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 Red lesions ( part 11 )
PROF. MAGDY KAMEL KHALED HAMAM
PROF.OF ORAL MEDICINE & PERIODONTOLOGY
FORMER VICE DEAN COLLEGE OF DENTISTRY. AL-AZHAR UNIVERSITY
PROF. & FORMER HEAD DIVISION OF ORAL MEDICINE
( COLLEGE OF DENTISTRY - KING SAUD UNIVERSITY.)
HEAD OF ORAL MEDICINE & PERIODONTOLOGY
SINAI UNIVERSITY

REFERENCE >>
CLINICAL OUTLINE OF ORAL PATHOLOGY DIAGNOSIS AND TREATMENT
CHAPTER 3
EVERSOLE, 3RD EDITION

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Prof. M.Hamam

 1-Candidiasis
 2-Scarlet fever
 3- Atrophic lichen planus
 4 - Ecehymosis & clotting factor deficiencies
 5 - Field cancerization
 6 -Petechiae
 7- Suction petechiae
 8- Infectious mononucleosis ( Glandular fever )
 9- Thrombocyte disorders
 10- Hereditary Hemorrahagic Telangiectasea
 ( Rendu – Osler – Weber disease )
Wed
 Dec 6 20:28:54
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 1-Candidiasis
 Age & sex.
 Clinical features:
 Pseudomembranous/white lesions
diffuse and multifocal red patches.
 Denture sore mouth. Palate, a patchy
distribution, speckled easily displaced by
rubbing.

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 Candidiasis
Angular cheilitis.
 Inflammation and may represent hypersensitivity to
the organism.
Candida albicans & in some case with a mixture of
other microorganism such as Staphylococcus
aureus seems to represent a major cause.
 May become systemic immunodeficiency disorder.
 Microscopic features: PAS staining.

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Differential Diagnosis:
 Denture candidiasis allergic reaction.
 Non-denture-related candidiasis erythema
migrans, radiation change, lupus
erythematosus, erosive lichen planus,
dermatitis herpetiformis, or malignancy.

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 Treatment:
 Antifungal: Nystatin cream or ointment 4
times per day./ single 200- mg tablet per
day for 10 days  Liver disease.
 Nystatin in conjunction with an S.aureas
agent or metronidazole .
 Reconstruction or relining.
 Erythematous candidiasis not related to ill-
fitting dentures can be manged by nystatin
oral suspension , 3 times/day as mouth
rinse for 7-10 days ,
 Nystatin vaginal tablets dispensed .
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 2-Scarlet Fever
 Clinical features:
 It is a systemic bacterial infection, are the result of
an erythrogenic toxin that causes capillary damage
and that is produced by some strains of group A
streptococci
 Spread by droplet
 Vascular dilation and damage with an erythematous
macular rash on the skin ( chest area ).
 Face →flushed except for zone of circumoral pallor
 pharyngitis & tonsillitis cervical lymphadenopathy.
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  Tongue may covered with white coat
 Fungi form papillae are enlarged , reddened
→ strawberry tongue ( raspberry tongue )→
coat is lost → leaving a beefy red tongue
 Constitutional manifestation of infectious
disease are epitomized by fever and
malaise .
 Complications: rheumatic fever,otiti media ,
abscess.
 Treatment.- Penicillin.

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Scarlet Fever

Fungi form papillae are enlarged , reddened → strawberry

tongue ( raspberry tongue )→ coat is lost → leaving a beefy red
tongue
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 3-Atrophic Lichen Planus
 When erythema, superficial ulceration,
and desquamation accompany the white
component, the term erosive lichen
planus is used.

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 4-Ecehymosis & Clotting Factor
Deficiencies
Clinical features:
Submucosal extravasation  red lesions
diffuse bruise.
The color will range from red to brown to
bluish black, depending on the duration.

