09/10: DX and TX of Oral Mucous Membrane Diseases

Transcribed by Anam Khalid Monday, July 14
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[Diagnosis and Treatment of Oral Diseases] [Lecture #9 & 10] [Intro to
Diagnosis and Treatment of Oral Mucous Membrane Diseases] by [Dr. Shah]

[1] [Diagnosis and Treatment of Common Oral Mucous Membrane Diseases]
[Dr. Shah] Good afternoon. How are you guys? Excited about oral pathology?
Alright. Lets get this party started. Okay. Alright guys, let me have your attention.
Okay, so today let me see if I can get rid of this echo here. Today were going to
talk about diagnosis and treatment of common oral mucous membrane diseases. So
I think, was it last week, after I saw you guys on Monday, Dr. Phelan spoke about
salivary gland pathology, right? Okay. So today Im going to talk about a very I
mean its all important but this is an extremely important topic because so many
patients suffer from the things Im going to be talking about today. And so many
dentists and health care providers have no clue whats going on. You know? And so
we could really make a difference beyond someones root canal, crowns, bridges,
and dentures, in the quality of the patients life because these mucous membrane
diseases, many of them are so chronic. And a lot of them are very painful. Okay?
These patients get referred, you know? From provider to provider to dentist to
dentist to this and that and many times they come to our oral medicine clinic that
Dr. Kerr and I work in and they have such distrust for dentists and for just health
providers in general and it really reflects poorly on all of us. So Im here to really,
you know, strengthen and solidify your knowledge of this area so that eventually,
when you get a patient with these diseases, which I promise you will, youll know
what to do and you wont be one of those people that refers a patient round and
round with no clue as to whats going on. Okay? So. Diagnosis and treatment of
common oral mucous membrane diseases. Also, Im going to make one comment
before I forget. Next Monday, Im actually on vacation next week so Im excited
about that.
[Student]-- Woo!
[Dr. Shah]-- Thank you. But its not going to be that much of a vacation because my
family from Texas is coming. So five people are coming to stay in my house so Ill be
busy working. But, you know? So, Im going to show them the area and so itll still be
not coming here but the point of this was that next Monday, youre going to have a
speaker, Dr. Stabulus, from radiology, on Monday. Okay? have you guys not heard
of her? Professor Stabulus? Okay so you havent met her yet. But you will, you will.
Okay. So you have a speaker, Professor Stabulus. Shell be here next Monday, and I
just want to point out one thing, hopefully shell be here next Monday because she
comes from Long Island. And youve all heard about the possible strike thats
coming up? Okay. You guys are so busy studying, youre not keeping up with the
news, right? But no, theres a possible strike coming for the Long Island Railroad
and its going to affect a lot of commuters. So, if theres a strike, she comes from
Long Island, I dont know whether shes going to come in or not so stay posted.
Theres a chance that we may have to reschedule next Mondays lecture. Okay, I
know youre getting really upset. You want to hear Professor Stabulus but lets see
what happens. Okay. So guys if youre ready for me to begin, let me know and Ill
get started. Okay, lets do it.

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[2] [Herpes Simplex Virus Infection]
[Dr. Shah] Alright, so Im going to start off by talking about herpes and candidiasis.
Okay? We just barely touched upon these when I was talking about the mucosal
smear and common oral lesions. But I want to spend more time going over these.
Also, Im going to talk about the two types of ulcers that occur in the oral cavity.
Obviously herpetic is one and the other is whats another type of ulcer that occurs
in the mouth? That we talked about in common oral conditions canker sores,
which are also known as? Aphthous ulcers. Aphthous ulcers. So Ill talk about those
and then Im going to go into the second half of this lecture is on mucous membrane
diseases known as desquamative gingivitis ::muttering under breath:: desquamative
gingivitis, Ill cover pemphigus, pemphigoid, lichen planus and erythema
multiforme. Okay.

So let me start by talking about herpes simplex virus infection, HSV. Okay? You are
going to get a lot of patients with this and theyre going to ask you questions so have
to know whats going on here.

[3] [Types of HSV]
[Dr. Shah] Types of HSV. There are 2 main types of HSV, herpes simplex virus.
Theres type I and type II, known as HSV I and HSV II. HSV I is mostly linked to oral
infections and HSVI II is mostly linked to genital infections. But due to um
miscellaneous activities you can have type I in the genital area and type II in the oral
area. Hopefully you understand and I dont have to explain that further.

[Student]-- Dr. Shah!

[Dr. Shah] You need an explanation?

[Student]--No, its a little loud.

[Dr. Shah] Whats that?

[Student]--Its a little loud.

[Dr. Shah] Okay, yeah.

[Student]-- Sorry.

[Dr. Shah] When I put it here, its like echoing ::fixes mic:: Okay, maybe thats
better? Lets try it. ::mic echo:: Every time I put it here, it just doesnt want to be
here. Okay, is this better or should I go even lower?

[Students]-- Lower.
DR. SHAH: Okay, maybe I just need to lower my voice better? Okay. Alright.

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[4] [Herpes Simplex Virus Infection]
[Dr. Shah] So moving on to HSV infection, I told you about the two types, right? Oral
and genital. Okay. Now I want to talk about oral HSV infection has two clinical
manifestations. Two clinical manifestations. You can have a primary infection, okay?
Which is the first encounter. This usually happens in children and young adults. And
this is known as primary herpetic gingivostomatitis. Primary herpetic
gingivostomatitis. Okay. So primary herpetic gingivostomatitis not only occurs in
young patients but the onset is acute and many patients will also have systemic
signs such as fever and lymphadenopathy.

Okay? And secondary herpetic eruptions is obviously secondary means the
patient has already been exposed to the herpes virus. And not everybody the
majority of people have a subclinical infection the first time youre infected with
herpes. You may not have a full-blown primary herpetic gingivostomatitis like Im
going to be describing, which happens in just a few patients.

So secondary herpetic eruptions occur in 20-40% of the population. Thats a pretty
significant number. And the lesions as I mentioned to you before, in the previous
lectures, are localized to keratinized mucosa fixed, keratinized mucosa such as
such as what? Where are you going to find herpetic ulcers? Fixed keratinized.
Whats fixed and keratinized in your mouth? Hard palate and gingiva. Those are the
two most common areas. Okay?

[5] [Primary Herpes]
[Dr. Shah] Alright lets talk about primary herpes.

[6] [N/A]
[Dr. Shah] Okay, so primary herpetic gingivostomatitis. I already told you guys. Its
an acute onset, usually young patients, fever, lymphadenopathy. Intense pain, okay?
And basically what happens is patients entire mouth pretty much falls apart. They
get these ulcers, erythema, and pain throughout their gums and mouth. Okay? And
when a patient has primary herpetic gingivostomatitis, the rules arent followed.
Like I told you in the past, that as we just discussed, herpetic ulcers occur on fixed
keratinized mucosa and aphthous ulcers or canker sores occur on movable, non-
keratinized mucosa such as the labial mucosa, buccal mucosa, and the floor of the
mouth. But when a patient has a primary herpetic infection, the rules go out the
window and anything can happen anywhere. You can get ulcers herpetic ulcers
everywhere in your mouth. Okay? So this picture, you can see that the gums are
infected. You have some erythema and some ulceration.

[7] [N/A]
[Dr. Shah] Okay, this is the same patient. This is looking at the palate and the
palatal gingiva. You can see the erythema here and sort of the ulceration around the
marginal gingiva.

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[2] [N/A]
[Dr. Shah] Okay, look at this patient. Primary herpetic gingivostomatitis. It can
actually look quite nasty and scary and I see many of these patients and you might
too, where the parent worries I would worry too if my child looked like this and
they, you know, bring you to the bring their child to the emergency clinic and
theyre like, Whats going on? What happened here? And so its very acute onset,
its very painful and it really looks disturbing. But the good news is: that this will all
self resolve in two weeks. Okay? And most of the time theres not much of a
treatment. Im going to go over treatment very shortly though what you can do.

[9] [N/A]
[Dr. Shah] Okay, heres another picture of primary herpetic gingivostomatitis. This
is you can see lesions on the lip and on the tongue. Okay? And there are mild,
moderate, and severe presentations. Some patients will have very little, their gums
will be infected a little bit. And some patients will have the full stomatitis
component and theyll have, you know, their lips and their tongue, and their buccal
mucosa, everything involved. Okay.

[10] [N/A]
[Dr. Shah] Heres some more examples. This is some herpetic primary
gingivostomatitis lesions on the buccal mucosa.

[11] [N/A]
[Dr. Shah] This is a patient that has primary lesions on the lip.

[12] [Scalpel Biopsy: low power]
[Dr. Shah] Okay. So if a biopsy is done and you really shouldnt be doing biopsies,
especially for primary herpetic gingivostomatitis. Its a young patient, its an acute
onset, it really .. From the history and clinical presentation, you should be able to
make the diagnosis and really give the patient two weeks to heal and do a follow-up.
So really there should not be a biopsy.
But if a biopsy was done, then you are basically looking for do you guys remember
the name of the cells I told you on the smear you look for?
[Student] Tzank cells.
[Dr. Shah] Yea, the Tzank cells, right? So youre going to see those same things on a
scalpel biopsy. So here, this is a low power view and what youre going to see, even
on at this low power, you can see these big cells. These are big, multinucleated
Tzank cells. Okay? Thats at low power.

[13] [N/A]
[Dr. Shah] Then we go to a higher power. And in the ulcerated area where the
epithelium is falling apart is where you see these kind of shiny, translucent,
multinucleated Tzanck cells here. Okay? And thats positive scalpel biopsy. Okay?

[14] [N/A]
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[Dr. Shah] And even higher power view of multinucleated epithelial cells that are
infected with the herpes virus.

[15] [Mucosa Smear]
[Dr. Shah] Okay, and you might have seen this one before, this is from a smear. So
if youre in doubt about a herpetic lesion, rather than do a scalpel biopsy, a smear is
the way to go for sure. Okay? But the thing is the smear is going to work best when
its early on. If the lesions have already ulcerated and crusted over, you may actually
not see the Tzanck cells. So, a smear may give you a false negative.

[16] [Treatment]
[Dr. Shah] Okay as far as treatment goes, the main thing is to reassure the patient
that the condition is self-limiting, okay? So, its not going to turn into cancer, nothing
bad or permanent is going to happen with this. But one of the major issues is when
this involves very young children in the five to ten-year old age group, is, obviously,
their mouth is in pain. Theyre not going to want to eat or drink, okay? And if they
dont eat or drink, kids have a very delicate electrolyte balance and they can get
severe dehydration and become hospitalized for that. So maintaining fluid intake is
a big deal. Okay? Also as I mentioned to you, theres often a history of fever in
primary herpetic givngivostomatitis. So antipyretics if fever is present. Depending
on the age of the child, viscous liidocaine or xylocaine rinses and over the counter
medications for pain can be given. Okay? And its important that the patient
maintains oral hygiene and rinses and also, the patient or the patients parents need
to be advised about not spreading the disease. Obviously theres a contagious phase
and the contagious phase is when you have the vesicles, thats the contagious phase
of herpes. So, you want to advise the patient about not spreading the disease when
the patient has active lesions, no kissing, no inoculating other areas of the body, for
example, you dont especially with kids it could be a problem where they touch
their mouth and then they touch their eyes and then they touch their face or skin.
You can actually, in early stages, spread the herpes virus along that way. Okay, and
then but I want to point out that even though these primary infection happens
usually in young patients, Ive seen it in patients as old as 75, a primary herpetic
infection. So, I mean, you can have older ages and you can also have people that are
immunocompromised that have AIDS or severe systemic diseases that can present
with primary herpetic gingivostomatitis. And in these cases you can prescribe and
anti-viral. Systemic valacyclovir or valtrex can work for immunocompromised
patients. It can also be used, very early onset in a normal healthy patient as well.
Okay, so when I say early onset, usually like the first three days. If a patient comes to
you with primary herpetic and theyve already had it for like probably a week,
prescribing an antiviral is really not going to do much. You have to catch it very
early and then itll kind of abort some of the lesions and decrease the severity. Also,
for children, there is an antiviral suspension called acyclovir suspension. Acyclovir
suspension. But the kid has to be old enough to understand how to use it and rise
with it and spit it out. And then that really can help too. Okay? So, again, in summary,
most of the time we dont treat it, let it run its course. You treat the symptoms but if
you have a patient thats very early onset or immunocompromised, you can give
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them systemic valtrex. And also in some kids, early on, acyclovir suspension will
work.

