Blood Blister In The Mouth

Sometimes you wake up in the morning and notice a black dot inside your mouth. You look closely into the mirror and notice that it looks like a blood-filled blister. Is it a serious problem?

It may be the first time you notice it, or it may have come and go for a few times before. Most likely the blood blister is caused by break of small blood vessels (capillaries) on the inner side of the mouth. If the bleeding continue, the lesion may enlarge. When the bleeding stops, the lesion will usually disappear within few days time. There may be slight pain or no pain at all.

       blood blister at inner cheek

This condition is usually benign, and is said to caused by minor trauma or injury to the oral mucosa. The trauma can be from chewing hard food, hot food, dentistry, brushing teeth, oral treatment, accidental self-biting during sleep etc. This condition is also called "angina bullosa hemorrhagica".

Nevertheless, you need to rule out whether you bleed abnormally easily or not. You need to check whether you have blood blisters elsewhere in the body other than inside the mouth. If you have easy bruising, easy bleeding from gum or nose and your wound is slow to clot after injury, you might need to check your blood for platelet count and coagulation profile. Low platelet (thrombocytopenia) can cause easy bleeding, which is not very uncommon.

Sometimes the blood blister could be "pyogenic granuloma", which is actually a bunch of abnormal capillaries present as a red nodule and can bleed easily. Compare to angina bullosa hemorrhagica, pyogenic granuloma can occur on the skin all over the body. Its size can be large and may not heal even within weeks. Pyogenic granuloma is more common in children while angina bullosa hemorrhagica is more common in older adult. 

       pyogenic granuloma

If the blood blister in your mouth come and go within few days, and you don't have any other problems such as fever or easy bleeding elsewhere, then it is probably angina bullosa hemorrhagica and is completely benign. If you are still worry, you should see a doctor and perhaps check your platelet and coagulation profile.

Hepatitis B in Pregnancy

If you are a female and you are a hepatitis B carrier, is it alright to become pregnant?

The answer is yes. However, you need to take extra precaution during pregnancy and delivery.

Hepatitis B is mainly transmitted through contact with blood, where it is present in high concentration. Other body fluids like saliva, semen, vaginal discharge etc contain less concentration of the virus.

First of all, the spouse of hepatitis B carrier need to check his hepatitis B virus and antibody status. If he is not a carrier and does not have the antibody, then he needs to get the 3 doses of hepatitis B vaccination at the interval of 0, 1, 6 months. When he gets the antibody, viral transmission during sexual intercourse with his carrier wife can be prevented. However, the antibody level may wean off with time and he should check its level regularly.

When a woman who is also a hepatitis B carrier conceive, pregnancy is to continue as usual. Examination and blood test are done to make sure that she does not already reach the stage of chronic liver damage.

If a woman with no known hepatitis B status first found to be infected during pregnancy, then the possibility of an acute infection need to be ruled out. If acute infection occurs in the first trimester, there is a 10% risk of transmission of virus to the baby. If it occurs in the third trimester, the risk is 80-90%. The incubation period of hepatitis B can range from 6 weeks to 6 months.

Generally, the risk of transmission of hepatitis B virus from a carrier mother to her baby is about 10-20%. If immunoprophylaxis (hepatitis B immunoglobulin - HBIG) is given to the baby soon after birth, the risk can be significantly reduced. Thus, every baby born by a hepatitis B carrier mother will receive a dose of HBIG and a dose of hepatitis B vaccine within 12 hours after birth. The vaccine need to be continued for another 2-3 doses later.

Normal vaginal delivery does not significantly increase the risk of hepatitis B virus transmission to the baby compare to Cesarean section. Breast feeding should be allowed and encouraged, as long as the baby get the HBIG and vaccination.

    Hepatitis B virus

If unfortunately the newborn is infected with hepatitis B virus, there is a high chance (90%) that the baby will become a carrier. Not everyone infected will become a carrier. For children between 1-5 years old, the chance to become a carrier is 30%, while for adults, the chance is about 5%. Nevertheless, hepatitis B virus usually does not cause other problems such as malformation or organ malfunction to the infected baby.

If you are not a hepatitis B carrier and would like to get  hepatitis B vaccination during pregnancy, you can do so as the vaccine is reported as safe when given during pregnancy.

Herpes Simplex 1 & 2

Herpes simplex is often regarded as a sexually-transmitted infection, but it is not necessarily so. There are 2 types of herpes simplex virus (HSV): HSV type 1 and HSV type 2.

HSV-1 is associated with infection around the mouth and face region, and is also referred to as "oral herpes" or cold sores. It is estimated that about 50% of population in the US has been exposed to HSV-1. Whereas HSV-2 mainly cause infection around the genital area called "genital herpes", and it is sexually-transmitted.. Nevertheless, sometimes HSV-1 can cause genital infection and HSV-2 can cause oral infection. 

