn centerswhere necrotic skin is removed andhealing takes place under sheets of porcinexenografts

12 Recent concept: SJS is less severe form of

TEN and both are separate from EM Skinlesions of SJS and TEN are more severeand arise on chest, called atypical targets(erythematous, purpuric macules) SJSassociated with drug allergy and myco-plasma and EM with HSV infection.Diagnosis is based on—history, clinicalcharacteristics, histopathology and biopsy ofintact bulla

Fig 2.7: Erythema multiforme—lip lesions and target lesions on the palms

Fig 2.8: Erythema multiforme showing bloody crustations on lip and ulcerations on tongue

Histopathology: Shows intraepithelial lesions

which may form subepithelial lesions,

liquefactive degeneration of upper layers of

epithelium, thinning or absence of basement

membrane and inflammation of coreum It is

not specific

D/D

1 Allergic stomatitis: Difficult to differentiate,

erythema, vesiculations, ulcerations with a

positive history of allergy helps, however,

both these conditions are similar

patho-logically and clinically

2 HSV: Primary HSV with prodromal

symptoms, small round symmetrical

shallow ulcers as opposed to EM with acute

explosive onset and large irregular deep

bleeding ulcers HSV associated with

marginal gingivitis, lymphadenopathy

which is not seen in EM

3 Herpes zoster: Unilateral distribution is

pathognomonic of HZ with the lesions

abruptly stopping in the midline, severe

pain, EM bloody crustations on both the

sides of the lip

4 Herpangina: Lymphadenopathy, lesions

affecting posterior part of oral cavity

5 Pemphigus vulgaris: Patient gives history of

chronic lesions (H/o 2–3 months), EM is of

acute duration, i.e very short duration

history of few days

in tapering dose

2 Topical steroids in orabase—Betamethasonewith neomycin, fluocinolone N, triamcino-lone acetonide

3 Cases suspected to be HSV associated aretreated with 400 mg acyclovir bid whichprevents the development of EM

4 For non-HSV related EM—Azathioprine(100–150 mg/day), Dapsone (100–150 mg/day), antimalarials are partially successful

in preventing recurrent outbreaks

5 Local anesthetic mouthwashes prior tomeals as lesions are painful

6 Local as well as systemic effect by use of0.5 mg tab Betamethasone (tab Betnesol) –crush the tablet + water and hold in mouthfor 5–10 mins swish and swallow Thisregimen lasting 20 days includes givingBetamethasone 0.5 mg 1 tab 4 times a day

for 5 days

3 times a day for next 5 days

2 times a day for next 5 daysOnce a day for next 5 days

Fig 2.9: Stevens-Johnson syndrome

In patients with diabetes or acidity or peptic

ulcer, systemic steroids are contraindicated

and patients can be asked to Swish and Spit

the medication

7 Treatment: In severe cases, high dose of

steroid, I.V immunoglobulins and

thalido-mide are given

which mast cells release histamine, bradykinin

and SRSA

Anaphylaxis a patient previously exposed to

a drug or other antigen has antibody

(primarily IgE), fixed to basophils and mast

cells When the antigen in the form of a drug,

food or air borne substance is re-introduced

into the body it will react with the fixed

antibody, bind complement and open mast

cell releasing active mediators such as

histamine and slow reacting substance of

anaphylaxis (SRSA) These substances cause

vasodilation, increased capillary permeability,

emigration of leukocytes in the tissues All

these lead to edema Constriction of bronchial

smooth muscles also may result when IgE is

bound in pulmonary region Anaphylactic

reac-tion can be localized (angioneurotic edema,

urticaria) or generalized (anaphylactic shock)

Allergy is of two basic types: Immediate

reaction and delayed hypersensitivity

2 Fixed drug eruption

3 Contact allergy—stomatitis venenata,

dermatitis

Delayed hypersensitivity reaction: Antigen

antibody reaction caused by systemic intake

of any allergen is called as stomatitis

medicamentosa This term should be

discarded Lesions when present as erythema,

ulcers, vesicles and edema it is more likely to

be EM (Fig 2.10) while lesions when present

Fig 2.10: Patient presenting with diffuse erythema and vesiculations after self-medication with indigenous preparation

as a white lesion and ulcer it is more likely to

be lichenoid reaction Separation of theseentities leads to confusion

Causes: Penicillin, barbiturates, phenyl

butazone, analgesics

Characterized by edema along with vesicle

formation and ulceration Oral vesicles andulcers of allergic etiology that should bedistinguished from EM or lichenplanus arefixed drug eruptions and contact allergy

Contact allergy: On skin is dermatitis

venenata and that on oral mucous membrane

is stomatitis venenata Here due to contact,there is antigen—antibody reaction It can bedue to contact with leather, nickel-chrome,cosmetics and synthetic material

In mouth, amalgam restoration (due torelease of mercury), chrome cobalt, goldcrowns, denture base, acrylic dentures (due torelease of free monomer), toothpastes, chewinggums, lipstick can cause contact allergy.Another oral manifestation of contactallergy is plasma cell gingivitis which ischaracterized by generalized erythematous,

edematous attached gingiva occasionally

accompanied by cheilitis and glossitis

Histopathology shows sheets of plasma cells

that replace normal connective tissue

Causes for the relative infrequency of

contact allergy of oral mucosa:

a Relatively low number of Langerhans cell

b Saliva dilutes antigen and physically

washes them away Increased vascularity

of the oral mucosa (compared to skin)

allows rapid removal of potential antigens

c Lesser keratin than skin thus decreases the

possibility of hapten formation

Fixed Drug Eruption

1 Definition: Characterized by localized area

of involvement due to intake of allergen,

presenting with erythema, edema and

vesicle formation

2 Clinical features: Multiple vesicles which

may rupture and form ulcers and further

coalesce to form large ulcers Its

chara-cteristic is the acute nature, recurrence of

similar lesion at the same fixed location

after contact with the same allergen (hence

called fixed drug eruption)

3 Diagnosis: History to identify allergen.

Family history of allergy/asthma Previous

history of similar lesion History of allergy

to food, drugs Systemic administration of

any drugs Change in cosmetics or dental

treatment

4 Treatment: Identifying and removing

the allergen Antihistaminics like tab Avil

(25–50 mg), Incidal, Cosavil, Benadryl

(50 mg – 4 times) In severe cases 0.2 ml s.c

epinephrine 1:1000 dilution

Corticosteroids: 5–10 mg of prednisolone or

1–2 mg of betamethasone (in local or

systemic form, given in tapering dose)

Increased fluid intake

Local anesthetic mouthwash—xylocaine

viscous mouthwash, diclonine

hydro-chloride (half an hour before meals)

Diagnosis: For contact allergy—patch test

(Fig 2.11) The suspected allergen is taped tothe relatively non hairy skin of the back or theforearm and left for 48 hrs, the patch is removedand the area is examined for persistenterythema (test positive)

Localized anaphylaxis: When a localizedreaction involving superficial blood vesselsresults in urticarial (hives)

Urticaria begins with pruritis in the area ofrelease of histamine and other active sub-stances Wheal appears as an area of localizededema over an erythematous base Lesions canoccur on skin or mucous membrane

Angioneurotic edema: When the blood vessels

deeper in the connective tissue are attacked,large diffuse area of subcutaneous swellingunder normal overlying skin (Fig 2.12).Swelling around eyes

Fig 2.12: Angioneurotic edema showing diffuse swelling of lower lip

Fig 2.11: Patch test

A

B