[17] [Secondary Herpetic Eruptions]
[Dr. Shah] Now for secondary herpetic eruptions.

[18] [N/A]
[Dr. Shah] Okay, so we start with . What is this here? Who knows what this
condition is called? Herpes labialis, right? Herpes labialis. Okay, so this is one of the
most common presentations of recurrent herpetic infections, right? So, the patient
will have vesicles a crop of vesicles. Remember, I used that word, crop, before? It
means like a group of multiple, tiny ulcers. Okay, and they can have multiple sites
involved on the lip or it could just be one area. Okay? And it could be bilateral,
unilateral, at the commissures but somehow most of the time its the lower lip but it
can also involve the upper lip. But here so, Im showing you this patient with
herpes labialis has some lesions here. Theyre sort of in the vesicular stage here. And
here, its sort of ruptured in this area and ulcerated.

[19] [N/A]
[Dr. Shah] Heres another area, another example, in the commissure, of herpes
labialis. Okay? You have some vesicles here, fluid-filled blisters and then you have
some areas, which are ulcerated and ruptured.

[20] [N/A]
[Dr. Shah] This is an example intraorally the most common sites intraorally for
herpes are going to be the gingiva and the palate. So, on the gingiva you might see
these focal, tiny ulcers in the interdental papilla or marginal gingiva area. Okay? And
I want to point out that sometimes, stress, trauma and dental work are triggers for
intraoral herpes and even herpes labialis, okay? So if some patients are really prone
to herpetic outbreaks after dental treatments, like if youre working in that area or
using a retraction cord or clamp, that might promote a herpes outbreak and so
sometimes you can give prophylactic antivirals to these patients, valtrex
prescriptions. Okay, so here you can see some lesions.

[21] [N/A]
[Dr. Shah] Heres an example on the palate. So, youre going to get these multiple,
tiny ulcers, okay? And if theres a lot of them, sometimes they fuse together into this
big irregularly shaped ulcer. And thats whats happening on this palate. So you can
see some single lesions and then some of them have fused together to form this big
irregular shape here. But this is intraoral recurrent herpes.

[22] [N/A]
[Dr. Shah] Heres another example. This is a pretty typical presentation. You get
whats called punctate, means like point-like, tiny kind of multiple red ulcers here on
the hard palate, okay? And then heres an example on the gingiva, right near this
tooth. Perhaps, when this patient was getting some dental work or got this
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restoration this could have been caused. Or it could just be idiopathic, you dont
really know the cause and the patient is just having an outbreak here.

[23] [Treatment]
[Dr. Shah] As far as treatment goes, for herpes labialis, this is a million-dollar
question. Many patients that suffer with cold sores, you know, its kind of ugly and
its sort of has a stigma, right? If somebody has cold sores on their lip. So, a lot of
people are searching for a cure for this. And you know if you go down the oral
products aisle through any drugstore, there are lots and lots of different products
for cold sores and other things. Some of them work, some of them dont and theres
ongoing research. But maybe you have heard of Abreva. Its one of the few over the
counter type of antivirals that do actually evidence shows that it does work and
this is the brand name and this is the generic name, docosanol. Okay, and then
theres also an ointment called Zovirax that has been shown to work quite well. This
is acyclovir ointment, 15 gm tube. And what the patient needs to do though, they
have to use it a lot and it says the directions are apply continously during
prodromal stage and then 6 times daily 6 times daily for three days. Who knows
what the word prodromal means? What is prodromal stage? Anyone? Yes?

[Student] [unintelligible].

[Dr. Shah] True. Yeah, before the onset but I dont know, I dont want to single out
anybody that might be suffering from herpes labialis but does anyone know what
kind of symptoms a patient might have?

[Student] [unintelligible].

[Dr. Shah] Thats what Ive heard that patients can get a tingling. Or kind of some
sensation. A little numbness, a little twitching, a little tingling. Some sense that
theyre having an oncoming herpetic attack and if you use these medications at that
time, thats the best optimal time to use them and to really decrease the severity and
then in some cases, maybe even abort the incident. Okay? So thats what the
prodromal stage is. So we have the Zovirax ointment and Abreva and theres other
things out there too, okay?

[24] [Treatment]
[Dr. Shah] Patients that get recurrent herpes infections this works for herpes
labialis and intraoral secondary herpes. This is one of the best medications, and the
ones that I like to prescribe, Valtrex, Valacyclvoir. Okay?

And it comes in 500 milligram tabs, and I want to make one comment to you all, on
the exam you do need to know the medications but you wont have to write a
prescription. Okay? This is Im giving this to you for the sake of completeness and
your knowledge but you wont be asked to write a prescription but you do need to
know the generic and trade names and the classes of medications and the uses of
the things that we talk about.
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Okay, so the normal treatment regimen for recurrent herpes infections is Valtrex,
500 milligram, 8 tabs. You tell the patient to take 4 tabs as soon as the prodromal
signs appear and then they take 4 tabs, 12 hours later. And this really helps the
situation out and to abort or decrease the severity of the herpes infection.

[25] [Prophylaxis to Prevent Recurrent Herpes]
[Dr. Shah] Theres also a similar regimen for those patients that really have to deal
with regular recurrent herpes episodes. They can be on Valtrex this is a regimen
basically for once in a while when the patient feels an attack or even for dental
work, dental prophylaxis, if a patient tells you, every time I get some dental work or
cleaning done I get a herpes outbreak, you can give them this prescription and they
can take it before you do the work and then 12 hours after and it really helps out.
But then theres those patients that get so many outbreaks that they need to take
something every day. And this is the same thing, Valtrex, but they take basically 2
tabs, 1 tab twice a day for some period of time, and then theyre re-evaluated
regularly.

[26] [Prophylaxis to Prevent Recurrent Herpes]
[Dr. Shah] Okay, and then one more thing to help patients that have recurrent
herpes. They can take a lysine supplement. Lysine is an amino acid. They can take
about 1000 mg or 1 g a day every day and how does this work? It affects the viral
replication ratio by affecting the lysine-arginine ratio. Okay? So this is a natural
supplement that can really help reduce recurrent herpes outbreaks and severity.

[27] [Herpes Zoster]
[Dr. Shah] Okay. I want to talk about another type of herpes. Herpes zoster. Herpes
zoster is special because it has a dermatomal distribution. Who knows what a
dermatome is? Dermatome. So dermatome is like an area of skin that is innervated
by a certain sensory nerve or a branch of a nerve, right? And for us, which nerve are
we mostly concerned with? The trigeminal nerve, right? You all know theres 3
branches, V1, V2, V3. So the herpes virus can basically move into the sensory ganglia
for any one of those branches or even more or all of the branches and then you can
get recurrent lesions in that area thats innervated by that nerve. So Ill show you
some pictures shortly.

[28] [Features of Herpes Zoster]
[Dr. Shah] So features of herpes zoster infectious disease. Its caused by its a
type of herpes virus called VZV. Varicella zoster virus. And herpes zoster can be
really really really painful, okay? In adults, its the equivalent of shingles. Youve
heard of shingles. And its really painful and itchy and bright red and very
uncomfortable. It manifests as pain for about 3 to 5 days over the area supplied by a
cranial nerve ganglion. And what happens is you get these vesicles that will
eventually ulcerate, will rupture, ulcerate, and crust. But the key clinical feature of
herpes zoster is that its distributed unilaterally which means its on one side. It
respects the midline and Ill show you pictures of this. And the lesions will heal
spontaneously in about 2 weeks, okay?
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[29] [N/A]
[Dr. Shah] So, heres a picture of herpes zoster on the skin following a dermatomal
distribution.

[30] [N/A]
[Dr. Shah] Now Im going to show you involving the trigeminal nerve. V1, V2, V3.
This is probably, I dont know, V2 involvement here, okay? You can see some
vesicles here, okay? And you cant see the patients other side of the face but if this is
truly a herpes zoster, theres nothing on the other side. It respects the midline and
its only on one side.

[31] [N/A]
[Dr. Shah] This is obviously V3 involvement, right? Of the left side. And you can see
that it really does, I mean, it may not be a 100% perfect or maybe its the camera
angle or something but for the most part, it does kind of respect the midline, okay?

[32] [N/A]
[Dr. Shah] Heres some more examples. This was a patient that had herpes zoster
involvement of V2, maxillary nerve. And you can see some ulcers, and ruptured, and
crusted lesions here involving the midface. For the most part, if you draw a line
down the face, it does respect the midline. It is unilateral.

[33] [N/A]
[Dr. Shah] This is the same patient, kind of a closer view here.

[34] [N/A]
[Dr. Shah] And then this is the same patient intraorally. So obviously the V2 nerve
innervates the upper labial mucosa as well. And so you can see some ulceration here
and involvement.

[35] [Recurrent Aphthous Stomatitis]
[Dr. Shah] Okay, so thats pretty much all I wanted to say about herpes before I
move to aphthous stomatitis. But I want to ask you guys do you have any
questions about herpes, herpes treatment, herpes manifestations? Yes?

[Student]Would you ever give an ointment and a tab

[Dr. Shah]Together? You can, you can if the patient has maybe intraoral and
because the ointment is for the lips. Right? Youre not really supposed to use it
intraorally. So if a patient has extraoral and intraoral you could possible prescribe
both. But generally speaking, the Valtrex tabs will work extraorally and intraorally,
its systemic. So you dont really need to, but if you use both, it speeds it up along.
You could. So yea?

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[Student] If you get type II orally, is it going to manifest the same way? Do you get
primary and secondary types of appearance?

[Dr. Shah]- Thats a good question and I would say the answer to that is yes. Yeah.
Okay, any other questions about herpes? Yeah?

[Student] When you said acute, how fast does it progress? For primary?

[Dr. Shah] Well, acute means the patient may come and see you and say this just
happened a couple of days ago. So, acute, you know, could mean, I mean it depends
on when the patient sees you but usually from start to finish, from when the first
you know that when you get infected theres a little bit of a latent period and when
it, once the virus activates and presents, from start to finish, from the first sign to it
resolving could be within two weeks. So, thats what acute means. And its a little bit
subjective but its a good question and good point because many of the other
diseases Im going to be talking about in the second half of this lecture are a lot more
chronic. And chronic means kind of long term and using this is really important
information to making a good diagnosis, whether its acute or chronic.

Okay Im going to move on to recurrent aphthous stomatitis. Okay? Or aphthous
ulcers.

