Ulcerative Soft Tissue & Vesiculo-bullous Disease

Question 1

A 65 year old female presents with erythematous, desquamatous and ulcerated appearance of the gingiva. Direct immunofluorescence microscopy shows a positive linear fluoresence for IgG at the basment membrane zone. Which of the following diagnosis matces with the clinical and histological findings?

Oral lichen planus
Oral lichenoid lesion
Pemphigus vulgaris
Mucous membrane pemphigoid

Answer 1

Mucous membrane pemphigoid

Question 2

A 50 year old female patient visits your dental clinic for a dental checkup. She has been complaining of pain since a week ago. Intraoral examination revealed irregularly shaped ulcerations on the mucosa surface and a positive Nikolsky’s sign is noted. You took a sample of fresh perilesional tissue and sent it to the lab for direct immunofluorescence examination. Results show chicken-wire staining of intracellular spaces. What is the most likely diagnosis?

Herpes Simplex
Mucous membrane pemphigoid
Oral lichen planus
Pemphigus vulgaris

Answer 2

Pemphigus vulgaris

Question 3

A friend of yours brought his 3 y.o. son to you as you are his only “doctor friend”. Your friend says that he noticed small ulcers started appearing on his son’s soft palate, buccal mucosa, tongue after he pick his son up from his child care centre yesterday. He decided to seek help as the ulcers are numerous and his child keeps crying due to the pain. Upon closer examination, you noticed that the ulcers has coalesce into larger, shallow, irregular ulcerations. After reasurring that his son has contracted a common viral infection from his child care buddies, what other advice can you give to your friend?

“You can bring your son to his child care as per usual starting from tomorrow onwards”
“Apply either viscous lidocaine or topical benzocaine on ulcers shall the pain become untolerable”
“If ulcers persists for the next 3 days, visit an OMS surgeon to get them surgically removed”
“Let your child rest for the next few days and ensure that he drinks enough water and eat enough food”

Answer 3

“Let your child rest for the next few days and ensure that he drinks enough water and eat enough food”

Question 4

Which type of pemphigus affects the oral cavity?

Pemphigus vulgaris
Pemphigus foliaceus
IgA pemphigus
Paraneoplastic pemphigus

Answer 4

Pemphigus vulgaris

Question 5

Patient presents with large shallow ulcers with irregular borders, and crusting of lips. She does not complain of any pain. Which of the following corresponds to the treatment required?

Anti-inflammatory therapy
Steroid therapy
Withdrawal of the trigger if known
Antifungals

Answer 5

Withdrawal of the trigger if known

Question 6

Which disease should be immediately referred to an ophthalmologist upon diagnosis, due to risk of blindness?

Epidermolysis bullosa
Mucous membrane pemphigoid
Verrucous carcinoma
Pemphigus vulgaris

Answer 6

Mucous membrane pemphigoid

Question 7

Which of the following statements is true regarding ulcerative soft tissue lesions and vesiculo-bullous diseases?

Recurrent aphthous stomatitis is usually found on non-keratinised epithelium and triggers include stress, trauma and allergies. Diagnosis is best done with histological investigations.
Pemphigus vulgaris usually presents in younger patients (as compared to mucous membrane pemphigoid). It is caused by antigenic targets on desmosomes. Diagnosis is best done via direct immunofluorescence.
Herpangina is often caused by Coxsackie A16 and Enterovirus A17 in more severe cases. It initially presents as macules before transforming into vesicles and oral ulcers on the tongue and buccal mucosa in the oral cavity.
Ulcerations on the buccal mucosa that last for 1 week and are associated with a temporal relationship to an event are highly suspicious of cancer and malignancy.

Answer 7

Pemphigus vulgaris usually presents in younger patients (as compared to mucous membrane pemphigoid). It is caused by antigenic targets on desmosomes. Diagnosis is best done via direct immunofluorescence.

Question 8

Which of the following is a true regarding pemphigus vulgaris and mucous membrane pemphigoid?

Pemphigus vulgaris has an older demographics compared to mucous membrane pemphigoid
Pemphigus vulgaris is a type I hypersensitivity reaction while mucous membrane pemphigoid is a type II hypersensitivity reaction
Mucous membrane pemphigoid is more common in females than males
Pemphigus vulgaris is a blistering disease and blisters are often seen clinically

Answer 8

Mucous membrane pemphigoid is more common in females than males

Question 9

Which of the following is not a systemic cause of ulcers?

