12. Ulcerative lesions Flashcards
What is an ulcer?
A break in the continuity of the skin or mucous membrane leaving an inflamed area of exposed connective tissue.
There is loss of the whole thickness of the epithelium.
What is an erosion?
More superficial- not all layers of the epithelium have been lost.
No exposure of the connective tissue.
How can ulcerations be divided?
Primary- de novo
Secndary to vesiculo-bullous diseases- vesicles rupture exposing the connective tissue
What is the definition of vesicle?
A collection of clear fluid within or just beneath the epithelium measuring up to 5mm in diameter.
What is the definition of bulla?
A collection of clear fluid within or just beneath the epithelium larger than 5mm in diameter.
What are mechanisms of ulcer formation?
Trauma
Ischaemia- eg, endarteritis obliterans
Altered cellular metabolism
GI disease
Cytopathic- viruses
Immunological
Neoplastic
Idiopathic
What do you do if a patient has traumatic ulceration?
Identify the cause- the cause must fit the size and shape of the ulcer
Removing the cause must show improvement in 10 days
If not, take a biopsy
How long does the epithelium take to regenerate itself, and the connective tissue?
Epithelium- 11 days
Connective tissue- 20 to 40 days
What is the histology of traumatic ulcer?
Non-specific chronic ulceration as you are exposing the connective tissue to all the pathogens in the mucosa.
Epithelium next to the ulcer may show increased number of mitoses.
What are the 6 types of trauma?
Mechanical
Chemical
Thermal
Irradiation
Factitious
Eosinophilic ulcer
What are examples of mechanical trauma?
Denture irritation
Biting
Sharp teeth
Toothbrush injury
External irritant
Removing cotton rolls without wetting
What are examples of chemical trauma?
Irritants and caustic agents
Mouth washes
Antiseptics
Aspirin
How does radiation cause ulcer?
Radiation kills fast dividing cells so also the epithelium. The epithelium becomes so thin that it may become atrophic.
What is factitious cause of ulceration?
Stress
Anxiety
Hypochondria
Malingering
Munchhausen syndrome
What is an eosinophilic ulcer?
Normally occurs in the tongue, very large ulcers that do not heal very quickly. Happens when the muscle becomes traumatised.
Full of eosinophils and histiocytes which are CD68 positive.
Which disease is eosinophilic ulcer found in?
Riga Fede disease in infants- the children have premature teeth and the ventral surface of the tongue rubs over them and gets ulcers
What is the histology of traumatic ulceration?
Break in the epithelium
Large amount of chronic inflammatory tissue- plasma cells, macrophages, lymphocytes
Coagulated formation of granulation tissue
Formation of new blood vessels and endothelial cells
What are 4 bacterial infections that involve ulceration?
Acute ulcerative gingivitis
Tuberculosis
Syphilis
Actinomycosis
What are 3 fungal infections that cause ulceration?
Histoplasmosis
Blastomycosis
Candidosis
What are the 3 stages of syphilis and what do they involve?
Primary- chancre- small sore that appears where the bacteria first enters the body
Secondary- snail ulcers
Tertiary- gumma, syphilitic leukoplakia- syphilitic leukoplakia is a white lesion.
Gumma is inflammatory response of arteries. Can involve endarteritis obliterans.
What type of ulcer does a Tb ulcer create?
One with deep, undermined edges
What is the histology of TB ulcer?
Lack of epithelium
Inflammatory infiltration
TB granulomas- caseating
Giant cells with multiple nuclei in periphery
Epitheiloid cells
Lymphocytes
What are the 3 types of RAS?
Minor apthous ulcers
Major apthous ulcers
Herptiform ulcers
What is Behcet’s syndrome?
RAS plus 2 of the following:-
- skin lesions
- genital ulcers
- eye lesions- uveitis
- skin hypersensitivity to needle puncture- pathergy test
What are 3 examples of idiopathic ulceration?
RAS
Behcet’s syndrome
Erythema migrans
What has Behcet’s got a strong genetic link to?
HLA-B51
Has silk road distribution
What are clinical features of RAS?
Onset in childhood
Recurrent
What does RAS ulcers look like?
Round or ovoid, yellow-greyish base, erythematous halo
What are the prodromal symptoms of RAS?
Soreness
burning
prickling sensation
erythematous macules 1 to 2 days before ulceration
What age do minor, major and herpetiform ulcers affect?
Minor- 10-19
Major- 10-19
Herpetiform- 20-29
How many ulcers are seen in minor, major and herpetiform?