[36] [Features of Recurrent Aphthous Stomatitis]
[Dr. Shah] So recurrent aphthous stomatitis or RAS .. What do I mean by this? I
mean patients that suffer from canker sores or aphthous ulcers, multiple episodes; I
dont just mean a patient that maybe had one aphthous ulcer in their life. That
doesnt really go in this category. Okay, so recurrent aphthous stomatitis affects
about 20 percent of the general population. Its more common in females. This is a
common theme, I have to tell you. Women are, were meant to suffer I guess. But
most of these mucous membrane diseases I talk about, theyre all more common in
females. Okay? But then men will suffer too because if women are unhappy, thatll
make the men unhappy. Which is what my husband says I do, so. Okay. So well get
you one way or another.
Anyway, tendency to occur within families, so aphthous ulcers can have a genetic
component or some type of familial component. The exact etiology is not known but
evidence shows that it is an immune process, an immune dysregulation type of a
process. Okay.

[37] [Recurrent Aphthous Stomatitis
[Dr. Shah] There are three classifications of aphthous ulcers. Theres the minor
type, which people refer to also as canker sores. But realistically, on an exam, you
should never use that term. Okay? Major type, Suttons disease. And then theres
also something called herpetiform ulcerations, which has nothing to do with the
herpes virus, but they call it herpetiform because theyre multiple, tiny crop of
ulcers, okay?

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So, of course, the minor type is the most common type and these also are usually are
pretty small, less than a centimeter in size. The major type is usually greater than a
centimeter and theyre often deep ulcers. The minor ones are more shallow and heal
quickly. The major ones are deeper and take a longer time to heal and may heal with
scarring. I also want to point out that the minor aphthous ulcers tend to occur more
in the anterior part of the mouth and the major aphthous ulcers tend to occur more
in the posterior part of the mouth, in the soft palate, oropharynx area and posterior
buccal mucosa.

And then herpetiform ulcers, I mentioned to you, they have nothing to do with
herpes and they never go through that vesicle stage like herpetic ulcers do.

[38] [Minor Aphthous Ulcers]
[Dr. Shah] Okay so here are some clinical pictures of minor aphthous ulcers. And
they have a very typical clinical presentation. As you can see, first of all, theyre on
movable non-keratinized mucosa such as the labial mucosa, which is a pretty
common site. Theyre almost always round to oval in shape, and they have a yellow-
white fibrin coating with the red halo around them. So thats a typical aphthous
ulcer, it doesnt get much better than that. Heres another example on the lower
labial mucosa. Its round, it has a yellow-white fibrin coating and I hope you all know
what an ulcer is. Ulcer means youre missing epithelium there. Okay? And then you
can see kind of the red border around this ulcer, so this is a typical presentation of
aphthous ulcers. And these are pretty minor. Theyre less than a centimeter, theyre
not that deep and theyre in the anterior part of the mouth.

[39] [N/A]
[Dr. Shah] Heres another example sort of in the labial mucosa area. This ones a
little more oval in shape but it still fulfills all the criteria of a minor aphthous ulcer.

[40] [Treatment: Topical Steroids]
[Dr. Shah] As far as treatment goes, generally you dont treat aphthous ulcers.
Okay? And especially if a patient only has a few. But if you have a patient that is
really in a lot of pain or has multiple aphthous ulcers, you can prescribe topical
steroids. Okay? And there are two topical steroids that Ive been trained to use. And
that I mention to you all and that you need to know. One of them is an ointment. Its
called Temovate, is the brand name and Clobetasol is the generic name. and then the
next one Im going to be talking about is Dexamethasone. It comes as a rinse. So, if a
patient has localized lesions like aphthous ulcers, lets say they have one or two
deep ulcers, I would prefer to give them the ointment so they can put it locally into
the lesion. But if a patient has widespread lesions, then I would prefer the rinse
because it can cover more area.

So this is the prescription. Again, you dont need to know the prescription but you
do need to know the use and the names here. It comes as a 0.05 --- very low
percentage. Theres also a 0.1% that many dermatologists will use for various
lesions. But for the oral cavity, this is the strength that we use. 15 g tube and the
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, 2014

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patient has to repeatedly apply it to the affected area or ulcer. Q.I.D. What does q.i.d.
mean? Okay, I just want to make sure were all on the same page. I dont mean to
offend or insult anyone. But q.i.d. is, yea, four times a day. And I want to tell you that
many of these things I tell are not written in stone. If I see a patient that, you know,
has a more minor presentation, I can make this b.i.d. or t.i.d., twice or three times.
And if I see its really severe, I can make it q.i.d. or even five times a day, okay?

One other point is when you use this ointment, in order for it to stick and work well,
I always tell the patient to have guaze and dab dry whichever area theyre going to
put it on. And then kind of rub it in so itll stick a little bit better. And its okay if its
going to dissolve in their mouth and if they swallow a little bit, its alright, okay?

[41] [Treatment: Topical Steroids]
[Dr. Shah] And this is the rinse, its called Dexamethasone and this is the
prescription for it. And Dexamethasone can be used in two ways. Its a rinse. So we
call it swish and spit, where they rinse with it and hold it for two minutes and then
they spit it all out. Theyre not supposed to swallow it. Okay? And then theres
another way of using it. Some patients dont respond to Clobetasol so if I give them
dexamethasone and I tell them to put it on a two-by-two gauze and then the put the
gauze on the ulcer or the sore, that can also work. Okay? For more localized ulcers
or lesions.

[42] [Major Aphthous Ulcers]
[Dr. Shah] Heres examples of major aphthous ulcers. These are going to be bigger
and deeper. They tend to occur more toward the back of the mouth, but occasionally
they do occur more towards the front. So heres an example, were on the labial
mucosa again. This is a pretty large ulcer. Its relatively deep, its not as shallow as
some of the minor aphthous ulcers. Heres an example of a major aphthous ulcer.
This is in the posterior soft palate area. Okay? But you can see it still has the
characteristics of aphthous ulcers. You have the yellow-white coating and the red
border around it.

[43] [N/A]
[Dr. Shah] Heres an example of a major aphthous ulcer. This is a little bit
irregularly shaped but it still follows the criteria for the most part.

[44] [N/A]
[Dr. Shah] This is a really large painful major aphthous ulcer, in the posterior left
soft palate part. And you can see the yellow white coating and the red halo around it.
Its a little bit irregular in shape and this is very very painful. This patient, any time
they eat or drink or swallow, is going to have this. And Ive seen patients like this
so this is definitely an indication for prescribing a steroid medication. Okay, but the
thing is depending on how far back it is, obviously I may not be able to tell the
patient to put a cream there. They may not be able to put the ointment back there
and even also if you give them a rinse it may also not work because they may also
not be able to get it that far back without gagging. So this might be an indication for
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, 2014

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systemic steroids such as Prednisone, okay? And Im going to go over that, I think, in
the next couple of slides.

[45] [Treatment]
[Dr. Shah] So major aphthous ulcers if localized, you can try these same topical
steroids, Clobetasol and Dexamethasone.

[46] [Treatment]
[Dr. Shah] And if longstanding diffuse disease or really far back or really painful,
systemic steroids, such as Prednisone. And the regimen that we usually use is 40
milligrams a day in the morning, for one week, for seven days. 40 milligrams. They
come as 10 or 20 milligram tabs. Its important that the patient takes it in the
morning. Does anybody know why? If youre taking Prednisone, its best to take it in
the morning? I dont know if you guys have taken any physiology class or anything
like that. Anybody know? Okay, where in our body, which organ makes our steroids?
Corticosteroids? Which gland makes our steroid hormones? The adrenal gland,
which is on top of the kidneys. Okay, so this is its important that the patients take
this medication in the morning because if they take it other times, it affects the
adrenal gland release of normal corticosteroids and the cycle. Okay? And normally
you dont want to keep them too much long term on this because long term
Prednisone has a lot of negative health affects. It can cause something called
Cushings syndrome, weight gain, blood pressure, diabetes. It affects the CBC, the
blood cell count. So, definitely. But there are going to be some chronic diseases. Im
going to be talking about later in the lecture where you do have to keep people on
long-term high dose Prednisone.
Okay, so what you want to do is youll give, maybe if someone has an ulcer like this, I
may put them on a week of Prednisone, call them back, hopefully theyre doing
much better. If theyre still not doing well I can extend it one more week or I can
move them to topical and then I can move them to topical meds if they can get back
there.

[47] [Herpetiform Ulcers]
[Dr. Shah] Heres some examples of herpetiform ulcers. Again, these are aphthous
ulcers that have nothing to do with the herpes virus, we just call it that because its
like multiple, tiny ulcers. So here we are, you know, on the labial mucosa. If you look
closely, where the arrow is, you can see multiple tiny ulcers. Here we are on the
ventral surface of the tongue. Mualtiple ulcers. Some of them have fused together
into these big irregular shapes. But again, one thing to help you distinguish this from
herpetic ulcers is what? How can you distinguish? If a patient presents with this,
how can you distinguish this from herpetic ulcers? Based on location here, right?
Assuming you have a normal, healthy patient, right? Sometimes in HIV patients are
really immunocompromised or severe systemic disease, the rules dont really apply.
But in a normal, healthy immunocompetent patient these should be aphthous ulcers
based on the location of movable, non-keratinized mucosa. Okay?

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[48] [Treatment]
[Dr. Shah] As far as treatment for herpetiform ulcerations go, its the same thing.
You know, if you dont need to treat it, itll come and go within a few days. But if its
really diffuse and painful like something like this ... I would not really treat, but if I
had a patient that looked like this this looks like it might be really painful, so I
might give them a Dexamethasone rinse or a Clobetasol ointment to use. Or if its a
really bad case, a short course of Prednisone, okay?

[49] [Various Other Products for Aphthous Ulcer Pain Relief]
[Dr. Shah] Alright, I want to point out also that there are many other products
available in drug stores for canker sores or for aphthous ulcer pain relief. There are
some products that coat the ulcer, because basically a lot of the pain for aphthous
ulcers comes from the fact its exposed in the oral cavity. So if you were to have
something hot, spicy, or acidic, or drink orange juice, its going to really burn that
ulcer. Okay? So many of these products that are available over the counter will
basically cover the ulcer. Okay? So theres something called Canker Cover, its like a
big disc that covers on top of the ulcer. Many products have numbing agents in them
like topical benzocaine. Then theres also something called Zilactin and there are
also products, which cauterize or will burn the ulcer. Theres something called
debacterol, its a chemical caustic agent and it basically just burns the vessels and
the nerve endings so you dont have pain in that area. It hurts for that five seconds
you put it on, but then after that you dont feel anything. Okay? So lots of products
available out there.

[50] [Systemic conditions associated with recurrent aphthous stomatitis (in
alphabetical order)]
[Dr. Shah] This is an important slide, because I want to point out to you all that if
you have a patient that has recurrent aphthous ulcers, one of the first things I do is
try to see if its a manifestation of a systemic disease. This is a list of systemic
diseases that can present as recurrent aphthous ulcers. Okay? So you evaluate the
patient because if youre able to diagnose and treat and make any of these
conditions under control, the patients aphthous ulcers will get much better. Theyll
have less episodes and less severity. Okay, but the thing is, fortunately or
unfortunately, I dont know but most of the time the patients that have aphthous
ulcers, you dont find any systemic conditions. So its just idiopathic or familial or
genetic. Theres not much you can do about it.

Okay but this is a list of systemic diseases and I put it in alphabetical order. This isnt
the order of frequency. Theres something called Behcets syndrome. Its kind of an
autoimmune condition where patients get eye ulcers, genital ulcers, and mouth
ulcers. Celiac disease or gluten sensitivity, cyclic neutropenia, IgA deficiency,
immunocompromised conditions, such as HIV. HIV patients often will get recurrent
aphthous ulcers. Okay, also, inflammatory bowel disease, Crohns and ulcerative
colitis. These patients can often present with recurrent aphthous ulcers. And then
even severe nutritional deficiencies such as iron, folate, zinc, or B vitamins
deficiencies. Okay? So this is a list of things that you should evaluate any patient for
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, 2014

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that has recurrent aphthous ulcers and ask the right questions, order blood work,
things like that. And if you find one of these things, then treating these things will
really help with the aphthous ulcers. But as I said, in most cases, its not linked to
one of these.

