18 - Oral Ulcers Flashcards
What is aphthous stomatitis?
It is a recurrent aphthous ulcer or canker sore. It affects 20% of the population
What is the etiology of aphthous stomatitis?
It affects the T lymphocyte-mediated by the autoimmune condition.
How do we determine whether or not it is a erythroplakia or leukoplakia?
Through a biopsy.
How does aphthous stomatitis often start as?
Starts as an erythematous macule which develops into an ulcer. It is also covered with a fibrinous membrane
What are the 3 clinical presentations of aphthous stomatitis?
1.) Minor
2.) Major
3.) Herpetiform
How does an aphthous stomatitis present itself in the minor category?
1.) Single or multiple
2.) 3-10mm
3.) Heals in 7-10 days without scarring
4.) Non-keratinized tissue
How does an aphthous stomatitis present itself in the major category?
1.) Up to several centimeters
2.) Heal over several weeks (2-6 weeks), with scarring
3.) non-keratinized tissue
How does an aphthous stomatitis present itself in the herpetiform category?
1.) Clusters of hundreds of ulcers
2.) Not viral, despite name
3.) Heals in 7-10 days
4.) Small in size 1-3mm
In what type of mucosal surface do aphthous stomatitis usually present itself?
In the lining mucosa:
- lips
- soft palate
- cheeks
- oropharynx
What are some triggers to aphthous stomatitis?
- Stress
- Minor trauma
- Genetics
- Dietary triggers: gluten & milk proteins
What are the 2 diseases in which aphthous stomatitis can give rise to?
1.) Behcet’s disease
2.) Crohn’s disease (inflammatory bowel disease)
Where can Behcet’s disease typically present itself?
- As an oral ulcer
- genital ulcer
- Eye lesion
- skin lesion
- positive pathergy
What are the criteria for Behcet’s disease?
If it has recurrent oral ulcerations + 2 of the following:
- Recurrent genital ulcerations
- eye lesions (uveitis)
- skin lesions (erythema nodosum)
- Positive “parthergy test”, interpreted by a physician
What is Behcet’s disease?
- It is a systemic autoimmune disorder and is treated with systemic immunomodulatory medications
- More common in people of eastern Mediterranean countries
What is Crohn’s disease?
It is an inflammatory bowel disease which often oral ulcers will parallel the insteinal manifestations
How is Crohn’s disease treated?
Treated with systemic immunomodulatories
What are the oral manifestations of Crohn’s disease?
1.) Aphthous stomatitis
2.) Healing and fibrosis: cobblestone appearance
How is Aphthous stomatitis managed?
1.) Rule out aforementioned systemic disease
2.) Rule out predisposing factors: test for micronutrient deficiencies
3.) Therapeutic intervention:
- pain control
- covering agents
- anti-inflammatory agents
- systemic immunomodulatory medications
What pain control management can trigger aphthous stomatitis
5% lidocaine ointment
What covering agent can trigger aphthous ulcers?
orabase and zilactin film
What anti-inflammatory agent can trigger aphthous ulcer?
Topical corticosteroids (mainstay of treatment)
What systemic immunomodulatory medication can trigger aphthous ulcers?
1.) Prednisone, thalidomide
What is lichen planus?
It is an immune ( T-lymphocyte) mediated condition. It is directed at an unknown antigen in the epithelium.
*typically limited to the mouth.
How is lichen planus characterized as?
By a pruritic (itchy, bumpy papule), papulosquamous rash, as well as oral lesions
In who does lichen planus affect the most?
More common in women. Prevalence of 0.1-2% of people
How does lichen planus present itself orally?
- As a red and white tissue changes
- typically found in the buccal mucosa
- can be limited to the gingival tissues
What is Wickham’s striae in Lichen Planus?
It is the appearance of lacey, white striations.
What is desquamative gingitivitis?
It is the irritated, sloughing appearance of the gingival tissues (gingivitis-like)
What are the 2 main forms of Lichen planus?
1.) Reticular Lichen planus (more benign)
2.) Erosive lichen planus (more soreness)
What are the other forms of lichen planus?
- papular
- plaque-like
-atrophic - bullous
What are the other conditions that can result in lichen planus appearing lesions (lichenoid appearance)?
1.) Lichenoid drug reaction
2.) Lichenoid amalgam reaction
3.) Hepatitis C
4.) Graft-versus host disease
5.) Systemic lupus erythematosus
What is the most common presentation of lichen planus?
Reticular Lichen Planus
What are the characteristics of Reticular Lichen planus?
- Characterized by Wickham’s striae
- Generally asymptomatic
- Rule out superimposed
What does the histology of lichen planus appear like?
1.) Liquefactive degeneration
2.) Hyperkeratosis
3.) Saw-toothed reted ridge
4.) Subepithelial band of lymphocytes
What are the treatments used for lichen planus?
1.) Rule out any possible causes (lichenoid drug reaction, contact sensitivity)
- NSAIDs are common cause of drug reaction
2.) Topical corticosteroids (maintaining good oral hygiene)
3.) Chlorhexidine. For superimposed infections
What is the prognosis of lichen planus?
