ulcerations Flashcards
Patient with chronic multiple lesions ?
-herpes simplex virus infection in immuno-supressed patient
-pemphigus
-subepithelial bullous dermatosis
Patient with acute multiple lesions ?
-Herpesvirus Infections
-Primary Herpes Simplex Virus Infections
-Coxsackievirus Infections
-Varicella-Zoster Virus Infection
-Erythema Multiforme
-Contact Allergic Stomatitis
-Oral Ulcers Secondary to Cancer Chemotherapy
-Acute Necrotizing Ulcerative Gingivitis
patient with recurring oral ulcerations ?
-aphthous ulcers
-behcets syndrome
-recurrent herpes simplex infection
Single ulcer?
-traumatic injuries
-traumatic ulcerative granuloma , eosionophillic ulcer of the tongue
-histoplasmosis
-blastomycosis
-mucormycosis
clinically , traumatic ulcers resemble what ?
aphthous ulcers
when should laboratory testing be done in traumatic ulcers?
- ulcer does not heal within a reasonable period of time
-leakage of endodontic filler is suspected, periapical films should be taken
-ulcer shows varying degrees of coagulation and necrosis
-mucosa will show ulceration with acute and chronic inflammation
what is the management of traumatic ulcers?
-antibiotics could be used
-topical anesthetic
-topical steroid
clinical manifestation of traumatic ulcerative granuloma ?
age distribution is bimodal :
-first group is in the first 2 years of life . lesions are associated with erupting teeth.
-second group is in adults 50-60 years old on the posterior and lateral aspects of the tongue.
-not painful in 2/3rds of cases.
-punched out apperance with surrounding erythema and some whiteness (if present for weeks or months)
-0.5cm to several centimeters in size
-recurrence is not common
-in some cases, lesions present as ulcerated , mushroom shaped polypoid mass on lateral surface of the tongue.
management of traumatic ulcerative granuloma?
- biopsy is often needed to confirm diagnosis
-intra-lesional steroids usually resolve them
-night guard on lower teeth to reduce chances of trauma
-wound debridement often leads to resolution but 1/3rd of the cases recur
whats one modifiable factor that can cause recurrent aphthous ulcers?
nutritional deficiencies such as serum iron, folate, or vitamin b12
where do aphthous ulcers usually occue?
buccal and labial mucosa
ventral tongue
floor of the mouth
soft palate
rarely occurs on keratinized mucosa- major and herpetiform varients
what are the clinical features of aphthous ulcers?
burning starts 2-48 hours prior to ulceration. localized area of erythema.
difference between major Aphtous and minor aphthous ulcers?
minor Aphthous ulcers:
-<1cm in diameter
-resolves in 10-14 days
-no scars
major Aphthous ulcers:
>1cm in diameter
lasts 6 weeks or more
scar upon healing
why are herpetiform aphthous ulcers called as such?
they resemble HSV ulcers but the difference is here we dont have a vesicular phase
possible differential diagnosis for minor and major aphthous ulcers?
minor :
-recurrent herpetic infection
-viral infection
-ulcers associated with neutropenia
-traumatic ulcers
major :
-pemphigus vulgaris
-mucous membrane pemphigoid
-traumatic ulcers
-SSC
Laboratory investigations are only done on aphthous ulcers when :
ulcers start or worsen past the age of 25
-biopsies are only taken to exclude other diseases such as crohns disease or sarcoidosis
-biopsy reveals superficial ulcer covered by a fibrinous exudate with granulation tissue at the base and a mixed acute and chronic inflammatory infiltrate
treatment for minor and major aphthous ulcers?
minor :
-topical gels to minimize pain applied after meal times and at bed time 2-3 times a day
major:
gauze containing topical corticosteroid held on lesion for 15-30 minutes. intra-lesional steroid may also be used (shortens healing time and reduces size of ulcer)
in extreme cases systemic steroid such as prednisilone 20-40mg daily can be used
pain relief can be achieved through topical diclofenac
what triggers behcets syndrome ?
bacteria or virus triggers an immune reaction in genetically predisposed individual
most common site of involvement in behcets syndrome ?
oral mucosa.
ulcers appear anywhere on oral or pharyngeal mucosa and in any type.