[51] [Candidiasis]
[Dr. Shah] Okay any questions about aphthous ulcers before I move to the next
topic?

[52] [Candidiasis]
[Dr. Shah] Okay. Good. Okay, now Ill speak a little about candidiasis. Candidiasis
you all know is the most common oral fungal infection. Its actually the most
common fungal infection in humans. Okay? And we break it into acute and chronic.
There are different clinical presentations of candidiasis. Acute, theres
pseudomembranous candidiasis, also known as thrush, and the key hallmark of this
is you get these wipeable white plaques or patches that you can actually wipe off
with gauze. Okay? And theres another presentation of acute called acute atrophic
candidiasis. The word atrophic means thin. The epithelium is thin so it has more of a
reddish look to it because you can see the underlying blood vessels and vasculature
in the connective tissue. Okay? And many times, acute atrophic candidiasis is related
to long-term antibiotic use. So I want to ask you guys to think. What do you think
long-term antibiotic use has to do with a fungal infection? Yea. Youre changing
the bacterial flora. And theres a delicate system of checks and balances in the
mouth. And everything is balanced. So this antibiotic use kills off certain bacteria,
which allows the fungus to proliferate, okay?

Chronic candidiasis, you should know chronic atrophic candidiasis, this is usually
linked to dentures, partial and complete dentures. Hyperplastic candidiasis, also
known as leukoplakia, candidileukoplakia. Its a white patch that doesnt wipe off.
And then of course, angular cheilitis. So now Ill show you pictures and go into more
detail for each of these.

[53] [N/A]
[Dr. Shah] Which one do you think this is? If I told you this wipes off with gauze?
Which one do you think this is? Thrush, but we dont use that word. So what type of
candidiasis is this? Pseudomembranous, okay? And I want to point out one more
thing. Ive had many times, a student will see this and theyll diagnose this as
candidiasis and theyll try to wipe it off and theyll say it doesnt wipe off. And ten
theyll send me the patient and then Ill wipe it off. Wipe off doesnt mean dab, okay?
It means wipe. Okay? So one point I wanted to make.

You dont see this florid pseudomembranous anymore. I have to tell you, when I did
my oral path residency in New York Hospital, Queens, I had to do rounds on
HIV/AIDS patients and I would see things like this, but typically, now you dont see
this kind of stuff. Because, you know, we have early detection; we have HIV meds
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and a lot of information and safer sex practices. And a lot of that out there. So you
rarely will see a presentation like this now. Every now and then I do.

[54] [N/A]
[Dr. Shah] But more likely youre going to see something that looks like this.
So here you have these kind of white plaques or patches or areas and they do wipe
off with gauze if, hopefully, if you do it with a little bit of pressure. Okay, and so, one
thing is when you do wipe it off, like lets say this was a full plaque or patch like this.
It could be really red underneath and inflamed or it could just be normal oral
mucosa underneath. And patients may or may not be asymptomatic. If theyre
symptomatic, they may tell you they have a burning sensation, okay, or a soreness.
But many patients can look like this and not have any symptoms at all, okay?

[55] [N/A]
[Dr. Shah] What about this? How would you describe this? Is this
pseudomembranous? Theres a red area here. Right? So whats the word that we
would use for this? Atrophic. Right? Atrophic means the red presentation. Or
actually erythematous is another word. Erythematous candidiasis is a similar thing.
Okay? And this was actually due to antibiotic use. This person was on antibiotics for
like a month or so for some condition. And they developed these red patches, okay?
Alright.

[56] [N/A]
[Dr. Shah] How about this? What do you think is going on in these pictures? What is
this related to? Dentures. Right? So this is also known as denture stomatitis. Or
erythematous candidiasis or chronic atrophic candidiasis. Okay? Again, atrophic,
red, and you can see that this follows completely the denture base. Okay? For a
complete upper denture and this as well, okay? In this picture I want to point out,
theres two types of candidiasis. Okay? Theres no rule and this is one of my favorite
things youre going to hear me say regularly: diseases dont read the textbooks, they
do what they want, right? So theres no rule that says that you cant have more than
one type of candidiasis. So, this patient has denture stomatitis and what are these
white things here? And pseudomembranous, okay? Well, I mean, I would have to tell
you that it wipes off but I want to point out to you the type of candidiasis thats
called hyperplastic, that presents as a leukoplakia, thats probably one of the rarest
types of candidiasis. So, you know, keep that in mind when youre giving a
differential diagnosis. And differential diagnosis means a list of realistic possibilities
in order from most likely to least likely. Okay? So this patient has two things going
on, a pseudomembranous and kind of an erythematous here.

[57] [N/A]
[Dr. Shah] Alright. This is an example, one of the rarer examples of hyperplastic
candidiasis. Or candida leukoplakia. Here you have white patches on the tongue and
on the buccal mucosa that do not wipe off. Yet this is still candidiasis. And if you look
on this patients palate, youll also see some red and white candidiasis up here as
well. Okay? So how do you know for sure this is candidiasis. Well, I mean, most of
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the time when you see this I would say, in my practice of 7 years, Ive probably seen
maybe like 7 cases, maybe 1 a year of candidal leukoplakia or hyperplastic
candidiasis. And every single one of those cases has been in an HIV/AIDS patient,
okay? I want to point out too and I want to start this early because next year when I
teach OMPR, students, I dont know why, they love to write hyperplastic candidiasis
and that is I want you guys to know how rare that really is. Okay?

So you wouldnt really know here. Perhaps this is from cheek-biting, or maybe this is
a pre-cancerous lesion. You dont know for sure. But in a patient that has other
lesions that might be HIV and have bad counts, you can suspect that. And if youre
really unsure, what can you do? What can we do if were we think this is
candidiasis but were not sure? What can we do? Okay, what kind of biopsy? Okay,
so you could do a mucosal smear because its one of the indications but sometimes I
will say this, the person that said scalpel, sometimes these are so embedded when
you have a hyperplastic type that sometimes a scalpel gives you the diagnosis. But a
smear could theoretically work. And another thing you can do, its called empirical
treatment. Okay? Does anybody know what that means? Empirical? Okay, it means I
can prescribe an antifungal and see if this goes away without even diagnosing it.
Right? So its using the treatment to diagnose. Thats what empirical means. So I feel
strongly that this is fungal, let me put this patient on an antifungal for a couple of
weeks and see if this gets better or goes away to prove my point that it is fungal.
Okay?

[58] [N/A]
[Dr. Shah] Alright what about his? What presentation is this? What do we have
here? This is median rhomboid glossitis, one of the common oral lesions I talked
about, right? So this is in the midline of the tongue and sometimes this is just a
developmental thing. But many times its superimposed with candidiasis and the
patient might have a burning sensation or soreness there. Okay? You could do a
smear or you could do an empirical treatment with this as well.

[59] [N/A]
[Dr. Shah] How about this? Whats happening here? Angular cheilitis, right? Which
can be unilateral but its often bilateral. You can see the fissuring and the erythema
here, right?

[60] [N/A]
[Dr. Shah] Heres another presentation of angular cheilitis. This one has a little bit
more kind of a white look to it at the corners. This presentation Ive seen more in
diabetic patients, uncontrolled diabetic patients.

[61] [Treatment]
[Dr. Shah] Okay, as far as treatment goes for candidiasis, antifungals, right? But you
need to know the names of some antifungals. Its not just good enough to say
antifungal.
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One of the commonly prescribed medications for oral candidiasis is Clotrimazole.
And you should know that you haven't taken pharmacology yet, I think are you
taking it right now? Okay, but azo- is a suffix for antifungals. Okay? Antifungal
medications. Dont confuse this with clobetasol, which is another common student
mistake. Clotrimazole and Clobetasol are two totally different things, okay? So
youve got to be clear on whats what. Okay, so this is an antifungal and this is the
brand name, Mycelex. They comes as troches. Whats a troche? Its like a lozenge
that you suck on slowly. Okay? 10 mg, 70 troches, dissolve one slowly in mouth five
times a day until finished. And, oops, I want to say that, this doesnt have to be the
exact protocol. I can adjust this. If a patient has very mild candidiasis I can make this
for less than 14 days, I can make them 3 times a day or 2 times a day. This is the
maximum prescription though, for a relatively severe case of any of these types of
candidiasis, hyperplastic, acute, atrophic, or pseudomembranous. Okay?

[62] [Newer treatment!]
[Dr. Shah] And this is kind of a newer treatment. Its not new. It used to be new. But
now its a newer treatment, as compared to these things. Its called see, one of the
issues you may have with antifungals or even antibiotics is patient compliance,
right? You may tell them to do this and if you tell them to do anything multiple times
a day, they forget, they dont want to do it, whatever, okay? So the good news is that
this prescription is a disc that comes as 50 mg and you only have to use it once daily.
You put it on in the morning after you wake up and it lasts all day. It dissolves in the
saliva. Its a disc thats placed in the canine fossae, okay? And it dissolves over the
day and you could do this up to 14 days. Okay? Its called Oravig, Miconazole is the
generic name. again, -azole.

[63] [Treatment]
[Dr. Shah] Okay, then the treatment for chronic atrophic candidiasis or denture-
related candidiasis, you want to tell your patient, one important thing is patient
should not be wearing their dentures at night when they sleep. And a lot of dentists
forget to tell their patients that and I get so many patients that have denture
stomatitis and candidiasis and tell me, oh my dentist didnt tell me that. You know?
But patient should not be sleeping with their dentures. They should be soaking it
overnight and allowing their tissues to rest. Okay? So if a patient has denture
stomatitis or chronic atrophic candidiasis we tell them to keep the dentures out at
night, soak it in anti-fungal solution. Also, can prescribe Nystatin ointment. Okay? So
this is a formulation of antifungal that comes as an ointment. So antifungals can
come in any formulation. Right? I just told you about the Clotrimazole troches and
the Miconazole discs. You can also get ointments or creams. You can also get
Nyastatin can be made as a rinse as well, a mouthwash. Okay? So but here, in a
denture stomatitis patient, I might prescribe it as an ointment and tell the patient to
put it in the denture base. They clean the denture and then before they put the
denture on they put a thin layer of this and this gives constant direct contact to the
inflamed, infected area. Okay? A 15 g tube applied to denture base and wear tid
three times daily.

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[64] [N/A]
[Dr. Shah] Okay, heres an example of a denture stomatitis, erythematous
candidiasis, chronic atrophic bunch of names, right?

This person has, and this is hyperplastic tissue here, okay? But you can see where
they were wearing their complete denture. Its really red and inflamed and the
patient might have no symptoms or they might have soreness or burning. Some
patients will even say they have metallic taste when they have a fungal infection.
Okay? So you give this patient Nyastatin ointment and tell them to keep their
dentures out at night, call them back two weeks later

[65] [N/A]
[Dr. Shah] And they can look like this, before and after. Okay?

[66] [Treatment]
[Dr. Shah] Alright, then treatment for angular cheilitis. These are two prescriptions
I like to use.

