12. Ulcerative lesions Flashcards by paddington 26

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.

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What is an erosion?

More superficial- not all layers of the epithelium have been lost.
No exposure of the connective tissue.

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How can ulcerations be divided?

Primary- de novo
Secndary to vesiculo-bullous diseases- vesicles rupture exposing the connective tissue

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What is the definition of vesicle?

A collection of clear fluid within or just beneath the epithelium measuring up to 5mm in diameter.

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What is the definition of bulla?

A collection of clear fluid within or just beneath the epithelium larger than 5mm in diameter.

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What are mechanisms of ulcer formation?

Trauma
Ischaemia- eg, endarteritis obliterans
Altered cellular metabolism
GI disease
Cytopathic- viruses
Immunological
Neoplastic
Idiopathic

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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

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How long does the epithelium take to regenerate itself, and the connective tissue?

Epithelium- 11 days
Connective tissue- 20 to 40 days

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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.

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What are the 6 types of trauma?

Mechanical
Chemical
Thermal
Irradiation
Factitious
Eosinophilic ulcer

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What are examples of mechanical trauma?

Denture irritation
Biting
Sharp teeth
Toothbrush injury
External irritant
Removing cotton rolls without wetting

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What are examples of chemical trauma?

Irritants and caustic agents
Mouth washes
Antiseptics
Aspirin

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How does radiation cause ulcer?

Radiation kills fast dividing cells so also the epithelium. The epithelium becomes so thin that it may become atrophic.

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What is factitious cause of ulceration?

Stress
Anxiety
Hypochondria
Malingering
Munchhausen syndrome

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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.

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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

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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

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What are 4 bacterial infections that involve ulceration?

Acute ulcerative gingivitis
Tuberculosis
Syphilis
Actinomycosis

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What are 3 fungal infections that cause ulceration?

Histoplasmosis
Blastomycosis
Candidosis

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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.

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What type of ulcer does a Tb ulcer create?

One with deep, undermined edges

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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

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What are the 3 types of RAS?

Minor apthous ulcers
Major apthous ulcers
Herptiform ulcers

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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

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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