     HSV-1: Cold sores

The signs of HSV infection are painful blisters around the skin/mucosa surface of the mouth (oral herpes) or genitalia (genital herpes) which can last 1-2 weeks, often associated with fever. These blisters will break and become ulcers. About 80% of herpes simplex infection however, are asymptomatic (no signs and symptoms).

HSV is transmitted through contact with infected oral or genital secretion, either through kissing, touching, sharing towels, sexual activity etc. Most people are infected with HSV-1 during childhood by close skin contact with infected adults. HSV-2 is mainly transmitted through sexual act. HSV-2 can also spread from an infected mother to the new born during vaginal birth. 

Once a person first get the infection (primary infection), the virus will stay dormant in his/her body forever and it can't be cured. However, the dormant (sleeping) viruses do not cause any problem unless they are "activated". When the viruses are activated, they can spread to other people who come into close contact with the sufferer. The virus reactivation is referred to "recurrence" or "outbreak". The recurrence may or may not produce visible skin lesion thus the sufferer may not even know that he/she has a recurrence. Pain in the skin usually precedes the eruption of skin lesion.

     HSV-2: Genital herpes

The frequency of recurrence varies, sometimes once a month, sometimes once in a few years. Generally the recurrence will be less severe, less frequent with shorter duration over the time as our body get the antibody against it. That means the first or primary infection should be the most severe. HSV-2 causes more frequent recurrence (typically 4-6x a year) compared to HSV-1. Some factors which may trigger the recurrence are emotional stress, fever, illness, sunburn, trauma, surgery and menstruation.

Diagnosis of HSV infection is often made from the history and skin lesion. It can be confirmed by taking swab from the lesion for culture or viral DNA (PCR) test. 

When there is no symptoms or lesions, measuring antibody level (IgG & IgM) through blood test can be done. The presence of IgM means recent or current infection whereas IgG means previous or past infection. Once infected, IgG will only appear in the blood after 2-12 weeks and will persist for life. Thus, it is wise to repeat a negative IgG result after 8-12 weeks if the exposure is there. IgM cannot distinguish HSV-1 and HSV-2 accurately and may cross react with other viruses, thus giving false positive results. The glycoproteinG based antibody test can distinguish both types of virus. However, generally HSV antibody tests do not give very accurate results.

    HSV blisters / vesicles

The blisters caused by HSV can disappear by itself without any treatment. However, anti-viral treatment (oral or cream) may lessen the severity and duration of the signs and symptoms. The anti-viral (eg. acyclovir 400mg tds / 200mg 5x/day) is best given early at the first sign of recurrence or within the first 5 days, for a duration of 5-10 days. Some doctors suggest daily low dose anti-viral medicine (suppressive therapy eg. acyclovir 400mg bd) to reduce the frequency and severity of recurrence, especially for those with recurrence more than 6 times a year.

To reduce the risk of spreading to others, avoid close personal contact and sexual activity during recurrence. The problem is, sometimes recurrence may not produce any skin lesion and no one will be aware of it. Thus, it is advisable to always use condom during sexual intercourse to minimize the transmission of genital herpes. The risk cannot be eradicated totally even when using condom because skin around the genitalia not covered by condom may also spread the virus.

HSV infection cannot be cured but can be controlled or prevented. It is not life-threatening if you are infected with it, unless you are immunocompromised (extremely low immunity).

Pap smear: When to start and What to expect?

Pap smear/test is a screening test used to detect early changes in cervical cancer. "Pap" is named after Dr George Papanicolaou. Before the cells in the cervix turn into cancer cells, they undergo a few pre-cancerous changes. If these changes can be picked up early, then treatment can be given and cervical cancer can be prevented.

The precancerous cell changes are called dysplasia or cervical intraepithelial neoplasia (CIN). CIN can be divided into mild (CIN 1), moderate (CIN 2) and severe (CIN 3). CIN 1 usually can go away on its own but it still can progress to CIN 2/3. CIN 2 and 3 are more serious and need further test.

Through Pap smear, a brush is used to sample cells around the cervix and viewed under a microscope. Liquid-based cytology is more accurate compared to the conventional Pap smear. It is best to do pap smear between 10-20 days after the first day of menstruation.

Pap smear schedule:

Start: Age 21, or 3 years after first vaginal intercourse

Stop: Age 70, and with 3 consecutive negative tests, and no abnormal test in prior 10 years.

Post total hysterectomy: discontinue if benign reasons & no high grade CIN

Interval:

• Conventional pap test: annually
• Liquid-based cytology (LC): every 2 years
• LC with negative HPV test: every 3 years

•  For conventional and LC, if age >= 30 years old with 3 consecutive negative Pap smears, can repeat in 2-3 years.

 Updated Oct 2012

The American Congress of Obstetricians and Gynecologists has updated its 2009 practice bulletin on cervical cancer screening; its guidelines generally align with those released earlier this year (2012) by the U.S. Preventive Services Task Force, the American Cancer Society, and other groups.