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 Ecehymosis & Clotting Factor
Deficiencies
 Petechiae and ecchymosis are purpuric submucous
or subcutaneous hemorrhages.
 They have the same basic mechanism :
 Both appear as bluish macules differing only in size .
Petechiae are minute pinpoint Hemorrhages .
 Whereas ecchymosis are larger than 2 cm in
diameter
 If these lesions are observed soon after their
inception, they are red. Within a few hours, they
change to a bluish- brown color.
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 Echymosis:
Clinical features:
The hemorrhaging is slow in this
spectrum of lesions:-there is insufficient
blood to pool and cause the fluctant
swelling characteristic of early
hematoms .*Purpura: Leukemia.

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Etiology:
Trauma.,hemostatic mechanism or /
systemic disease ( generralized distribution
)

Defective clotting:
Gingival hemorrhage.
Uncontrolled bleeding.
Hereditary.
Medications.
Wed Dec 6Primary
20:28:54 liver disease.
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Systemic diseases produce generalized skin
and mucous membrane ( ecchymosis ,
petechiae)
 Thrombocytopenia
 Leukemia
 Hemophilia or plastic anemia
 Sub acute bacterial endocarditis
 Infectious mononucleosis
 Sickle cell anemia
 Polycythemia
 Vitamin C deficiency
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Differential Diagnosis
 On clinical examination, petechiae and
ecchymosis begin as reddish macules .
 On palpation, they do not blanch on
pressure , but within a few days( color
changes from red to blue to greenish-
blue to yellowish-green to yellow, and
then they disappear as the hemoglobin
is degraded to hemosiderin and is
2023 removed.
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 A single petechical maculae resulting from local
trauma has a bluish-brown appearance within a
day or tow and must be differentiated from :-
 Amalgam tattoo, oral melanotic macule,
junctional nevus, and melanoma
 A history of recent trauma,accompanied by
 The change from bluish-brown to green to
yellow and then finally disappearance within 4-5
days.

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Mangement
 Hemostatic disorders divided into 3 groups
 1- disorders of the vessels
 2- disorders of the platelets
 3- disorders affecting coagulation
 Upon patient exam.:
 1-Thorough history
 2- clinical exam.
 3- laboratory tests
 N.B. surgery should not be performed until the
defect
Wed Dec has been identified and treated
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Coagulation evaluation:
Partial thromboplastin time (PTT).
Prothrombin time (PT = 12-15 sec.).
Thrombocyte count (Platelets count =
200.000 to 250.000 cu/ml )
Thrombocyte aggregation assay.

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Bleeding evaluation:
Bleeding time = 1-3 min.
clotting time = 1-5 min.
 Tourniquet test.
Treatment:
Referral.
Oral surgical procedures.

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 5-Field Cancerization
Age:middle aged and eldery adult .
Clinical Features:
Multifocal erythroplakias.(velvety red
macules , patchy or speckled leukoplakia )
Tobacco and alcoholics.
History of oral cancer.
Larynx  primary carcinomas.

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Differential Diagnosis:
Red lesions in elderly patients  tobacco &
alcoholBiopsy.
Other red lesions.
Treatment:
Surgical stripping and radiation Therapy.
Oncologist.

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 6-Petechiae
Suction petechiae (circular vacuum cups ).
Infectious Mononucleosis.
Thrombocyte Disorders.
Hereditary hemorrhagic telengectesis.

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 7-Suction Petechiae
Age & sex.
 Clinical features.
 1- 3 mm in diameter.
Multifocal, confluent.
Beneath a denture or soft palate.
Pruritus in the region  patient to suck 
microvascular rupture.
Prodromal sign for sore throat.
Soft palate may result from orogenital sexual
activity.( fellatio )
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 Erythema on the palate, caused after fellatio.

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Microscopic Features:
Damaged vascular walls of small vessels.
Differential Diagnosis:
Infectious mononucleosis.
Thrombocyte deficiencies or leukemia.
Hereditary hemorrhagic telangiectasia.
Scurvy.
Treatment:
Denture induced.
 Non-denture.

