Ulcers, vesicles and bullous lesions are seen in the oral cavity as well. They sometimes are the first signs of skin diseases and is essential to diagnose them early for better prognosis.

1. DIAGNOSIS OF ULCERATIVE,
VESICULAR AND BULLOUS
LESIONS
R.K.Haritha

2. CONTENTS
 HSV
 VZV
 CMV
 CV
 NUG, NUP
 Erythema multiforme
 Steven-Johnson syndrome and Toxic epidermal necrolysis
 Plasma cell stomatitis
 Recurrent aphthous stomatitis
 Behçet’s syndrome
 Pemphigus
 Pemphigoid
 Traumatic injuries causing solitary ulcerations
 Traumatic ulcerative granuloma

3. HSV
1. Prodrome – fever, loss of appetite, malaise
and myalgia + headache, nausea
2. Erythema and clusters of vesicles and/or
ulcers
3. Vesicles break down to ulcers (1-5mm)
4. Coalesce to form large ulcers with scalloped
borders and marked surrounding erythema
5. Gingiva – erythematous
6. Pharyngitis – swallowing difficulties

4. RECRUDESCENT HSV
 History of triggers – fever, ultraviolet radiation,
trauma, stress and menstruation
 Site – lips (20-40% of young adult population)
 Prodrome – Itching, tingling, or burning
 Appearance of papules, vesicles, ulcers,
crusting and resolution

5. PRIMARY VZV
Low grade fever
Development of intensely pruritic, maculopapular rash
Vesicle formation ‘dew-drop like’
Cloudy and pustular, burst and scab
Crusts fall off in 1-2 wks
 First 2 decades
 CNS – Cerebellar ataxia and encephalitis
 Other complications – Pneumonia, myocarditis and hepatitis
 Oral – Acute onset ulcerations in the mouth that often pale
 Immunocompromised – more blisters + often involvement of
lungs, CNS and liver – higher mortality rate

6. HERPES ZOSTER (SHINGLES)
Prodrome - deep, aching or burning pain
Vesicles in dermatomal or Zosteriform pattern – 2-
4days
Scarring and hypopigmentation – 2-4wks
 V1 – lesions on the upper eyelid, forehead, & scalp -
blindness
 V2 – lesions of the midface and upper lip – Prodrome of
pain, burning and tenderness, usually on the palate on
one side – painful, clustere ulcers (1-5mm) – coalesce
– heal 10-14days
 V3 – Blisters and ulcers on the mandibular gingiva &
tongue (uncommon)

7. CMV
 90% of AIDS have circulating Ab to CMV – single
large ulcers + usually painful +present for
weeks or months Marked lymphocytosis + Fever
+ 1/3rd coinfected with HSV/ VZV
 Occasional reports – mandibular osteomyelitis &
tooth exfoliation
 Serious complications – meningoencephalitis,
myocarditis, and thrombocytopenia

8. COXSACKIE VIRUS
INFECTION
 <10yrs
 Low grade fever + sore
mouth + erythematous
macules  vesicles 
ulcers
 Site – tongue, hard and
soft palate & buccal
mucosa
 Skin rash – hands & feet
75-100%; buttocks 30%
 <10yrs
 Epidemics in summer
 Fever, headache,
myalgia 1-3days
 Sore throat + pain on
swallowing + erythema
 Site - oropharynx, soft
palate & tonsillar pillars
HFM disease – Herpangina –

9. NUG & NUP
 Excessive salivation + metallic taste + sensitivity
of the gingiva  extremely painful & erythematous
gingiva + scattered punched out ulcer 
malodour + gingival bleeding + plaque buildup
 Immunocompromised and neutropenic –
osteonecrosis or necrosis of soft tissue
 Severe immunodeficiency – cone shaped orofacial
lesions – base of the cone within the oral cavity +
sloughing + sequestration of necrotic bone & teeth
 mortality 70-90% if not treated

10. ERYTHEMA MULTIFORME
 Prodrome Rapid skin lesions redmacules –
papular (several forms) {target or iris lesion} 
centripetal towards the trunk from hands  skin
feel itchy & burnt  Postinflammatory
hyperpigmentation
 Oral – mild erythema and erosion to large painful
ulceration  large & confluent ulceration –
difficulty in eating, drinking, & swallowing 
blood tinged saliva
 Extensive lip involvement – inflammation,
ulceration & crusting (common)

11. STEVENS-JOHNSON SYNDROME &
TOIC EPIDERMAL NECROLYSIS
 SJS less severe variant of TEN
 H/O medication use and M.pneumoniae 
sulfonamides, penicillins, anticonvulsants, NSAIDs
in children; allopurinol, oxicams, nevirapine in
adults
 Oral – extensive oral ulceration with hemorrhagic
crusts on the vermillion border. Localised in the
epidermis