Among the recommendations for routine screening:

• Women under age 21 should not be screened, regardless of behavioral risk factors. 
• For those aged 21 to 29, cytology alone should be performed every 3 years.
• For women aged 30 to 65, cytology plus human papillomavirus co-testing every 5 years is preferred; however, cytology alone every 3 years is acceptable.
• Women should not be screened after age 65 provided they've previously had sufficient negative screening results and no history of cervical intraepithelial neoplasia grade 2 or higher.
• More frequent screening may be required for women who have a history of cervical cancer or CIN2 or higher, who are immunocompromised (including HIV-infected), or who were exposed to diethylstilbestrol in utero.

    Pap smear

The Bethesda System is often used to interpret pap smear's result. In this system, the term squamous intraepithelial lesion (SIL) is used instead of CIN. 

Pap smear result can either be:

• Negative (normal)

• Atypical squamous cells of undetermined significance (ASC-US)
• most common result
• usually indicate HPV infection which may normalize if infection is cleared

• Squamous intraepithelial lesion - low grade (LSIL)
• equivalent to mild dysplasia (CIN 1)
• may goes away without treatment
• may indicate mild precancerous change

• Squamous intraepithelial lesion - high grade (HSIL)
• more likely to progress to cancer
• equivalent to CIN 2,3 and carcinoma in-situ

• Atypical squamous cells, cannot exclude HSIL (ASC-H)
• not clearly HSIL but could be

• Atypical glandular cells  (AGC)
• suggest precancer cells

• Cancer
• abnormal cells may have spread deeper

Abnormal Pap smear results will require further tests, either repeat Pap smear, do HPV test or colposcopy. Biopsy or other minor intervention such as conization, cryocauterization, laser therapy, large-loop excision of the transformation zone or endometiral sampling may be needed.

      Follow up test for abnormal pap smear result

HPV and Cervical Cancer

Human Papillomavirus (HPV) is a common sexually transmitted infection. If you are sexually active, there is a 50% chance that you have already infected with HPV at some point of time. Most of the time HPV infection will not produce any symptoms and our body immune system can cure it by itself within 2 years time without any treatment (median 8 months). However, some infected people may have genital warts and for female, it may lead to pre-cancerous changes in the cervix. The pre-cancerous changes need further monitoring and possibly treatment.

           Human Papillomavirus

HPV has been widely discussed now because of its link to cervical cancer, though the risk is very small. Besides, HPV is also related to other types of cancer around genital area such as vagina, vulva, penis and anus. 

There are more than 100 types of different HPVs, however, only about 40 has clinical significance to human. Base on their risk to cause cancer, they can be divided into "high risk" type and "low risk" type. HPV type 16 and 18 are the most well known high risk type and both are associated with almost 70% of cervical cancer.

HPVs can infect both male and female equally. It can be transmitted from a person to another through direct contact during sexual intercourse. So if you start to have sex at early age, have multiple sexual partners or if your partner has multiple sexual partners, your risk of getting HPV infection is higher.

Most HPV infection is transient, but about 10% of women may have persistent infection. If the persistent HPV type is HPV 16/18, then the risk of developing cervical pre-cancerous changes is higher. It may progress to cervical cancer if left untreated.

Since long time ago Pap smear has been available as a screening tool for cervical cancer in female. Now Pap smear is still the most important screening test that save lives. Its accuracy is improved with the new liquid base cytology test, which is better than the conventional "scrape and spread on slide" test.

Not long ago, HPV DNA test is recommended as as "add-on" to Pap smear to further help the decision making for doctors in patients with abnormal pap smear result. HPV DNA test is not recommended routinely for women <30 years old unless the Pap smear shows abnormality. It cannot substitute Pap smear as the main cervical cancer screening tool. If the HPV DNA test is positive for high risk HPV type in a patient with "borderline" Pap smear result, then it may prompt further investigation.

      

    Changes in cervix caused by HPVs

HPV infection can be prevented through vaccine. Currently there are 2 types of vaccines available: Gardasil (HPV 6, 11, 16, 18) and Cevarix (HPV 16, 18). HPV 16 & 18 are the most common high risk HPV that account for almost 70% of cervical cancer. HPV 6 & 11 are low risk HPV that can only lead to genital warts.

These vaccines are given in 3 separate intramuscular doses (0, 1-2, 6 months apart). They are found to be 100% effective in preventing pre-cancerous cervix lesion caused by HPV 16 & 18. Thus it should be able to prevent 70% of cervical cancer (as HPV 16 & 18 cause 70% of cervical cancer). It is not 100% prevention from cervical cancer. There are other types of high risk HPVs and many other possible causes for cervical cancer. So Pap smear is still mandatory even after you have received Gardasil or Cervarix vaccination.

Vaccination is best given to girls/women before they are infected with HPV 16 & 18, or in other words, before having their first sex. It can be given as early as 9 years old up to over 40 years old. However, the earlier the better it is.