Crohn’s disease
Uremic stomatitis
Celiac disease
Epidermolysis Bullosa

Answer 9

Epidermolysis Bullosa

Question 10

Which of the following describes the histologic features of lichen planus?

Acantholysis, bandlike chronic inflammatory infiltrate, saw tooth-like rete ridges
Acanthosis, bandlike chronic infilammatory infiltrate and saw tooth-like rete ridges
Acanthosis, acute inflammatory infiltrate, saw tooth-like rete ridges
Acantholysis, acute inflammatory infiltrate, normal appearance of rete ridges

Answer 10

Acanthosis, bandlike chronic infilammatory infiltrate and saw tooth-like rete ridges

Question 11

Which of the following factors does NOT differentiate MMP from PV?

Positive/negative Nikolsky signs
They have different antigenic targets
involvement of other mucosal sites especially the eye
Presence of oral lesions

Answer 11

Presence of oral lesions

Question 12

Which of the following accurately describes Varicella Zoster Virus?

Its form of transmission is through direct cutaneous contact with vescicle fluid from skin lesions
Even when the skin lesions have fully crusted, it is still infectious
It is not possible to have a reinfection of the virus
It is not a self limiting condition

Answer 12

Its form of transmission is through direct cutaneous contact with vescicle fluid from skin lesions

Question 13

What can be done to differentiate between pemphigus vulgaris and mucous membrane pemphigoid?

H&E stain
Visual observation
Direct and indirect immunofluorescence
Biopsy

Answer 13

Direct and indirect immunofluorescence

Question 14

Which is not an appropriate means of management for Epidermolysis Bullosa?

Corticosteroid use
Drainage of large blisters
Symptomatic care such as use of antidepressants for pain
Use of topical antibiotics

Answer 14

Corticosteroid use

Question 15

Which of the following statements regaridng oral ulcers is true?

a) Histological investigation is necessary to establish a definite diagnosis for recurrent aphthous stomatitis
b) OLP is a autoimmune disorder that has a unique histological feature of predominantly B-cell lymphocytes in the lamina propria
c) Pemphigoid and Pemphigus is caused by antibodies directed against hemi-desmosomes and desmosomes respectively
d) Recurrent aphtous stomatitis / ulcerations have malignant transformation potential

Answer 15

c) Pemphigoid and Pemphigus is caused by antibodies directed against hemi-desmosomes and desmosomes respectively

Question 16

What type of defect is attributed to Dystrophic Epidermolysis Bullosa (EB)?

a) Defect in type Vll collagen
b) Keratin gene defect
c) Hypothalamic defect
d) Defects of hemidesmosomes

Answer 16

a) Defect in type Vll collagen

Question 17

A 5 year old child presents to your clinic with small aphthae-like ulcers on the palate and buccal mucosa. You notice that the child also has prurititic rashes on his face and his arms and neck. His mother mentions that the kindergarten that the child is attending has been closed as many children had fallen sick in the past 2 weeks. Which of the following would you not expect in the lab results of samples taken from the child?

Tzank cells present in cytological swabs.
Viral inclusion cells present in histological sample.
Owl-eye cells present in histological sample.
VZV IgM positive in serology testing,

Answer 17

Owl-eye cells present in histological sample.

Question 18

A 63 year old patient presents with multiple oral lesions. On examination, you observe irregularly shaped ulcers with a denuded surface. Additionally, there are blisters on the skin. Histological examination of a biopsy from the oral lesion shows suprabasal acantholysis. Direct immunofluorescence reveals intraepithelial IgG deposits. What is the most likely diagnosis?

Mucous Membrane Pemphigoid
Pemphigus Vulgaris
Epidermolysis Bullosa
Cyclic Neutropenia

Answer 18

Pemphigus Vulgaris

Question 19

Which type of lesion (ulcer) best fits the following description: “presents with blisters & postive Nikolsky sign”?

Neoplastic ulcers
Infectious ulcers
Reactive ulcers
Developmental ulcers

Answer 19

Reactive ulcers

Question 20

An 8 year old child comes into your clinic presenting with a fever and multiple small ulcers found on her oropharynx, soft palate, tonsils and uvula. What is the most likely diagnosis?