12. PLASMA CELL STOMATITIS
 Brightly erythematous macular areas + ulcers
(sometimes) + swollen and edematous gingiva +
pain, sensitivity & bleeding + angular chelitis,
fissuring, dry atrophic lips (sometimes
 Site – marginal & attached gingiva, alveolar
mucosa, max and man sulcus or buccal mucosa

13. RECURRENT APHTHOUS
STOMATITIS
 RAS Minor – Prodromal brurning or sensation of a
small bump 2-48hrs before ulcers  small white
papule forms (round, symmetric, & shallow)
ulcerates , gradually enlarges (0.3-1 cm) 48-72hrs
 begin healing  healing without scarring 10-
14days
 RAS Major – >1cm + become confuent 
extremely painful, interfering with speech & eating
 heal after weeks or months with scars 
decreased mobility of tongue & uvula
 Herpetiform – More than 10 small punctate ulcer +
<5mm + scattered over large portions of the oral
mucosa

14. BEHÇET’S SYNDROME
 Diagnostic criteria
1. Oral, ocular, genital lesion – 2 points
2. Skin lesions, neurologic & vascular
manifestation – 1 point
3. Positive pathergy test (optional) – 1 point
4 or more points – strongly associated

15. PEMPHIGUS VULGARIS
 Classic bulla on a non inflamed base/ shallow
irregular erosions & ulcers  thin epithelium
peels away in irregular pattern – denuded base 
extend peripherally for weeks
 Site – buccal mucosa often in areas of trauma
along occlusal plane, palatal mucosa, gingiva
 Candidiasis may mask

16. PARANEOPLASTIC
PEMPHIGUS
 Rapid onset + Severe blistering & erosions +
severe oral & conjuctival lesions + lesions in
palms & soles (characteristic) + respiratory
epithelium (severe)  continue to progress over
weeks to months
 Oral – inflamed & necrotic with large erosions
covering the lips, tongue & soft palate +
hemorrhagic crusts on lips(characteristic)

17. PEMPHIGUS VEGETANS
Gingival lesions may be
1. Lace-like ulcers with a purulent surface on a red
base
2. Granular or cobblestone appearance

18. BULLOUS PEMPHIGOID
 Tense blister on an inflamed base + urticarial
plaques in scalp, abdomen, extremities, axilla &
groin + pruritis  self limiting last months to
years
 1 episode or recurrence
 Oral (10-20%) – smaller, form slowly & less
painful than P.vegetans + desquamative gingivitis
(sometimes)  early remission than mucous
membrane pemphigoid

19. MUCOUS MEMBRANE
PEMPHIGOID (CICATRICIAL)
 Older than 50 yrs
 F 2x> M
 Oral (80%) – Desquamative gingivitis (most common)
+ intact vesicles/ nonspecific appearing erythema &
erosions  scars rarely
 Eye – Conjuctiva (2nd common) – symblepharon;
corneal damage, progressive scarring  blindness
 Genital mucosa – pain & sexual dysfunction
 Laryngeal – pain hoarseness, difficulty in breathing 
death due to asphyxiation
 Esophageal – dysphagia  debilitation & death
 Skin lesions (20-30%) – head & neck region

20. LAD & BULLOUS DISEASE OF
CHILDHOOD
 Annular pruritic papules & blisters  ‘cluster of
jewel’
 Oral (70%) – blisters, erosions & ulcers of the
mucosa accompanied by desquamative gingivitis

21. TRAUMATIC INJURIES
CAUSING ULCERATIONS
 Acute ulceration & necrosis of the mucosa + h/o
trauma
 Electrical burns – charred & dry appearing 
sloughs  excessive bleeding when underlying
structures exposed
 Burns from hot foods & beverages – small &
localised to hard palatal mucosa or lips +
tenderness & erythema  ulcers within hours 
several days to heal
 Ulcers from vascular compromise – necrotising
sialometaplasia & vasculitic lesions – last for weeks
or months

22. TRAUMATIC ULCERATIVE
GRANULOMA
 Congenital incapacity to sense pain
 Children – anterior, ventral or dorsal tongue
associated with erupting max & man inciors
 Adults – posterior & lateral aspect of tongue
 Ulcers - Painless + clearly punched out +
surrounding erythema & keratosis (if present for
weeks or months), >0.5cm

23. REF: MICHAEL GLICK,BURKET’S ORAL
MEDICINE 12 TH EDITION