Minor- 1-5
Major- 1-10
Herpetiform- 10-100
What is the size (mm) of minor, major and herpetiform ulcers?
Minor- less than 10mm
Major- larger than 10mm
Herpetiform- 1 to 2 coalescing
How long do minor, major and herptiform ulcers last for?
Minor- 7-14 days
Major- more than 30 days
Herpetiform- 10-30 days
Which sites do minor apthous ulcers affect most?
Lips, cheeks and tongue
Which sites do major apthous ulcers affect most?
Lips, cheeks, tongue, palate, pharynx
Which sites do herpetiform ulcers affect most?
Lips, tongue, cheeks, palate, pharynx, floor of mouth, gingiva
What are 4 reasons that RAS may occur?
Trauma
Stress
Associated with smoking cessation- perhaps related to keratinisation changes which occur when you stop smoking
Hypersensitivity to S.Sanguinis- some epithelial cells may have antigens that react to the antibodies of S.sanguinis
What disorders are RAS linked to?
Haemotological disorders- ferritin, folate and B12 deficiency
Gastrointestinal disorders- coeliac, Crohn’s and ulcerative colitis
Allergies- food allergies show increased levels of IgE
What is the histology of RAS in the pre-ulcerative stage?
Predominantly lymphocytic infiltration in the lamina propria and some in the epithelium.
What is the histology of RAS in the ulcerative stage?
Inflammatory infiltration, especially cytotoxic lymphocytes in the epithelium, ulceration.
What is the CD4 to CD8 count in the pre-ulcerative, ulcerative and healing stage?
2:1
1:10
10:1
What triggers the immune reaction in RAS?
Epithelial antigens triggering the reaction are unknown but are likely to be cross reacting streptococcal antigens.
What is the histology of erythema migrans?
Neutrophil infiltration in the borders of lesion
Chronic infiltrate in the centre
Desquamation of epithelium
No association with candida
What is primary ulceration in haematological disease due to?
Iron, folate and B12 deficiencies
What is secondary ulceration in haematological disease due to?
Secondary to gastrointestinal disorder where even if b12, iron and folate are present in the diet, they cannot be absorbed.
Eg, ulcerative colitis, Crohn’s disease, coeliac disease
What are reasons someone may be low in iron?
Poor nutritional diet
May have had chronic blood loss- menstrual, GI
Malaria
What are oral features when someone has iron deficiency?
Glossitis
Sore mouth
Ulceration
Angular stomatitis
Burning mouth
What is low folate due to?
Cannot store this so mostly due to nutritional deficiencies
Leads to anaemia
What are oral features of low folate?
Sore mouth, ulceration, angular stomatitis
What are causes of low B12?
Vegan diet
Malabsorption
Some drugs which interfere with its absorption such as neomycin and colchicine
Pernicious anaemia- autoimmune
What are oral features of B12 deficiency?
Glossitis, ulceration, beefy red tongue (Hunter’s glossitis)
What is ulcerative colitis?
Inflammatory bowel disease of the large intestine
What are the general symptoms of ulcerative colitis?
Intestinal ulcers
Pseudopolyp formation
Anaemia
Increased risk of colon carcinoma by 30 times
What are oral features of ulcerative colitis?
Chronic ulceration
Pyostomatitis vegetans- white or yellow pustules on erythematous base
Avoid NSAID
What are oral features of Crohn’s disease?
cobblestone appearance of oral mucosa
polypoid tags
linear ulcers
RAU
swelling of lips and cheeks
What is the cause of coeliac disease?
Genetic hypersensitivity to gluten’s gliadin in wheat, rye or barley leading to villous atrophy of jejunal mucosa, leading to malabsorption.
What are oral features of coeliac disease?
4-20% have RAU. Removal of gluten improves ulceration and villi in gut.
What are dermatological diseases that ulceration is associated with?
Lichen planus
Chronic lupus erythematous
Vesiculobullous diseases
What is the histology of Lichen planus?
Hyperkeratosis
Irregular acanthosis- saw-tooth rete ridges
Band like lympho-histiocytic infiltrate
Liquefaction or degeneration of basal cell layer
Presence of civatte hyaline bodies
What is the possible pathogenesis of lichen planus?
Damaged or modified keratinocytes
Altered keratinocyte antigenicity- HLA-DR
Ability to present antigens to T-lymphocytes
Induction of cell-mediated immune response
Differentiation of cytotoxic T-lymphocytes which causes basal cell damage
Cytokine release from Langerhans cells and keratinocytes