This one is not as readily available. Many insurances dont cover it. So this is the
most generic one of the one thats mostly used. I should say. But Vytone cream 1%,
15 g tube, rub into affected are qid. Then theres something called Mycolog cream,
15 g tube, apply to corners of mouth, qid means four times a day. So wherever, if its
bilateral then they put it to both corners, if its unilateral, they put it to one corner.
When youre treating angular cheilitis, its important to tell the patient that they
have to stretch the corner of their mouth, dab dry and then rub the cream in. okay?
Because if they dont do that, it wont get deep in. if they dont stretch it. If they dont
dab it dry, then theres a layer of saliva on top of it, so the medicine wont stick. So, I
do want to point out to you all that eventually when you have patients its really your
duty not to just write a prescription but to explain how to use the prescription
because I cant tell you how many patients, if you dont tell them the proper
instructions, then you dont know if the medicine didnt work because they didnt
use it right or because it didnt work, right? So, it is very important, Im very very
clear every time I have a patient on how they should use medication, okay? To the
point where I even ask them to repeat it before they leave. So, they need to stretch it
out, dab dry, rub it in, four times a day, okay?

[67] [N/A]
[Dr. Shah] Alright. So this is a mucosal smear thats positive for candidiasis. Okay?
So this is a fungal hyphae infecting a cluster of epithelial cells.

[68] [N/A]
[Dr. Shah] And heres another example of long hyphae stained with PAS which
helps identify the fungal organisms. And these are the spores, these round purple
things. And this is a clump of epithelial cells.

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[69] [Desquamative Gingivitis]
[Dr. Shah] Okay, so that was candidiasis. Any questions on candidiasis before we go
to the next part? This lecture has a lot of material, its pretty jam packed so I hope
Im not too overwhelming here. Are we okay?

[Student]-- Acute [unintelligible] wipe off?

[Dr. Shah]--No it doesnt.

[Student]--Is it contagious?

[Dr. Shah]--No. But I do want to point out one thing. Actually, in some cases, if a
patient has acute atrophic candidiasis of the palate, they can get whats called a
kissing lesion on the tongue. Or if a patient has median rhomboid glossitis with
candidiasis and their tongue touches the top of their mouth they can get whats
called kissing lesion on the palate. So, to a certain extent, its contagious. You can
auto-inoculate. But acute atrophic doesnt wipe off you have a question?

[Student] can we get a break?

[Dr. Shah]-- Okay, thats a critical question. But before that, does anyone else have
another question?

[Student] Does candidiasis [unintelligible] partial denture?

[Dr. Shah] Okay, no, I mean its much more likely with complete but you can get it
with partial dentures as well. And one point is that 95% of the time, its maxillary.
Very rarely, from a mandibular partial or complete you can get a candidiasis but its
almost 95% maxillary. Any other questions? Okay, I will give you guys I still have
a lot to cover and I think you would like me to finish because there is no other time
to give this lecture. So I will give you guys a five minute break, okay? Thanks.
Okay, let me continue. I feel like this is getting weaker. But okay. Alright. Somebody
asked a question that I just wanted to answer about the format of the exams. The
truth is, it can be short answer, and it has been in the past. Youre going to see in oral
path, Im not a believer in multiple choice. It doesnt test knowledge, you know? I
mean if you have somebody with a lesion, nobody is going to be there to say A)
fibroma, B) lipoma, C) you know. So the truth is, you know, I mean, being able to
write terms and understanding the language and communicating professionally is
really really important and reflects our profession. So, I mean, despite the fact that
theres so many of you, you know, and I have to spend a ton of time grading these
and my husband and kids get mad at me when I bring work home. I am a true
believer that, you know, multiple choice doesnt test knowledge. So the format of the
exam could be it depends, honestly. I will let you know closer to the exam. I think in
previous years, its been a combination of both, multiple choice and then a little
short answer. But I will let you know what happens. This year, the scheduling is a
little different and Ive got multiple things going on so well see. But I want to let you
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know its also in preparation for next year. The D3 OMPR course, the exams have
half short answer, okay? And so we have competencies that are all written so you do
have to have a good sense of being able to write these things. So please be prepared
and modify your study technique so its not just, you know, pattern recognition or
word recognition. So again, I tell you all its important to understand this and not
just blindly memorize it. Because, you know, if youre just able to recognize terms
blindly, it may not work out for you, so please, make sure you have a deep
understanding. Okay, but you will know closer to the time, once weve decided
whats going to happen, okay?

Anyway, moving on. Desquamative gingivitis is the second part of this lecture. What
is desquamative gingivitis? What does desquamative mean, first of all? Who knows
what desquamative means? If you say something desquamates or something like
that, what does that mean? Desquamation. Exactly. Desquamate means, you know,
squamous epithelial cells slough off. Desquamate. Desquamative gingivitis. So Im
not talking about when I say desquamative gingivitis, Im not talking about, you
know, plaque or calculus related gingivitis here. Were talking about mucous
membrane diseases, autoimmune diseases that cause desquamation or peeling of
the mucosa, okay?

[70] [N/A]
[Dr. Shah] So this is a typical clinical presentation. This is probably a mild to
slightly moderate case of desquamative gingivitis. If you look at this patients gums,
you see areas of erythema. There are some focal areas of ulceration and again this is
a milder to moderate case. Im going to show you some more pictures. But many of
these patients will have peeling gingiva, peeling or sloughing gingiva. Theyll say
when they brush, pieces of tissue fall off or come off. Okay? And then theres
something actually called a Nikolsky sign, which mean, its a test, its a clinical test
where you can use air pressure like an air tip syringe or a mirror handle and
actually horizontally wipe the mucosa and peel off tissue, okay? So that is a test for
some of these diseases, namely pemphigus and pemphigoid that were going to be
talking about, okay? So heres a picture of that.

[71] [Desquamative Gingivitis]
[Dr. Shah] So when we say a patient has desquamative gingivitis, thats a clinical
term. Thats not a definitive diagnosis at all, okay? Its a clinical presentation. The
patient will have most likely one of these four specific diseases when they have a
desquamative gingivitis. Erosive lichen planus, benign mucous membrane
pemphigoid, pemphigus vulgaris, or erythema multiforme, okay? So one of these
four diseases will go under the category of desquamative gingivitis.
Okay and this is actually in order of decreasing frequency. So this is the most likely
on top then pemphigoid and then pemphigus and EM are in the bottom of the pile in
terms of frequency, alright? Frequency of occurrence.

[42] [Lichen Planus]
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[Dr. Shah] Alright, let me start off by talking about lichen planus, which is the most
likely and really its all over the place. Its in the air, youre going to see multiple
patients with lichen planus, guaranteed, okay?

[73] [Features of Lichen Planus]
[Dr. Shah] What is lichens planus? We talked about it as one of the common oral
lesions, right? And I showed you you remember the slides where we have the
radiating white striae, called Wickhams striae? Often the buccal mucosa are
involved but other sites can be involved. Its actually a skin disease. Some people can
have it in their skin and not in their mouth. Some people can have it in their mouth
and not on their skin and some people have both. And I want to say you can have
lichen planus also in other mucosal sites. Theres genital lichen planus too. I have
quite a few female patients that have lichen planus at the mouth and lichen planus of
the vaginal area as well. Which has been misdiagnosed as thrush or fungal or yeast
infection and is not getting any better with antifungal treatment, okay? So Ive been
able to actually, the same stuff you use here you can use down there. So Ive been
able to help out patients multiply. Okay?

So, common chronic skin disease, which often affects oral mucosa. As I mentioned to
you all, women suffer more in all these mucous membrane diseases, so its twice as
common in females. Buccal mucosa is involved 85% of the time, usually bilaterally.
And there is a subtype of lichen planus. Most cases are completely asymptomatic.
The patient has these radiating white lines on their cheeks and they have no
symptoms they dont even know about it until you tell them about it or you ask them
about it. But a small percentage of people will have erythema and ulceration to go
with the lichen planus so redness and ulceration. And then they become
symptomatic and its painful and it is this subtype of lichen planus that has a slightly,
a small pre-malignant potential and has a five percent higher risk of developing into
a squamous cell carcinoma, the normal mucosa. Okay?

So any time a patient has a diagnosis of lichen planus, we put them on strict three to
six month, follow-up. So I have many patients I will regularly see every three to six
months that have lichen planus to look for any changes that are pre-malignant or
malignant, okay? So thats called the erosive type of lichen planus.
And again, this is one of the autoimmune diseases that no body can say what really
causes it. Its said to be immunologically mediated and something called heat shock
proteins have been implicated or suspected.

[74] [N/A]
[Dr. Shah] Okay, so this is the skin manifestation. Now remember what I said, you
may just have skin and not oral, you may just have oral and not skin or you may
have both, okay? So this is a patient with skin lesions. The skin lesions have oral
lichen planus are often treated by a dermatologist, okay? And will present as purple,
polygonal, pyretic, papules, 4 ps. Purple, polygonal, pyretic means what? Who
knows what pyretic means? Itchy. Okay? Itchy papules. Okay? And often its on the
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forearms as you can see in this patient. You can see these kind of itchy, purplish
papules here. Papules are slightly raised, okay?

[75] [N/A]
[Dr. Shah] And this is a higher power view, okay? And theyre very itchy, so the
patients going to scratch these so you can see the scratch marks here.

[76] [N/A]
[Dr. Shah] Okay, those are what skin lesions look like. So if I have a patient that has
oral lichen planus, I always ask and you should too or anyone should about skin
lesions. Because sometimes I diagnose skin lesions. Their mouth may look like this. I
see the radiating white lines, I suspect lichens planus, I ask to look at their forearms.
I see some itchy papules like this and theyre like yea, I have no idea what this is.
And Im like you know what? This might be lichen planus, go see the dermatologist.
And get a biopsy done and if it is, then you know, the same type of topical steroids
that you can use for the treatment of symptomatic lichen planus in your mouth you
can use on your skin. Its all the same topical steroid creams. Okay? So it goes both
ways. Many of these autoimmune diseases its very important, because we can
diagnose these first, many times. I have to tell you, and youre going to realize when
you interact with more medical professionals, that some of us are definitely more
knowledgeable, in fact, the majority of us are more knowledgeable than many
medical professionals and we have more medical knowledge than, believe it or not,
some practicing physicians. I had many conversations with people and been the one
to tell them and explain things to them than the other way around. And itll be the
same for you guys so we have to be able to diagnose and know what to do about
these things. Okay, so if you see a patient with oral lesions, you look at the skin and
refer the patient if they have any skin lesions.

So this is your typical presentation of lichen planus, the radiating white Wickhams
striae, okay? Doesnt always look this pretty, theres also plaque-like variant, thats
just a white plaque and you may or may not see the radiating lines. Okay?

[77] [N/A]
[Dr. Shah] This is a nice example. You have kind of a white plaque-like area,
leukoplakia here. And then you have these radiating kind of white lines or
Whickams striae. So this is a good example of lichen planus on the buccal mucosa.

[78] [N/A]
[Dr. Shah] Okay, heres an example thats a little more.. Involves more sites.
You can see the buccal mucosa is involved and you can see the ventral tongue is
involved. You can also see the dorsal tongue is involved. And many times, the
presentation of lichen planus on the dorsal tongue is plaque-like. Youll see like a
white plaque, you wont see the radiating white lines and its hard to diagnose
without a biopsy but then you look around and hopefully you see more
characteristic striae on the buccal mucosa. Okay?

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[79] [N/A]
[Dr. Shah] Heres an example of the erosive type. You see this red background here
with some faint white striae here? Faint white striae here. Okay? And this kind, the
patient may often tell you that they have some burning, or soreness and one of the
common symptoms reported is I have a lot of sensitivity to hot, spicy, or acidic
foods. Okay? Thats a very common complaint with patients that have symptomatic
lichen planus or erosive lichen planus, okay? So theres an example.