- Chronic condition, no cure but is well-managed.
- no symptoms = no tx required but follow-up is still needed
- slight increase risk of oral cancer.
What is pemphigus vulgaris?
It is a life-threatening autoimmune condition.
- It is due to Type II hypersensitivity attack against INTERCELLULAR connections
Is more prone to having pemphigus vulgaris?
1.) Males/Females are equal
2.) 4th-6th decade
3.) Rare condition (1-2 in a million)
What are characteristics of pemphigus vulgaris?
1.) Oral lesions are first to show, last to go.
2.) Has bullae (big blister appearance) on the skin & mucous membranes
3.) Hard to visualize oral vesicles, as they tend to break quickly
4.) Uncommonly affects the eyes, unlike mucous membrane pemphigoid
What is Nikolsky’s sign?
It is a bulla that develops with shearing or pressing appearance.
It is a slight pressure of superficial mucosa that leads to sloughing and exfoliation
How do we diagnose pemphigus vulgaris?
1.) 2 separate biopsies: first is a routine, the second is immunofluorescence
2.) Requires an immunofluorescence to help differentiate from other conditions
What are some treatments for pemphigus vulgaris?
1.) Referral to the dermatologist
2.) Systemic medications required
3.) Prednisone and azathioprine are first line of defense
What is the prognosis for pemphigus vulgaris?
1.) Poor without treatment (people can die if not treated properly)
2.) Fair with medications (have many side effects to the medication)
What is mucous membrane pemphigoid?
It is known to be a cicatricial (tendency to cause scarring) pemphigoid. It is an autoimmune condition.
What are the characteristics of Mucous Membrane pemphigoid?
1.) It is a type II hypersensitivity attack due to SUBEPITHELIAL conditions.
2.) Antibody-mediated
3.) Different from pemphigus vulgaris towards which conditions it affects
Who is more likely to demonstrate symptoms of mucous membrane pemphigoid?
1.) Females>males
2.) 6th to 7th decade: older than pemphigus
3.) More common than pemphigus vulgaris
What are some clinical features of Mucous membrane pemphigoid?
1.) Occular involvement
- blindness can develop
- 25% have ocular lesions
2.) Can involve other mucosal surfaces: genital surfaces
3.) Any oral surfaces
4.) Superficial erosion and sloughing of tissue
5.) Often erythematous
6.) May present gingival complications: desquamative gingitivitis
Where can desquamative gingitivits be seen in?
1.) Lichen planus: most common
2.) MMP: 2nd most common
3.) Pemphigus vulgaris: least common
What is the diagnosis of Mucous Membrane Pemphigoid?
1.) routine microscopy
2.) Immunofluorescence.
Why is immunofluorescence used for mucous membrane pemphigoid ?
Because there are several other conditions that can present as an MMP. Immunofluorescence is required
What are some treatments for mucous membrane pemphigoid?
1.) Topical corticosteroids (limit oral involvement)
2.) Referral to the ophthalmologist, to assess for ocular involvement
What is the prognosis for mucous membrane pemphigoid?
1.) Prognosis: Fair, then pemphigus vugris
2.) Chronic condition
3.) Risk of blindness if not treated
What is the difference between pemphigus vulgaris and mucous membrane pemphigoid?
The pemphigus vulgaris has an intraepithelial split, while the membranous membrane pemphigoid has a subepithelial split.
What is the etiology of an erythema multiforme?
1.) Possibly from an allergic reaction
What may trigger erythema multiforme?
1.) Herpes Simplex Virus
2.) Mycoplasma pneumonia
What are the demographics of erythema multiforme?
Seen more in younger patients and males > females
What are the two varieties of erythema multiforme?
EM Minor and EM Major
What encompasses the Erythema Multiforme minor?
1.) It has a limited involvement
2.) 1 mucosal site
What encompasses the Erythema Multiforme major?
Mainly involved with 2 or mucosal sites
In what locations can we typically find Erythema Multiforme?
1.) In the lips (hemorrhagic crusting)
2.) Buccal mucosa
3.) Tagetoid lesions on the skin
Erythema Multiforme has a ________ onset.
Sudden onset
What association do oral lesions have with erythema multiforme?
1.) weight loss
2.) dehydration
3.) Difficulty eating and drinking
What are the treatment and prognosis for erythema multiforme?
1.) Self-limited generally
2.) if due to HSV, consider prophylactic antivirals
What is paraneoplastic pemphigus?
It is a pemphigus vulgaris appearing lesion induced by neoplasms.
What are two examples of pemphigus vulgaris appearing lesions?
1.) Lymphomas
2.) Leukemia
- patients with advanced cancers
Why do paraneoplastic pemphigus lesions appear?
Due to the cross-reactivity of antibodies attacking cancer cells
Who is most likely to show symptoms of paraneoplastic pemphigus ?
Older patients (rather than pemphigus vulgaris)
What are the treatment options for paraneoplastic pemphigus?
Treat the underlying neoplasm
What is the prognosis of paraneoplastic pemphigus?
Extremely poor (due to neoplasm nature of the lesion)
