Non-Infective Stomatitis Flashcards
Recurrent Aphthous Stomatitis is often precipitated by what? How do we know?
Trauma or emotional stress
Immunologic cause: T-cell mediated
Are Recurrent Aphthous Stomatitis (RAS) genetic?
Specific histocompatibility antigens have been associated, indicating a possible genetic predisposition
What percentage of aphthous ulcer are minor aphthae?
80%
In what patient’s do minor aphthae most commonly appear?
Affect females more than males
Begin to develop in childhood or adolescence
What location of the oral cavity are minor aphthae found?
Almost exclusively on moveable mucosa (not covering bone)
- Most often occur on buccal and labial mucosa
Symptoms and presentation of minor aphthae
Painful tan ulcers with erythematous borders
Prodromal symptoms of burning, itching
Less than 1.5 cm
Treatment of minor aphthae
Heal spontaneously in 7 to 14 days without scarring
Recurrence rate is variable
What percentage of aphthous ulcers are major aphthae?
10%
Another name for Major aphthae?
Sutton’s disease
What patient’s have major aphthae more commonly?
Onset in adolescence
Location and presentation of Major aphthae
Most commonly affect soft palate, tonsillar fauces or pharyngeal mucosa
- 1.5 to 3+ cm, deeper than minor aphthae
Treatment of major aphthae
Can take 2-6 weeks to heal, may cause scarring
Recurrent episodes
What percentage of aphthous ulcers are Herpetiform aphthae
10%
What patient’s have Herpetiform aphthae more commonly?
Onset in adulthood
Female prdeominance
Location and presentation of Herpetiform aphthae
- Resemble ulcers caused by herpes simplex virus
- 1 to 3 mm ulcers occurring in clusters
- No systemic signs or symptoms, as in primary herpetic gingivostomatitis
- Occur anywhere in the oral cavity (vs. herpes simplex ulcerations, which are usually on mucosa covering bone)
Treatment of Herpetiform aphthae
Heal in 7 to 10 days
Diagnosis of Aphthous ulcers is made how?
From clinical presentation and from exclusion of other diseases
Topical steroids
- Dexamethasone elixir 0.01% (Shouldn’t swallow)
- Fluocinonide (Lidex) gel 0.05%
Chlorhexidine
Amlexanox 5% oral paste (Aphthasol)
“pseudo” aphthae characteristics
Associated with systemic diseases
GI malabsorption diseases (Crohn’s disease)
Vitamin deficiencies: iron, folate, B1, 2,6,12
What is Behcet’s syndrome
Chronic, recurrent disease resulting from a systemic vasculitis
Explain the oral presentation of Behcet’s syndrome
Similar to aphthous ulcers
- 6 or more, commonly involving soft palate and oropharynx
- Ragged borders and variation in size
- Surrounded by diffuse erythema
Pathogenesis of Lichen planus
immune mediated through T Cells, slight association with hepatitis C.
Cause unknown
What patients does Lichen planus affect more commonly
Middle-aged adults
Women represent about 2/3 of patients
Location of Lichen Planus
Affects both skin and oral mucosa
Tends to affect tissue that are irritated or traumatized: Koebner phenomenon
Symptoms and presentation of Lichen Planus
Skin: purple, Pruritic, polygonal papules (PPP)
Orally: Reticular/erosive/bullous/plaque-like clinical appearance
Most common type of lichen planus
is reticular characterized by Wickham’s striae
Erosive is characterized by redness and/or ulceration and symptoms
T or F, Lichen planus is most common cause of desquamative gingivitis
True
Explain the difference between Lichen Planus and Lichenoid reactions
Lichenoid reactions are lesions that look like LP but aren’t: Assoc with systemic drugs, hypersensitivity reactions, esp cinnamon and amalgam and epithelial dysplasia
Treatment for Lichen Planus
Topical steroids
- Fluocinonide gel 0.05% applied topically 3-4x daily
- Clobetasol gel 0.05% applied topically twice a day
Name the 4 Pemphigus conditions
Blisters (autoimmune)
- Vulgaris (Most common)
- Vegetans
- Erythematosus
- Foliaceus
What group of people does Pemphigus most commonly affect
Often in adults age 40’s and 50’s
What is Pemphigus
Severe progressive autoimmune disease that affects the skin and mucous membranes: oral lesions are usually the first to appear
- Circulating autoantibodies to components of epithelial cell attachments: desmosomes (desmoglein 3)
Clinical features of Pemphigus
- Epithelial desquamation produces painful superficial erosions and ulcerations
- Affects most mucosal surfaces but often affects gingiva producing chronic desquamative gingivitis
- You can induce epithelial separation by manipulation tissue or producing lateral pressure (+ Nikolski sign)
- Rarely see blisters since they break early
Diagnosis of Pemphigus
Biopsy shows characteristic suprabasilar epithelial separation with acantholysis. Direct immunofluorescence demonstrates autoantibodies (usually IgG and C3) around the individual keratinocytes (Chicekn coop wire)
Treatment of Pemphigus
Systemic steroids +- steroid sparing drugs
What are paraneoplastic pemphigus
Affects patients who have a neoplasm, usually lymphoma or leukemia
Very serious, high morbidity and mortality
What is Benign mucous membrane pemphigoid
Chronic, autoimmune disease where patients produce antibodies against the structural proteins in their hemidesmosomes which anchor the basal keratinocytes to the underlying connective tissue, is a family of realted disorders where antibodies are not directed against a single antigen, but many different antigens that comprise the hemidesmosomes.