-arthitiis affects 40% of patients
what is the diagnostic criteria for Behcets syndrome?
recurrent oral ulcerations atleast 3 times in a 12 month period + 2 of these :
-recurrent genital ulceration
-eye lesions (uveitis or retinal vasculitis)
-skin lesions
-positive pathergy test (20 gauge needle 5mm in skin of forearm–> indurated papule or pustule greater than 2mm forms within 48 hours = positive
medications for management of Behcets syndrome ?
azathioprine and other immunosupressive drugs combined with prednisone
what are some triggers of EM?
HSV, NSAIDS sulfonamides , penecillin, anti-convulsants(carbamazepine, phenobarbital, and phenytoin.)
describe the clinical presentation of patients with EM
-Pedrome of fever, malaise , headache, sore throat , rihnorhea , and cough (suggestive of a viral infection)
-skin lesions appear over few days.
-red macules become papular. they start in the hands and move towards truck in a symmetric distribution. most common sites involved are extremeties, face , and neck
-classic lesion consists of central blister or necrosis with concentric rings of variable color (target lesions)
-skin may feel itchy and burnt
how long does it take a EM attack to resolve ?
2-6 weeks, recurrence is common
most common cause of bell’s palsy?
reactivation of HSV
what age group does primary herpes usually affect?
> 6 months, 2-3 years
presentation of primary herpes infection?
pre-drome of fever, arthralgia, myalgia, malaise, nausea, headache, cervical lymphadenopathy
-small vesicles involving different sites in oral cavity rupture in 24 hours leaving behind ulcerations
-ulcers usually heal within 10-14 days
oral findings of primary herpes infection ?
erythema and clusters of vesicles/ ulcers on keratinized mucosa and non-keratinized mucosa
coalesced ulcers that make it hard to eat
pharyngitis causes swallowing difficulties
characteristics of secondary herpes infection ? triggers?
triggered by ultra-violet radiation, trauma , stress, menstruation.
prodrome of itching and burning sensation 50% of the time
appearance of papules, vesicles, and ulcers, crusting and then resolution of lesion(heal without scarring in 1-2 weeks)
pain is generally only present within first 2 days
how to differentiate between EM and secondary herpes infection ?
EM : ulcers are larger, target iris lesions , gingiva is not affected
how to diagnose HSV infection?
systemic symptoms for 1-2 days before oral vesicles arise
generalized acute marginal gingivitis . entire gingiva is edematious and inflammed
scrape base of lesion. multinucleated giant cells
treatment of HSV infection ?
-symptomatic treatment
asprin or acetaminophen for fever , rehydration through IV
acyclovir has been shown to be effective in treatment for primary oral HSV in children if used in the first 72 hours
topical anesthetic before meals (dyclonine hydrochloride 0.5%)
antibiotics are of no help, corticosteroids are contra-indicated
clinical presentation of primary VZV infection?
chicken pox:
-low grade fever, malaise, development of rash followed by vesicles “dewdrop like”
-vesicles turn cloudy and pustular, burst , and scab with crusts falling off after 1-2 weeks
-lesions begin on trunk and face and spread centrifugally
-cerntal nervous system involvment may result in cerebellar ataxia and encephalitis
Primary HZV infection resembles :
aphthous ulcers. hzv is uni lateral?
what is needed for diagnosis of HZV ?
clinical picture usually all that is needed
direct fluorescent antibody test
ELISA PCR
What is ramsay hunt syndrome ?
HZV infection of geniculate ganglion
characterized by bell’s palsy
unilateral vesicles of external ear and vesicles of oral mucosa
herpangina ?
caused by coxsackievirus A4
mild fever, anorexia, sore throat, dysphagia, headache for 1-3 days
macules , papules and vesicles involve the posterior pharynx, tonsils and soft palate. after 24-48 hours they rupture forming small 1-2mm ulcers that heal without treatment in a week
patients complain of sore throat on swallowing