Cytomegalovirus
Hand Foot Mouth Disease
Herpangina
Varicella Zoster Virus

Answer 20

Herpangina

Question 21

What would be the treatment method for a recurrent apthous ulceration?

Chlorhexidine rinse
Leave the ulcers alone as it will heal on its own
Prescribe ibuprofen
Prescribe prednisolone

Answer 21

Chlorhexidine rinse

Question 22

At the 1-week recall visit of your denture patient, your patient presents with contact stomatitis. What type of hypersensitivity occurred?

Type I
Type II
Type III
Type IV

Answer 22

Type IV

Question 23

A 16 year old patient whom had undergone chemotherapy presented with multiple small apthae-like ulcers and vesicles on the palate. The dentist told him to come back after a week for a review to observe the progress of the condition. During the review, it was noted that some of the vesicles had already fallen out. Which of the following viruses could have been the reason for the patient’s condition?

Varicella Zoster Virus
Cytomegalovirus
Herpes Simplex Virus
Coxsackie Virus

Answer 23

Varicella Zoster Virus

Question 24

Which layer of the oral mucosa is commonly targeted by genetic defects and autoimmune disorders such as lichen planus, pemphigus and pemphigoid?

Basal layer
Submucosa
Prickle cell layer
Lamina propria

Answer 24

Basal layer

Question 25

A patient presents with small apthous-like ulcers on his palate and buccal mucosa. He also has rashes in successive crops on face over several days. What is the appropriate treatment plan?

Anti-viral medication only
Anti-pyretic and anti-viral medication only
Anti-bacterial drugs only
Supportive care only

Answer 25

Supportive care only

Question 26

Mr Loh, a washroom cleaner recently got a new set of partial dentures from FOD. 3 days later, he complained of ulcers forming on the soft palate, and he presented with high fever of 38.7 degrees. A clinical examination showed only ulcers on his soft palate. He mentioned that he had difficulty swallowing as well. Which is the most likely differential diagnosis

Herpangina
Pseudomembranous candidiasis
Pemphigus Vulgaris
VZV

Answer 26

Herpangina

Question 27

50 year old patient presents with autoimmune disease and positive Nikolsky sign. Which oral vesiculo-bullous lesion is most likely found?

mucous membranes pemphigoid
pemphigus vulgaris
epidermolysis bullosa
erythema multiforme

Answer 27

pemphigus vulgaris

Question 28

It is crucial for one to distinguish between Pemphigus Vulgaris (PV) and Mucous Membrane Pemphigoid (MMP) for proper management of these Vesicular Bullous Diseases. Which of the following is an accurate basis for differentiating the two?

Pemphigus Vulgaris can present clinically with a Positive Nikolsky Sign, whereas Mucous Membrane Pemphigoid can present clinically with ophthalmic presentations like conjunctival scarring.
Pemphigus Vulgaris has no racial predilection, whereas Mucous Membrane Pemphigoid has a racial predilection for Jews.
Pemphigus Vulgaris is more common in females, whereas Mucous Membrane Pemphigoid has no gender predilection.
Pemphigus Vulgaris occurs more in older patients, whereas Mucous Membrane Pemphigoid occurs more in younger patients.

Answer 28

Pemphigus Vulgaris can present clinically with a Positive Nikolsky Sign, whereas Mucous Membrane Pemphigoid can present clinically with ophthalmic presentations like conjunctival scarring.

Question 29

Which of the following HHV infection, if neonatal, results in tooth defects?

HHV 1
HHV 2
HHV 3
HHV 5

Answer 29

HHV 5

Question 30

Which of the following will giving NSAIDS be a possible treatment option?

erythema multiforme
lupus erythematosus
oral candidiasis
recurrent aphthous ulceration

Answer 30

erythema multiforme

Question 31

A 22 year-old female student visits the clinic with a small, sensitive, gray-white area forming along the lateral border of her tongue, 2 days before her final exams. On physical examination, there is a shallow, ulcerated 4mm lesion with an erythematous rim. The patient has no fever. The patient does not smoke or chew tobacco. Without specific therapy given, the lesion disappears within 2 weeks. Which is the most likely cause of this lesion?

Herpes simplex stomatitis
Oral leukoplakia
Recurrent aphthous ulceration
Sialadenitis

Answer 31

Recurrent aphthous ulceration