Patients most commonly found with Benign mucous membrane pemphigoid
Average age 50-60,
3x more common in females
More common than pemphigus vulgaris
What location is Benign mucous membrane pemphigoid found
Affects oral, ocular, and genital mucous +- larynx and esophagus and +- skin
*Most commonly affected site is gingiva where it produces desquamative gingivitis
Ocular scarring can progress to blindness if untreated.
Clinical features of Benign mucous membrane pemphigoid
Similar to pemphigus but not as severe
- Tissue desquamation produces erosions and ulcers (+ Nikolski sign)
Diagnosis of Benign mucous membrane pemphigoid
Biopsy shows characteristic subepithelial separation
Direct IF shows autoantibodies at junction of epithelium and connective tissue
Treatment of Benign mucous membrane pemphigoid
Ophthalmologic consultation
Topical or systemic steroids
Desquamative Gingivitis can be a clinical manifestation of what?
Lichen Planus
Pemphigus Vulgaris
Mucous membrane pemphigoid
Allergic reaction (toothpaste, ie. tartar control, cinnamon, prservatives)
What is Erythema multiforme
Acute onset
Immune mediated blistering mucocutaneous condition
Most often following systemic medications or often as a post infectious process, esp post viral
- Sometimes a cause cannot be identified.
What locations does Erythema multiforme
Affects skin and mucous membranes
Rarely only the mouth
Clinical features of Erythema multiforme
Young adults 20s and 30s
Men affected more
Often follows a bacterial or viral infection or drug exposure.
Symptoms of Erythema multiforme
Prodromal symptoms: Fever, malaise, headache, cough, sore throat
Treatment of Erythema multiforme
Self-limiting 2 to 6 weeks
- 20% recurrence rate
Erythema Multiforme: Skin
- Skin lesions highly variable “multiforme”
- Characteristic target or “bull’s eye” lesions
- Can occur without oral lesions
- Classically affects palms and soles
Erythema Multiforme: Mucosa
- Oral ulcers with erythema and irregular borders
- Lips, labial mucosa, tongue, floor of mouth, soft palate
- Crusting and bleeding at vermillion zone of lips
Erythema Multiforme: Steven-Johnson syndrome
- More severe form of erythema multiforme
- Extensive mucosal ulceration
- Also effects genital and ocular mucosa
- Usually triggered by medications
- Can affect internal organs and can be life threatening
Erythema Multiforme: Toxic epidermal necrolysis
- Most severe form of erythema multiforme
- Triggered by drug exposure
- Female predilection
- Diffuse sloughing of skin and mucosal surfaces
How is Erythema Multiforme diagnosed
Can be diagnosed clinically
Initiating factor should be identified
Topical and high dose systemic steroids
Geographic tongue affects what portions of the tongue
Primarily affects dorsal and lateral borders of tongue
Characteristics of geographic tongue
Depapillated areas that are erythematous or normal colored with characteristic yellow-white borders that marginate the lesions
What oral symptoms do patients with Systemic Sclerosis “scleroderma” experience
Oral: Micrstomia in 70%, dysphagia, +- xerostomia, DIFFUSE WIDENING OF PDL, resorption of ramus or condyle or coronoide
Oral symptoms experienced by patients with Graft vs Host disease
Most have oral lesions that can appear lichenoid and painful