[80] [N/A]
[Dr. Shah] Heres your desquamative gingivitis presentation of a patient with
erosive lichen planus. You can see the gums are kind of really red and inflamed.
There might be ulcerated areas. And sometimes in a case thats not too bad, if you
look closely, you might see some radiating white lines here, but in other cases, its so
erythemitous and inflamed that you cant identify any white striae. And it could be
any of those diseases and desquamative gingivitis, right? It could be the pemphigus,
the pemphigoid, or the erythema multiforme and a biopsy is going to give you your
answer. Okay what type of biopsy do you think you have to do for lichen planus and
for these other diseases? What type of biopsy? You think you can use a smear or a
brush biopsy? What type of biopsy? Anyone, someone? How are you going to get the
answers to this? Okay. Punch, yea. But incisional or excisional? Incisional youre not
going to take this whole thing out, most of the time. So an incisional biopsy, youre
not going to use a mucosal smear, youre not going to use a brush biopsy. This tissue
is already peeling so the last thing you want to do is take than invasive brush and
peel everything off. So you dont want to do that. So you want to use incisional
biopsy and most of the time we use a punch but you could do an incisional scalpel as
well, okay? And remember, when I gave my lecture last week about biopsy
technique, where do you biopsy for these lesions? Okay, for lichen planus, yea, its
the striae. Thats where you should go, okay? So, but then for some of these other
autoimmune diseases that Im going to be talking about, pemphigus, pemphigoid, its
perilesional, remember that word? That I said not straight in the lesion because
thats an area of missing epithelium but near it. Okay? So, anyway, this is lichen
planus.

[81] [N/A]
[Dr. Shah] This is what a biopsy looks like. Okay, one more point. You wont be
given a slide on an exam. Not this year, anyway. But youll get a description. So I may
show you a picture of this. And say in the description that the biopsy shows this,
this, and this. What is the diagnosis? So you do need to know the key microscopic
features. Okay? So the key microscopic features are that theres a band of T
lymphocytes. Do you see this purple, this band of purple dots here? These are T
lymphocytes and it forms a band. Theres nothing deeper. Its very superficial at the
top of the connective tissue. Okay, then also, theres degeneration of the basal cells,
okay? So the epithelium connective tissue has an interface called the basal cells and
it becomes obscured as the inflammatory cells go up so we call that degeneration of
the basal cells. So you have that and you have the band of t lymphocytes. Those are
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25
the key microscopic features for lichen planus. You can also get whats called saw-
tooth shaped rete ridges. So rete ridges are the epithelial ridges here. And
sometimes they have the shape of a saw, of a saw tooth, a sharp kind of triangular
shape, okay? So those are the key microscopic features to make the diagnosis.

[82] [N/A]
[Dr. Shah] Heres another representation. This is more of the erosive type. You can
see the epithelium is peeling from the connective tissue. But again, you have that
band of T lymphocytes and the degeneration of the basal cells.

[83] [Treatment]
[Dr. Shah] As far as treatment goes, as I told you, you only treat lichen planus if its
symptomatic. If the patient has white striae on their cheeks and they have no
symptoms, no burning, no soreness, you dont treat that, okay? You only treat if they
tell you they have soreness or burning and sensitivity. And then the treatment is
topical steroids. Okay? So Dexamethasone rinse if its widespread. You can use the
Clobestasol ointment if its just a few isolated lesions, okay? And I told you guys that
that Dexamethasone can be used if its localized and the gauze and then the gauze
put on the lesion. Or then theres also if its more widespread, swish and spit.
Rinsing, holding and spitting out. And you can adjust the dosage anywhere from bid
to like qid or even five times a day depending on the severity of the disease. Okay.

[84] [Lichenoid Drug Reactions]
[Dr. Shah] When youre talking about lichen planus, I have to talk about something
similar called lichenoid drug reactions. There is a type of reaction in the mouth due
to many medications, due to allergies to maybe cinnamon, or something in
mouthwash or a dental product or even dental amalgam sensitivities where a
patient can have lichenoid lesions that resemble lichen planus but are not an
autoimmune disease, theyre related to this irritant, I should say.

[85] [Lichenoid Mucositis]
[Dr. Shah] So lichenoid mucositis. But clinically you cant tell the difference. Youre
going to have the same radiating white striae, okay? But lichenoid mucositis tends to
be more symptomatic, usually theres more erythema and ulceration. Caused by
systemic meds, topical causes can be, as I told you, cinnamon-containing products or
contact sensitivity to dental amalgam.

[86] [Lichenoid Mucositis]
[Dr. Shah] Okay, so these are some medications that are linked to lichenoid
mucositis. And I have to tell you that nowadays you have so many patients taking so
many medications that we see a lot of this, a lot of lichenoid mucositis. Okay? And
the common culprit, heres a list, obviously, which you can read on your own. But,
blood pressure and cholesterol medications are very common culprits that can
cause lichenoid mucositis in the oral cavity, okay? And heres a list of other things.

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[87] [N/A]
[Dr. Shah] Okay so now for some pictures. This is a picture of a patient with
lichemoid mucositis. You can see some red and white lesions involving the anterior
tongue here. And if you look very closely, its subtle but you might see some
radiating white striae around this lesion.

[88] [N/A]
[Dr. Shah] Okay, heres an example of lichenoid mucositis involving the ventral
tongue. Heres a focal ulcer here. You see this ulcer here. You see the red and
radiating white striae everywhere, okay?

[89] [N/A]
[Dr. Shah] Heres an example also of lichenoid mucosisis. This is an ulcer here with
a pseudomembrane on it. Theres erythematous areas, and if you look in this area
here you can see some kind of white striae as well. Okay? Sometimes a diagnosis is
not clear-cut and anytime you have a lichen planus or a lichenoid lesion, you're
supposed to biopsy it with an incisional biopsy to tell the difference between lichen
planus and lichenoid mucositis. Theres no way you can do it clinically. Certainly if
you have a patient thats not taking any medications, you feel more comfortable
saying the patient has lichen planus and certainly if you have a patient thats taking
blood pressure, cholesterol, or a whole bunch of meds, its more likely theyre
having a lichenoid mucositis. But, you know, you dont know until you biopsy. You
can have lichenoid mucositis in a patient not taking meds and you can have lichen
planus in a patient taking meds.

[90] [N/A]
[Dr. Shah] Okay, heres an example of lichenoid mucositis related to amalgam. You
see this big amalgam over here? Right in the posterior buccal mucosa you have see
this kind of red and radiating white lesion here of lichenoid mucositis. Okay.

[91] [N/A]
[Dr. Shah] So if you biopsy this, how do we, you know, were going to see something
different under the microscope. Its not going to look the same as the lichen planus
that has the nice band. In lichenoid mucositis, first of all, the infiltrate is deeper. Its
not a band, okay? It goes deeper. It tends to be perivascular. Perivascular means
around blood vessels, okay? This is a blood vessel here, you can see that theres
inflammatory cells around it. This is a nice collection of inflammatory cells and even
down here at the bottom of the screen, theres a blood vessel, you can see some red
blood cells and you can see inflammatory cells around. So a deeper infiltrate around
blood vessels and also a mixed infiltrate. I told you in lichen planus, theyre just t
lymphocytes. In lichenoid mucositis, theyre mixed plasma cells and lymphocytes.
Okay? So thats how you tell the difference under the microscope.

Ultimately, does it make a difference in treatment? Not really. Because even
lichenoid mucositis is going to be treated with topical steroids. So then why do you
think you have to do a biopsy? If the treatment is going to be the same, why do we
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need to know what the diagnosis is? Between lichen planus and lichenoid mucositis,
why? Why put your patient through that? And your patient is going to ask you why
so you should have an answer. Why? What did we just say about lichen planus? Yes?
Not quite Whats that? okay so one of them does increase the risk for oral
cancer. And which one was it? Lichen planus, right? Okay, even though its a slight
risk, it is a risk. So its the more, the condition out of the two that has some serious
complications, right? Okay, and then theres one other reason too. Who can think of
one other reason you would want to know whether a patient has lichen planus or
lichenoid mucositis? Think systemically. The big picture. Yeah?

[Student]-- Because ones auto-immune.

[Dr. Shah]--Okay but what does that mean in terms of clinical presentation? Yes. Skin
lesions. Involvement extra-orally, right? So, thats why you would want to know the
difference, between lichen planus and lichenoid mucositis. With that being said,
there are many clinical scenarios where we actually cannot do or do not do a biopsy.
But the rule is, realistically, even when you have lichenoid lesions, you are supposed
to do a biopsy to get a baseline diagnosis, okay?

[92] [Treatment]
[Dr. Shah] As far as treatment goes, its the same topical steroids you use for lichen
planus. And I told you lichenoid mucositis is usually more symptomatic than lichen
planus but the Dexamethasone rinse and then also the topical steroid ointment.

[93] [Benign Mucous Membrane Pemphigoid (Cicatricial Pemphigoid)]
[Dr. Shah] Okay, the next condition Im talking about and Im looking at the time so
I think I need to get into, you know, move it ... gear here, so I can finish. But the next
condition that Im going to be talking about is pemphigoid. Its called benign mucous
membrane pemphigoid. Okay? Also known as cicatricial pemphigoid. And I really
love that word, but who know what that means? Whats a cicatrix? A scar, okay? So
surely youre going to find out what that has to do with anything in this condition.

[94] [Features of Benign Mucous Membrane Pemphigoid]
[Dr. Shah] Ok so pemphigoid. Its an autoimmune disease, okay? Its characterized
by full thickness sub epithelial cleavage. What does that men? It means the entire
epithelium peels off of the connective tissue, okay? Its considered pemphigoid and
pemphigus are called vesiculobullous diseases. They present as blisters, okay? And
then as the epithelium is separating from the connective tissue, and then they
completely slough off or come off and then you have an ulcer which crusts, okay? So,
they call it benign mucous membrane pemphigoid, not because theres such a thing
as malignant mucous membrane pemphigoid but what it means is that its more
confined than some of the other mucous membrane diseases. Its generally more
confined to just the gingiva but in some patients, it affects the eye mucosa, or the
conjunctiva of the eye, okay?

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So with pemphigoid and pemphigus, you can get a positive Nikolskys sign. And I
think I told you guys what the Nikolsky sign is. Its where you rub with a mirror
handle or blow some air and the tissue just slides off or peels off. Thats really
positive mainly for pemphigus but also for pemphigoid. Theyre very important
clinical tests. Okay, and pemphigoid is twice as common in females, peak age of
incidence is 30 to 50 and the pathogenesis is thought to be due to, theres an attack
on the basement membrane zone. Okay? Theres a deposition of Ig and complement
in the basement membrane zone and therefore, the entire epithelium peels off from
the connective tissue. So again, Im going to ask that you guys really think about the
mechanism rather than blindly memorizing or youre going to get really confused
between pemphigoid and pemphigus and the manifestations, okay?

[95] [N/A]
[Dr. Shah] So this lady who doesnt look too happy, she has pemphigoid
involvement of the eye, okay? And what you can see here is some erythema and
fissuring and ulceration of the eye mucosa here.

[96] [N/A]
[Dr. Shah] Okay, this is the same patient oh, no, this is not the same patient. This
is a different patient. But Im going to show you some other pictures of that lady
intraorally. This, okay, is what has to do with the cicatrix and the scarring. This is a
fibrous type of scar. This has a very specific word; its called symblepharon (?) Okay,
and what it has to do with is when you have repeated ulceration and healing you get
scarring and a fibrous band of tissue that attaches to the sclera of the eye. Okay? And
this can be a real issue as it progresses, if the patient is not being treated because it
can lead kind of to a temporary type of blindness. Okay? So this is kind of a mild
presentation of the symblepharon of pemphigoid.

