1. Vesicobullous Conditions Affecting The Oral Mucosa
KATHLEEN BERRY

2. Definition
Vesicle – a small fluid lesion/blister which can rupture to form an ulcer.
Bulla – a larger blister.
Ulcer – a break in the mucous membrane.
Vesicobullous conditions can be classified into intraepithelial or subepithelial vesicles.

3. Oral mucosa is made up of specialised stratified squamous epithelium with an underlying connective tissue layer (lamina propria)
Intraepithelial vesicles : lesion is formed within the epithelium as there is loss of cell-cell adhesion by breakdown of specialised attachments (desmosomes). This is acantholysis.
Subepithelial vesicles : lesions are formed between the epithelium and the underlying lamina propria (corium).

4. Intraepithelial

5. Pemphigus Chronic mucocutaneous disease
Aetiology – antibody mediated autoimmune
Binding of IgG antibody to pemphigus antigen leads to epithelial cell separation – acantholysis
Several types : Pemphigus vulgaris, vegetans , erythematosus, foliaceous, paraneoplastic pemphigus and drug related pemphigus.
Most common is Pemphigus vulgaris.

6. Pemphigus Vulgaris Most common >65 years Site – mouth and skin
Potentially fatal
Clinical Features:
Bullae readily burst to form large irregular ulcers.
Common sites : buccal mucosa, palate, tongue

7. Diagnosis and treatment
Nicolsky’s sign +ve
Biopsy
Immunofluorescent techniques. (Direct – uses biopsy sample to detect autoantibodies. Indirect – uses patient’s serum to detect circulating antibodies).
Treatment steroids – topical and systemic
Immunosuppressants eg. Azathioprine, methotrexate (allow lower doses of steroid to be used).

8. Primary herpetic gingivostomatitis
Aetiology – Herpes simplex virus type 1 rarely type 2
Severity usually increases with increasing age.
Prodromal period of 2-12 days
Self limiting usually heals within 2 weeks

9. Primary herpetic gingivostomatitis
Clinical features:
Fever , malaise
Enlarged cervical lymph nodes
Multiple vesicles which breakdown to form shallow , painful ulcers
Gingivitis

10. Diagnosis and treatment.
History and clinical examination
Treatment : soft diet, topical/systemic analgesics , fluids.
If patient is immunocompromised – antiviral Acyclovir

11. Herpes Labialis (cold sore)
Reactivation of primary infection- latent in trigeminal ganglion.
Predisposing factors eg. Trauma, stress, sun light
Usual site is lip but can affect intraoral mucosa of palate , gingivae.

12. Herpes Zoster (Varicella zoster)
Primary infection – chicken pox
Reactivates as shingles.
Confined to distribution of a nerve – oromucosal lesions follow trigeminal nerve branches
Following healing may result in post herpetic pain

13. Shingles Pre eruption pain Painful vesicles rupture to form ulcers
Treatment includes fluids, pain relief, antivirals?

14. Coxsackie Virus Herpangina. Hand Foot and Mouth disease.
Coxsackie A or B
Mainly children
Fever , malaise
Multiple, small vesicles posterior oral cavity and pharynx
Dysphagia
Self limiting 1-2 weeks
Coxsackie A16
Usually children
Fever , malaise
Multiple vesicles on hands, feet and oral mucosa – mainly palate
Self limiting 1-2 weeks

15. Subepithelial vesicobullous disorders.

16. Benign Mucous Membrane Pemphigoid
Aetiology – chronic , autoimmune disorder
Autoantibodies directed against basement membrane to form subepithelial vesicles.
F > M
>60 years
Affects any mucosa (can lead to blindness if conjunctiva affected)
Periods of inactivity
2 variants are seen affecting oral mucosa.

17. Mucous membrane pemphigoid
Variant 1.
Intact vesicles , bullae (maybe blood filled)
Ulcerations may lead to scarring.- if this affects larynx results in hoarseness, dysphagia
Variant 2.
Presents with desquamative gingivitis involving only the gingivae around the teeth.
Gingivae are erythematous and hyperaemic

18. Diagnosis and treatment.
History and clinical exam.
Biopsy
Immunofluoresence
Management – analgesics, topical/systemic corticosteroids, immunosuppressants

19. Erythema Multiforme.
Acute , inflammatory disease of skin and mucous membranes.
Aetiology : hypersensitivity reaction
immune mediated
idiopathic
predisposing factors- infection (particularly herpes), drugs (antibiotics, anticonvulsants, allopurinol and NSAIDs).
Most common in young adult males
Severe form is Stevens Johnson syndrome.

20. Erythema Multiforme
Vesicles and bullae which rupture to form ulcers and erosions.
Common sites: lips, buccal mucosa , palate , tongue, face.
Target lesions of erythema on skin.
Crusting of lips.
Fever , malaise.

21. Diagnosis and management.
History and clinical exam.
Biopsy
Self limiting but will need supportive therapy –fluids, soft diet , analgesics
Topical/ systemic corticosteroids.

22. Epidermolysis Bullosa
Aetiology-genetic or acquired.
Appears shortly after birth
Affects skin and mucous membranes
Symptoms mild-severe
Trauma to mucosa results in bullae formation
Healing leads to scarring which may make eating, swallowing , speaking difficult.

23. Other subepithelial vesicobullous disorders affecting oral mucosa.
Linear IgA disease
Dermatitis Herpetiformis
Bullous Lichen Planus
Bullous systemic lupus erythematosus.

24. Summary
Most vesicobullous disorders present initially with oral lesions.
With their associated morbidity and mortality early diagnosis is vital and should be referred – (apart from those known to be viral).

25. References: Oral Medicine (C. Scully and R.A. Cawson).
Oral Medicine (S. Gandolfo, C. Scully and M. Carrozzo).
An overview of vesicobullous conditions affecting the oral mucosa. (Emma Hayes, Stephen J Challacombe).