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 8-Infectious Mononucleosis
(Glandular Fever )
Glandula fever occurs predominatly in
children and adults as a result of Epstein Barr
Virus . EBV is found in the saliva during the
infection and for several months thereafter.
Glandular fever is called also kissing disease
because of occurance in younger age group
( commonly seen in college campuses and
physician )
It is spread by means of saliva, ( closed oral
2023contact )
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Clinical Features:
Petechiae  pruritic soft palate  tongue.
Epistaxis.
Stomatitis with erythema and ulceration.
Malaise with, lymphadenopathy,
hepatosplenomegaly, sore throat, and fever.

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 Infectious Mononucleosis

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Differential Diagnosis:
Sore throat.
Hereditary hemorrhagic telangiectasia.
Blood study. specific antibody tests
(Paul–Bunnell test, monospot test)

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 EBV spared to subjacent B lymphocytes in
lymphoid tissues .
 Activation of T- lymphocytes by EBV
antigen result in the appearance of atypical
T- lymphocytes in the peripheral blood (
Downey cells )( pseudopodia that project
from the cell surface in 3-4 directions)
 Virus infected B lymphocytes are stimulated
with the production of heterophil antibodies
.
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 Diagnosis
 Mild leukopenia precedes the development of
leukocytosis (4.000-15.000 /mm3 ) ,and absolute
lymphocytes , during the 2nd and 3rd week. Of illness.
 2- heterophil antibodies ( Ig M ) detected by
 A- Paull- Bunnel test ; heterophil antibodies can be
detected by agglutination of sheep erythrocytes.
 B- Monospot test rapid method to demonstrate
heterophil antibodies to horse erythrocytes by
detecting agglutination on a glass slid .
 N.B . The titer of heterophil antibodies develop by 1-2
weeks of the illness and disappear over 3-6 months.
 Treatment:
Dec
Wed Supportive:
6 20:28:54bed rest and high liquid intake. A mild analgesic and antipyretic.
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 9-Thrombocyte disorders
 Clinical features :-
 Spontaneous gingival bleeding ( early finding )
 . Purpuric skin rash, epistaxis, and bleeding from
 the gastrointestinal and urinary tract are common
 1-Inhibited platelet formation ;
 ( leukemia, lymphoma, metastatic carcinoma to
bone )
 2-Primary thrombocytopenic purpura pancytopenia
and bone marrow depression from cytotoxic drugs
→Wed
lack
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Dec 6 of platelets
20:28:54 .
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 3-Malfunctioning platelets may be responsible
for petechial hemorrhages in thrombocytopathic
purpura,thrombasthenia or secondary to
overuse of salicylates.
 4-Non -thrombocytopenic purpuras :
Anaphylactic purpura.
Snake venom purpura.
Infectious diseases.
 Gingival hemorrhage or prolonged bleeding
after extraction.

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Idiopathic thrombocytopenic purpura: petechiae and
ecchymoses of the buccal mucosa & skin lesions

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Differential Diagnosis:
Petechia-producing diseases.
Site: mucosa &skin.
CBC & tourniquet test.
History of drug use.
Treatment.

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 10-Hereditary Hemorrhagic Telangiectasia
(Rendu-Osler-Weber disease)
Age & sex: infancy, dominant trait.
Clinical Features:
spider telangiectasias face & neck.
Petechea-like  oral mucosa.
Epistaxis.
Bleeding from the gingiva.
Platelet and clotting factor  normal.
Per vascular supportive tissue.
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 The oral mucosa
 present as multiple bright red papules, 1–2 mm
in size, which disappear on pressure from glass
slide . Nodules and spiderlike lesions may also
be seen.
 Hemorrhage is common after minimal
mechanical damage .
 The lips, tongue, buccal mucosa, and palate
are most
 frequently involved.
 Epistaxis and gastrointestinal bleeding are
common
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Differential diagnosis:
Onset & angiomas.
Laboratory test . Histopathological
examination
Treatment:
Bleeding pressure.
Epistaxis  death.

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 Hereditary hemorrhagic telangiectasia: multiple
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Numerous telangiectasia on skin and tongue

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