[97] [N/A]
[Dr. Shah] And this is a more sever presentation that happens with repeated
ulceration and healing and scarring, okay? So whenever a patient gets a diagnosis of
pemphigoid, its important to do an eye exam and refer the patient to an
ophthalmologist, for eye testing, not necessary and optometrist, but an
ophthalmologist, okay?

[98] [N/A]
[Dr. Shah] So heres your presentation known as desquamative gingivitis and a
pemphigoid patient. Again, you have the erythematous kind of peeling gingiva here.
Alright?

[99] [N/A]
[Dr. Shah] And this is kind of a higher power showing you that this is after the
Nikolsky sign. If I took, you know, the mirror handle or sprayed some air on this, I
peeled off the epithelium this is kind of what you have underneath here.

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[100] [N/A]
[Dr. Shah] Okay heres some more examples. This is a very rare example of one of
the blisters or bulla of pemphigoid, okay? Most of the time youre not going to
youre rarely going to see in the mouth and I want to point out also that
pemphigus and pemphigoid are skin diseases, okay? They can also affect the skin or
they can same thing.. Many times they can affect the oral cavity before they affect
the skin. So if we diagnose and treat it before it progresses, we can actually help the
patient. But some patients have already skin involvement. Some patients dont have
oral involvement, things like that, okay? But, youre more likely to see the vesicles
and blisters on the skin than you are in the oral cavity. Why do you think thats true?
Why do you think that most of the time youre not going to see this blister here in a
pemphigoid or a pemphigus patient in the oral cavity? Think about it? Because were
always doing things with our mouth, right? Were always eating, were always
talking or using our mouth in other ways. Were always doing things with out
mouth. So, youre rarely going to see a blister or a vesicle or bulla of pemphigoid but
heres a nice, rare example that you can see here.

[101] [N/A]
[Dr. Shah] Most of the time youre going to see stuff that looks like this, okay? Or
other presentations here where you have ulceration and erythema and peeling.

[102] [N/A]
[Dr. Shah] This is an edentulous ridge. Heres an example as well over here. Okay,
so when you do a biopsy, a perilesional biopsy, okay? So you would not go in these
ulcerated areas that have already lost epithelium because we want epithelium.
Youre going to go close to it, perilesional, okay?

[103] [N/A]
[Dr. Shah] Youre going to see something like this. This is the epithelium and its
completely peeling from the underlying connective tissue. And then you have
scattered inflammatory cells in here. Okay? So you have a complete separation. The
basal cells, which are these dark cells are still, are attached to this entire epithelium.
This is full thickness or cleavage or separation. So this is what pemphigoid is, whats
happening in pemphigoid here, okay? And I have to say with this being said; doing a
biopsy for pemphigoid or pemphigus takes some practice and some skill. Because 8
think about it, if the epithelium sloughs off easily, and youre manipulating it and
you need epithelium in your biopsy, you can just peel it off and suction it away and
there is goes, right? And then if I end up with just this connective tissue and not this
epithelium, I cant diagnose this as pemphigoid or pemphigus. I just have to say
inflammation, missing epithelium, okay? So doing a biopsy of this takes really, you
know, gentle manipulation and care and good tissue handling technique.

[104] [Benign Mucous Membrane Pemphigoid]
[Dr. Shah] Okay, so for that reason, one of the standards for diagnosis for
pemphigoid and pemphigus is immunofluorescence. Immunofluorescence. So we
send the tissue out. Well do another biopsy, some people will do one biopsy and cut
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it in half, send half of it to an oral pathologist for H&E staining and one will, you
know, the other half to thats not a good idea. Cutting a specimen in half, youre
manipulating the tissue more, someone may get all the epithelium, someone may
not get any epithelium. So many clinicians will do two biopsies. One for, you know,
routine microscopic exam and one for immunofluorescence. Now, in
immunofluorescence whats happening? Okay, the antibodies are going to be
marked that are in the basement membrane zone. Theres going to be linear
deposition of IgG and C3 in the basement membrane zone.

[105] [N/A]
[Dr. Shah] So the immunofluorescence looks like this. Where because the attack is
in the basement membrane zone, okay? That youre going to get this fluorescence
marking here, a line, between the epithelium and the connective tissue in
pemphigoid, okay?

[106] [Treatment]
[Dr. Shah] So as far as the treatment goes, patients with pemphigoid do need to be
treated with topical steroids. Generally, always. There are some people with very
mild presentations that can use it on an as-needed basis, but most patient will need
to take topical steroids every day. Okay, so Clobetasol or Dexamethasone. And there
are some cases that are really severe of pemphigoid that you have to start off with
systemic steroids, Prednisone, then taper down, and then move to topical steroids.
Okay, and then another part of treatment is regular eye exams by an
ophthalmologist and also doing, you know, letting a patients dermatologist or skin
doctor or asking a patient about any skin lesions is also an important thing. Not so
much as in pemphigus that were going to be talking about next but its also an
important point.

[107] [Pemphigus Vulgaris]
[Dr. Shah] Okay, moving on to pemphigus vulgaris. Pemphigus vulgaris, its a lot
more severe but a lot less common of a disease.

[108] [Features of Pemphigus Vulgaris]
[Dr. Shah] So this is a life threatening skin and mucous membrane disease, which is
autoimmune in nature. Patients are usually 50 years of age or older. And then more
than half of patients can actually present with oral lesions before skin lesions. And
thats a big deal. Because we can help these patients by finding the oral lesions
before they even develop skin lesions or early stage lesions. And whats happening
in pemphigus, well theres an attack on certain proteins in the desmosomes. So you
all know desmosomes are the structures that hold epithelial cells together. So
theres a protein called desmoglein 1 and desmoglein 3. Desmoglein 3 is usually for
oral pemphigus and desmoglein 1 is usually for skin pemphigus. So, theres an
attack. Your own antibodies are attacking this component of your desmosomes
causing the epithelial cells to just fall apart and thats whats happening in
pemphigus vulgaris. And the cells that fall apart that rounded and degenerating are
called Tzanck cells as well. Tzanck. Im not talking about the herpes Tzanck cells but
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Tzanck was a famous, busy guy that discovered a lot of different things, okay?
Positive Nikolsky sign, again. Very important clinical test for diagnosing pemphigus
but of course, the gold standard is biopsy and immunofluorescence. You cant just,
you know, give a Nikolsky sign and say thats it, you have pemphigus, there need to
be more tests.

[109] [N/a]
[Dr. Shah] Okay so heres some pictures of pemphigus vulgaris. This is your
desquamative gingivitis presentation. Again, red peeling gingiva here.

[110] [N/A]
[Dr. Shah] This is the same patient. Look at the tongue and look at the lip
involvement, okay?

[111] [N/A]
[Dr. Shah] This is a different patient with pemphigus vulgaris that was just huge
chunks of tissue were just peeling off of the tongue here. Okay?

[112] [N/A]
[Dr. Shah] Here are some more patients with pemphigus vulgaris. These are some
irregular, ulcerated, erythematous type lesions on the palate and soft palate and
then heres an area in the retromolar pad, posterior buccal mucosa area.

[Dr. Shah] Heres some more examples of pemphigus vulgaris. Okay? This is
affecting the marginal gingiva. And I have to tell you, this is kind of the earliest
presentation, especially this. This is the in man cases this is the earliest clinical
presentation of pemphigus vulgaris. This irregular, ulceration or the marginal
gingiva, here.

[114] [N/A]
[Dr. Shah] Okay? This is skin involvement. If a patient is unlucky enough to have
skin pemphigus, and they get these vesicles and blisters, when they rupture, this is
what they look like. Heres an example on the skin. This is a bulla here, a large
blister. You can see an intact bulla here on the skin. Here its ruptured. Heres a
patient you can see with multiple bullae on the feet. That is a pemphigus patient.
Heres a lesion, a patient with lesions and you can see how, you know, just chunks of
skin are just sloughing off and this is what makes this life-threatening. Why do you
think this is life threatening? What makes this life threatening? Infection. Sepsis.
Life-threatening. Your skin is your barrier to the world around you. Chunks of skin
are just falling, you know, sloughing and coming off in this patient. So the patient can
develop severe systemic infections and it can be really life threatening. Many of
these patients are like, are treated like burn victims or intensive care units. Its
really a big deal. Okay.

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[115] [N/A]
[Dr. Shah] When you do a biopsy, perilesional biopsy, what you see in pemphigus is
the epithelium is coming off of the connective tissue but its degenerating. Youll see
separate, individual cells, which are Tzanck cells and a key point here is the basal
cells, which are these dark cells, are still attached to the underlying connective
tissue. Okay? So the attack is suprabasilar. Above the basal cells. Why do you think
and think about this, why should the basal cells still be attached to the connective
tissue? Why are they not coming off? Yeah, because the hemidesmosomes dont have
desmoglein 1 and 3. okay? So they still stay attached to the underlying connective
tissue whereas the rest of the stuff is falling apart here, okay? So you should see the
difference. You dont have to do a 3-year residency like me in oral path to know the
difference between this and what I showed you for pemphigus, right? In pemphigus,
I mean in pemphigoid its full thickness with the basal cells. In pemphigus, its above
the basal cells, the cleavage, okay? And if you think about the mechanism youll
completely understand whats going on here.

[116] [N/A]
[Dr. Shah] This is a nice, higher power view. Here, you can again see the basal cells
attached to the connective tissue. This is called the row of tombstone type of look
here. Okay? And then here you have degenerating epithelial cells. These are Tzanck
cells of pemphigus, Tzanck cells of pemphigus.

[Dr. Shah] Okay, immunofluorescence, if you perform immunofluorescence studies
here and you know that the auto-antibodies are attacking the desmosomes which
are between the epithelial cells, you can imagine that your immunofluorescence
pattern is going to look like this which is called the chicken-wire effect. Okay?
Chicken-wire effect, here.

[118] [N/A]
[Dr. Shah] And this is because the antibodies that are attacking desmoglein 3 are all
between these epithelial cells and thats why you have this immunofluorescence
pattern here.

[119] [Treatment: Refer!]
[Dr. Shah] Okay treatment. Pemphigus vulgaris really requires, you know,
treatment by a specialist and close monitoring, okay? I think a general dentist might
be able to manage some of these mucous membrane diseases but Im not so sure
about pemphigus. Many pemphigus patients are really very complex and there are
specialists for pemphigus, okay? And we probably have maybe about ten or fifteen
pemphigus patients in our practice upstairs between Dr. Kerr and myself. And he is
more of the expert on this than I am. He keeps up with the new medications and the
new treatments. But, you know, I stay involved and treat some of these patients as
well. These people have to be treated with high dose steroid therapy. Anywhere
from 40 to 80 mg of Prednisone, daily, okay? And what eventually happens is once
you get them sort of under control you cant keep them on such high dose steroids
th
, 2014

33
without really messing them up systemically. So you have to lower that and then
you add other immunosuppressant medications. Some of those are like heavy
chemo medications like Mycophenolate, azothioprine, some of these other heavy
immunosuppressive some of these big immunosuppressive drugs. Theres
another treatment called IVIG, and then also we regularly monitor desmoglein 1 and
3 antibody titers and CBC blood work. Okay? Because these medications are going to
affect the blood counts and the blood value and the blood glucose levels and the CBC
and a lot of things. Okay? So, you really have to monitor with regular blood work.
And then there is actually a new type of treatment going on, I dont want to spend
too much time on it but Rituximab, monoclonal antibody treatment. This is these
antibodies are injections that affect B cells and of course B cells are the ones that
differentiate into plasma cells which make these antibodies that attack the skin and
the mucosa. So, this is a new type of therapy thats being treated right now. I think
we put our first patient in Rituximab treatment and shes doing better, so

[120] [Erythema Multiforme]
[Dr. Shah] So that was pemphigoid, alright. Now I move to erythema multiforme. I
have this and one other topic to cover in about ten minutes. So Ill finish and then if
we have some time for any questions.

