Acute and Chronic Ulcerative Lesions Part 1

Question 1

Anesthetic Necrosis
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 1

Category:
-Injury

Etiology:
-Necrosis secondary to administration of local anesthetic
-May result from ischemia or faulty technique

Demographics:
-Patient who recently received oral local anesthetic

Clinical Presentation:
-Well-circumscribed ulcer at site of previous injection
-Hard palate most common site

Diagnosis:
-Clinical diagnosis based on history of recent local anesthetic injection

Tx:
-Heals with time

Question 2

Necrotizing Sialometaplasia
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 2

Category:
-Injury

Etiology:
-Ischemia of salivary tissue leads to local infarction

Demographics:
-Predisposing factors:
1. Trauma
2. Dental injections
3. Ill-fitting dentures
4. Eating disorder with binge-purging
5. Upper respiratory tract infection

Clinical Presentation:
-Most cases on hard palate
-Nonulcerated, painful swelling initially
-Within 2-3 weeks, a crater-like ulcer forms and pain is reduced

Diagnosis:
-Biopsy (a malignant process must be excluded)

Tx:
-Heals in 5-6 weeks

Question 3

Primary Herpetic Gingivostomatitis
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 3

Category:
-Infectious

Etiology:
-Initial infection of herpes simplex virus type 1 (HSV-1)

Demographics:
-Usually in children 6 months to 6 years
-Can occur in adults

Clinical Presentation:
-Acute onset
-May have fever and lymphadenopathy
-Multiple small vesicles progress to ulceration of oral mucosa, lips, and perioral skin
-Painful, erythematous gingiva

Diagnosis:
-Clinical diagnosis
-Viral culture (slow) or PCR
-Cytologic smear (least invasive, most cost effective)
-Biopsy

Tx:
-Lesions heal spontaneously in 2 weeks
-Symptomatic relief (NSAIDs, Lidocaine rinse)
-Antiviral (should be administered during day 2 or 3 for best effect)
-HSV-1 remains latent in the trigeminal ganglion

Question 4

What is a Cytologic Smear?

Answer 4

-Lightly moisten tongue depressor with water
-Gently remove cells (scrape) area
-Spread accumulated cells on microscopic slide
-Spray slide lightly with fixative
-Submit to pathologist

Question 5

List the prescriptions for Primary Herpetic Gingivostomatitis

Answer 5

Antiviral Prescriptions

Rx: Valacyclovir (Valtrex) 1 g
Disp: 14 tabs
Sig: 1 tab q 12h until finished

Rx: Acyclovir (Zovirax) 400 mg
Disp: 21 tabs
Sig: 1 tab TID until finished

Question 6

Recurrent Herpes Labialis
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 6

Category:
-Infectious

Etiology:
-Reactivation of HSV-1
-Risk factors:
1. advanced age
2. ultraviolet light
3. physical/emotional stress
4. dental tx
-Can recur multiple times

Demographics:
-Worldwide prevalence of HSV-1 is 67% in individuals under 50

Clinical Presentation:
-May experience prodrome 6-24 hours before lesions appear (pain, burning, itching, tingling, localized warmth, erythema)
-Multiple, small, erythematous papules form clusters of fluid-filled vesicles
-Affects vermillion border and skin adjacent to lips

Diagnosis:
-Clinical diagnosis
-Viral culture (slow) or PCR
-Cytologic smear
-Biopsy

Tx:
-Antivirals
-Heals in 7-10 days

Question 7

List the prescriptions for Recurrent Herpes Labialis

Answer 7

Antiviral Prescriptions - Must be taken at earliest prodromal symptom

Rx: Valacyclovir (Valtrex) 500 mg
Disp: 7 tabs
Sig: Take 4 initially, 2 at 12 h, then 1 at 24 hr

Rx: Acyclovir (Zovirax) 800 mg
Disp: 6 tabs
Sig: Take 3 initially, then 2 at 12 h, then 1 at 24 hr

Question 8

Recurrent Intraoral Herpes Simplex
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 8

Category:
-Infectious

Etiology:
-Reactivation of HSV-1
-Risk factors:
1. advanced age
2. ultraviolet light
3. physical/emotional stress
4. dental tx

Clinical Presentation:
-Affects keratinized mucosa bound to bone (attached gingiva, hard palate)
-Small vesicles collapse to form cluster of erythematous macules

Diagnosis:
-Clinical diagnosis
-Viral culture (slow) or PCR
-Cytologic smear
-Biopsy

Tx:
-Antiviral (same as recurrent herpes labialis)
-Heals in 7-10 days

Question 9

Herpes Zoster “Shingles”
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx
-Prevention

Answer 9

Category:
-Infectious

Etiology:
-Reactivation of Varicella Zoster Virus (HHV-3)
-Recurs once

Demographics:
-Incidence increases with age
-Immunosuppression increases susceptibility

Clinical Presentation:
-Prodrome: severe neuralgia (with or without fever, malaise, and headache)
-Acute: clusters of vesicles with erythematous base, terminate at midline
-Chronic: postherpetic neuralgia
-Pain and lesions tend to occur along one dermatome

Diagnosis:
-Clinical diagnosis
-Viral culture (slow) or PCR
-Cytologic smear
-Biopsy

Treatment:
-Antiviral (within 3 days of onset)
-Symptomatic relief:
1. NSAIDs
2. Diphenhydramine
3. Gabapentin
4. Steroids

Prevention:
-Shingrix vaccine recommended for adults 50 yrs and older

Question 10

List the Herpes Zoster “Shingles” Prescriptions

Answer 10

Antiviral Prescriptions

Rx: Valacyclovir (Valtrex) 500 mg
Disp: 42 tabs
Sig: 2 tabs TID until finished

Rx: Acyclovir (Zovirax) 400 mg
Disp: 70 tabs
Sig: 2 tabs five times daily until finished

Question 11

Hand-Foot-and-Mouth Disease
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 11

Category:
-Infectious

Etiology:
-Enterovirus infection

Demographics:
-Most common in children

Clinical Presentation:
-Oral lesions arise first –>
1. Multiple apthous-like ulcerations
2. Buccal mucosa, labial mucosa, and tongue most common
-Cutaneous lesions –>
1. Erythematous macules become vesicles
2. Primarily affect hands and feet

Diagnosis:
-Clinical diagnosis
-PCR confirmation if necessary

Tx:
-Self-limiting (no tx necessary)

Question 12

Necrotizing Ulcerative Gingivitis
-Category
-Etiology
-Demographics
-Clinical Presentation
-Diagnosis
-Tx

Answer 12

Category:
-Infectious

Etiology:
-Fusobacterium nucleatum (and other bacteria)

Demographics:
-Most frequent among young and middle-aged adults
-Risk factors:
1. psychologic stress
2. immunosuppression
3. smoking
4. local trauma
5. poor nutritional status
6. poor oral hygiene
7. inadequate sleep
8. recent illness

Clinical Presentation:
-Interdental papillae blunted, inflamed, edematous, and hemorrhagic
-“Punched out” craterlike necrosis covered with gray pseudomembrane
-Fetid odor
-Severe pain
-May be accompanied by lymphadenopthy, fever, and malaise

Diagnosis:
-Clinical diagnosis

Tx:
-Scaling, curettage, or ultrasonic instrumentation
-Chlorhexidine rinse
-Antibiotics if lymphadenopathy or fever present
-Evaluation for underlying cause of immunosuppression (HIV)