immunopathologic diseases part ii€¦ · • clinical: deep red gingival enlargement, generalized...
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IMMUNOPATHOLOGICDISEASES
PART II
IMMUNOGLOBULIN MEDIATED DISEASES
Plasma Cell Gingivitis
• Hypersensitivity to flavoring agents or resins within chewing gum
• Clinical: Deep red gingival enlargement, generalized
• Microscopic: Diffuse sheets of plasma cells in the submucosal gingival connective tissues
• Tx: Withdraw allergen, topical steroid
Plasma Cell Gingivitis
Immediate HypersensitivityAllergic Stomatitis
• An IgE mediated reaction to foods and drugs• Red lesions and vesicular eruptions, may have
cutaneous lesions as well• Painful, burning• Microscopic: nonspecific inflammation, may
have eosinophils• Common Allergens:
– Penicillin, other antibiotics– Sulfa drugs (erythema multiforme-like lesions)– Shell fish
• Tx: Antihistamines
Allergic Stomatitis
Shellfish allergens
Angio(neurotic) Edema• Antibody Mediated: IgG or IgE complexed with
antigen, facial connective tissues>histamine release, diffuse facial and prominent soft lip swelling– Managed with steroid and antihistamine therapy
• Genetic defect in Complement C1 esterase inhibitor with resultant urticaria of skin and facial edema, ofter precipitated by surgery or trauma
Angioedema
Mucous Membrane Pemphigoid• Differs from Bullous Pemphigoid• Marked Female>Male• Midlife – Elderly• Gingiva• Ig Mediated• Basement Membrane Antigens• DIF – basement Membrane Igs• Sub-basilar Clefting
Mucous Membrane Pemphigoid
Mucous Membrane Pemphigoid
symblepheron
Mucous Membrane PemphigoidHistopathology IgG anti-BM, DIF
SalivaryAnti-BM
Pemphigus Vulgaris
• Midlife-Elderly• Oral lesions precede skin• Can be fatal• Soft Palate/Fauces• Ig Mediated• Desmoglein 3 Target Antigen• DIF – perikeratinocyte membrane
Igs• Suprabasilar Cleft
Pemphigus VulgarisOral Lesions Cutaneous
Pemphigus
Pemphigus vulgaris
Suprabasilar split
Pemphigus VulgarisHistopathology IgG Antibodies - DIF
Erythema Multiforme
• Teens/Young Adults• Hemorrhagic Lip Involvement• Immune Complex Mediated
– Drugs (sulfa)– Postherpetic
• DIF – perivascular complement• Keratinocyte Necrosis
Erythema MultiformeLip Involvement Cutaneous Lesions
EM – Herpetiform Ulcers
Erythema MultiformePerivascular C3, DIF
Erythema Multiforme
EM 1 week post Prednisone
Epidermolysis Bullosa
• Mutation type VII Collagen• Enamel Hypoplasia• Disfigurement• Fatal Outcome
Epidermolysis Bullosa Acquisita
• Skin Lesions• Oral Lesions very rare• DIF – Basement Membrane• Subepithelial Clefting• Target Antigen – type IV collagen
Epidermolysis Bullosa
Epidermolysis BullosaDental Defects Histopathology
Paraneoplastic Pemphigus
• Lymphoma, Castleman’s Disease• Other malignancies• Lesions resemble Erythema
Multiforme• DIF – perikeratinocyte and BM• Antigen – Multiple plaque proteins,
desmoplakins
Paraneoplastic Pemphigus
Paraneoplastic Pemphigus
Perikeratinocyte, BM Igs
Pyostomatitis Vegetans
• Ulcerative Colitis, Crohn’s Disease• Serpentine Erosions• Intraepithelial Eosinophilic Abscesses• DIF – perikeratinocyte membrane Igs• Pyodermatitis Vegetans
Pyostomatitis Vegetans
Pyostomatitis VegetansHistopathology Perikeratinocyte Igs
Systemic Sclerosis (Scleroderma)• Collagen-Immune disease characterized by
progressive fibrosis• Females>Males• Mask-like facies• Limited opening• Dysgeusia (esophageal fibrosis)• CREST syndrome
– Calcinosis, Raynaud’s phenomenon, esophageal stricture, sclerodactyly, Telangiectasia
• Radiographic Features– Widening of the periodontal ligament spaces– Pregonial notching of the mandible
Radiologic Manifestations of SclerodermaAntegonial Notch
Scleroderma, wide PDL
Systemic Sclerosis (Scleroderma)
CREST (calcinosis, raynauds, esophageal stricture, telangiectasia
Orofacial Granulomatosis• Noncaseating granulomatous inflammation• Lesions are of unknown etiology and may be
localized or generalized• Some orofacial granulomas are a component of
systemic disease• Subtypes:
– Sarcoidosis– Crohn’s Disease– Melkerson Rosenthal Syndrome– Cheilitis Granulomatosa
Melkerson Rosenthal Syndrome
Cheilitis granulomatosa
Fissured tongue Oral granulomas
Cheilitis Granulomatosa
Crohn’s Disease• Regional enteritis• Young Adult to Mid Life onset• Ilium/Colonic lesions, segmental, chronic
inflammatory foci in gut wall, some with granulomatous type inflammation
• Diarrhea alternating with constipation, abdominal cramping
• Oral Lesions: Nodular submucosal masses comprised of noncaseating granulomas
Crohn’s Disease
Wegener’s Granulomatosis
• Vasculitis, Fibrinoid Necrosis• Palatal perforation• Gingival “strawberry gums”• Lung, Renal Lesions• ANCA (antineutrophil cytoplasmic Abs)• Potentially Fatal• Chemotherapy (Cytoxan, prednisone)
Wegener’s Granulomatosis
Ulceration“Strawberry Gums”
Nasal Mass
Treatment of Bullous Lesions• Systemic Steroids
– 40-60 mg Prednisone, 7 days, taper for 3– Medrol Dosepak
• Topical Steroid Mouth Rinse– Dexamethasone elixer (0.1mg/ml)
• Topical Steroid Gels.05% Fluocinonide (Lidex gel).05% Clobetasol (Temovate gel).05% Halobetasol (Ultravate gel)
Systemic Steroids
• Medrol Dosepak –recommend two, take both, double doses
• Prednisone 10 mg40-60 mg/day for 7 days20-40 mg/day for 2 days10 mg/day for 2 days