[121] [Erythema Multiforme]
[Dr. Shah] Okay, so erythema multiforme. Erythema multiform is a type of acute,
self-limiting, possibly recurring type 4 hypersensitivity reactions. So those three
other mucous membrane diseases, lichen planus, pemphigus, pemphigoid, do you
think theyre acute or chronic? Theyre chronic. Whereas erythema muliforme is
acute, okay? It can be recurrent where a patient can have regular episodes of it but
acute means it happened, you know, within two weeks, its from start to finish, its
gone. Okay? It can be self-limiting. Those other things are not self-limiting.
Pemphigus and pemphigoid are definitely not self-limiting. If theres no treatment,
they keep progressing. Where as EM can go away on its own but the patient will
really suffer so if you can help them and identify it and treat them with steroids, its
really going to help them out. Okay? EM is sub-classified, or subtyped, into two
types. Minor and major. And minor and major have to do with the number of sites
involved. So EM can affect the oral mucosa, the eye mucosa, the genital mucosa, and
skin.

So it has to do with the number of sites involved. If you only have one site involved,
even if its really severely involved. Its called EM minor. Okay? And if you have
multiple sites involved, its called EM major.

So EM minor, often, secondary theres a link to recurrent herpes infections. Those
patients that suffer with recurrent herpes can also get recurrent erythema
multiforme. Okay? And major EM is often due to a severe drug reaction, maybe to an
antibiotic. They used to use these penicillin derivative antibiotics in the past, which
caused Stevens-Johnson syndrome. Or even some sulfa drugs can cause Stevens-
Johnson syndrome, which is major erythema multiforme.
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34
Okay, so some key words here again, acute and self-limiting and possibly recurring.

[122] [Erythema Multiforme Minor]
[Dr. Shah] OK, EM minor.

[123] [Features of EM Minor]
[Dr. Shah] Features of EM minor. More common in females, usually seen in young
patients. Rapid onset. Thats an important clinical clue. Another important clinical
clue for EM minor and actually EM in general is whats called the bloody crusted lip
appearance. The lip is almost always involved and it has this distinct, what can only
be described as a blood, crusted lip. Hemorrhagic, crusted lesions. And then another
very pathognomonic. Pathognomonic means if you see it, its definitive, but
unfortunately you dont see it in the majority of cases but its called a target lesion
on the skin. You look at the palms of the hands or the soles of the feet and you see
what looks like a target, like an archery target or the target sign from the store and
Ill show you what that looks like. Okay, so some important important clinical
features, rapid onset, bloody crusted lip, target lesions.

[124] [N/A]
[Dr. Shah] Okay, this is a patient with EM minor. This is whats called the bloody
crusted lip appearance. Okay? Bloody crusted lip appearance.

[125] [N/A]
[Dr. Shah] Heres an example again also of lip involvement and a patient with EM
minor.

[126] [N/A]
[Dr. Shah] Heres another EM minor patient. Remember, all of these patients had
acute onset. This hasnt been going on for months, this just happened like last week,
okay?

[127] [N/A]
[Dr. Shah] Then, this picture is really disturbing. But this is still erythema
multiforme minor. You know, nothing looks really minor about this but it involves
only one site. As long as it doesnt involve other sites, its still EM minor. Erythema
multiforme can really make a patients life miserable and can, the entire mouth can
sort of slough and just become a mess. So you could tell this patient, although I
wouldnt, they might hit you if you tell them: you know what, this will heal in two
weeks, you know? Dont worry about it. So, no, they probably want some kind of
treatment. So I probably, I will give them a 1 or 2 week systemic steroids and that
will really clean it up and help them. But theoretically you can leave this patient
alone and they should heal in two or three weeks but you know you dont want to
put, maybe your worst enemy, but no one else through that.

[128] [N/A]
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35
[Dr. Shah] Okay, heres some more examples of erythema multiforme minor. You
can see lesions involving various parts of the oral mucosa but they almost all involve
the lips, okay? This is lip and tongue; this is lip and tongue as well. You can see this
big ulcer on the lip here.

[129] [N/A]
[Dr. Shah] Heres involvement of the buccal mucosa and erythema multiforme
minor.

[130] [N/A]
[Dr. Shah] Theres involvement of the tongue in EM minor.

[131] [N/A]
[Dr. Shah] These are the target lesions Im talking about. When you look at the
palms of the hands so lets say you see a patient that looks like any one of these,
okay? And they tell you this just happened in a week and you suspect EM minor.
Your very next step should be, hey can I look at the palms of your hands and then
you have to explain why you're doing that because otherwise theyre going to think
youre just weird, right? So, you would say that, you know, Im thinking of a certain
disease that can also have spots on your hands, can I see your hands? Certainly ask
before you just grab the hands and just take a look, right? So, here you see target
lesions. What they are are concentric circles of light and dark. Here, on the palms
and then here. Okay? And it doesnt have to be on the palms or on the soles, it can be
on the skin as well. And its easier to see on a white patient, obviously, than a dark-
skinned patient, where its harder to see what is there. Okay? Target lesions.

[133] [N/A]
[Dr. Shah] If a biopsy is done, I would say a biopsy is most useless for erythema
multiforme. Its good with all these other things, okay? Except for aphthous ulcers. If
you do a biopsy of an aphthous ulcer, you get nothing but nonspecific ulcer. But for
all these other lesions weve talked about biopsy will give you the diagnosis but
erythema multiforme biopsies, pretty nonspecific findings. You just have a bunch of
inflammation and peeling epithelium. Okay, and a mixed inflammation. The only
thing that sort of points you toward EM under the microscope is youll see some
collection of cells called eosinophils which are these bright red cells. If you see them,
they might point you that way. You may or may not see them so its very kind of
nonspecific here. Okay?

[135] [Treatment]
[Dr. Shah] As far as treatment goes, for EM minor, systemic steroids. Short course
of prednisone, 40 mg, 4 tabs taken for 7 days. I see the patient in a week and if the
patient is, you know, not completely healed, I may extend it for another week. Okay?
But usually the Prednisone works great, it really cleans up well.

[136] [Treatment]
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36
[Dr. Shah] Chronic, recurrent EM, if a patient keeps getting erythema mulitforme, it
might be linked to herpes. So if you treat the recurrent herpes, youll treat the
recurrent EM. So the same prophylactic treatment, the Lysine 1 g a day and the
Valtrex tabs can help with chronic, recurrent EM.

[137] [Erythema Mutiforme Major (Stevens-Johnson Syndrome)]
[Dr. Shah] Let me very quickly run through EM major, Stevens-Johnson syndrome.

[138] [Features of EM Major]
[Dr. Shah] Severe form, hemorrhagic skin lesions, genital lesions and its said that
antigens from the offending medication will localize and lead to a cell mediated
immune reaction. Okay?

[139] [Reaction to Dilantin]
[Dr. Shah] Heres a patient that had severe reaction to Dilantin, a Stevens-Johnson
syndrome, erythema multiforme. You see the eye is involved. You see the bloody
crusted lip appearance and then some of the skin is involved as well.

[140] [N/A]
[Dr. Shah] Heres an example affecting the genital area.

[141] [N/A]
[Dr. Shah] Heres eye involvement in Stevens-Johnson severe EM major.

[142] [N/A]
[Dr. Shah] Look at this. These lesions, Stevens-Johnsons in a young patient. Look at
the bloody crusted lip. Look at the lesions throughout the skin. Look at this patient.
These patients I mean, this can really be a Steven-Johnsons can be really
severely life threatening because for the same reasons. You can get a severe,
systemic infection or sepsis, right?

[143] [N/A]
[Dr. Shah] Look at this patient. This poor little child had a smallpox vaccination and
had this Stevens-Johnsons syndrome reaction here with target lesions and red
lesions on the skin here.

[144] [N/A]
[Dr. Shah] This is a really disturbing picture of a patient with Stevens-Johnsons
syndrome, treated in the intensive care unit like a burn victim.

[145] [N/A]
[Dr. Shah] As far as treatment goes, it goes without saying that the offending drugs
should be discontinued immediately. The problem is sometimes you cant identify
what it is but, you know, hopefully you can. The treatment is controversial. Theres
no definitive treatment. Systemic steroids can or cannot be used. You may not want
to use systemic steroids, because the patient already is prone to infection and if
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37
youre using a steroid, youre depressing their immune system more, right? And
then sometimes you can just use rehydration, topical anesthetic and pain meds.

[146] [Geographic Tongue (Benign Migratory Glossitis)]
[Dr. Shah] Okay, this is the last topic, give me one or two more minutes. Geographic
tongue, benign migratory glossitis. Migratory means it moves around, glossitis is an
inflammation of the tongue.

[147] [Features of Geographic Tongue]
[Dr. Shah] Weve talked about geographic tongue before, just a few more details
nobody knows what causes it. Its said to occur in about 2.4% of the population. I
think this is an old, low estimate. I think more people than that have it, and I told
you guys I have a geographic tongue.

Twice as common in females. Multiple red patches with these elevated yellow white
borders. Depapillated areas heal and reappear elsewhere on the tongue so theyre
moving around. What you see on a patients tongue one day, if you see them one or
two weeks later, itll probably look different. And there are periods where there are
no lesions in patients with geographic tongue. It can also occur elsewhere in the
mouth. That's called ectopic geographic tongue where you have these red spots with
these white borders in other parts of the mouth. Ectopic geographic tongue, okay?
And usually asymptomatic. Some patients have a burning or a sensitivity. Some
patients can get superimposed fungal infection as well, okay?

[148] [N/A]
[Dr. Shah] This is a mild presentation of geographic tongue. You see this red spot
here with the white border here and theres something here and here. Mild
presentation.

[149] [N/A]
[Dr. Shah] Youve seen this picture before. Here you have the red patch and the
elevated yellowish white, serpiginous border. Also, geographic tongue is many times
more often associated with fissured tongue. Fissured tongue and geographic tongue
so if you see a patient with fissured tongue, look closely and more cases than not,
youre going to find the geographic tongue.

[150] [N/A]
[Dr. Shah] This is ectopic geographic tongue. Every time I see cases like this I find it
really interesting. But look, here you have the same red patches with the elevated
yellow-white border around, it looks just the same as this but its on the labial
mucosa. Ectopic geographic tongue.

[151] [N/A]
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[Dr. Shah] Heres another example. Were in the floor of the mouth here. See the
ectopic geographic tongue? You can see red areas and you see a little bit of the white
border here.

[152] [Treatment]
[Dr. Shah] As far as treatment goes, you should not be treating or biopsying
geographic tongue. Its very clinically distinguishable. Reassure the patient the
condition is benign. Geographic tongue can never turn into cancer, okay? If theres
some symptoms, topical steroids can be used. Also, zinc supplements can help
promote epithelial regeneration. Alright, guys, thank you, I know it was a lot. And I
will see you all later. Thank you. If you have any questions, feel free to email me.

09/10: DX and TX of Oral Mucous Membrane Diseases

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Transcribed by Anam Khalid Monday, July 14

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