1. Ulcerative Disorders Flashcards
(40 cards)
Traumatic ulceration • Most \_\_\_\_ cause of ulceration • Mechanical • Factitial – \_\_\_\_ • Chemical • Thermal • Acute vs chronic
Result is a lesion - discontinuous structurally and the discontinuous area is the ulcer
The area around is not ulcerated (non necessarily normal)
This is why you biopsy a portion of the adjacent, nonulcerated tissue
Eg. Pemphegus vulgaris, pemphegoid, lichen planus - diseases that are characterized by
pathology that affects the epithelium directly or ____ - result in ulceration
Biopsy the surrounding area to make sure you are not dealing with a lesion that is inflammatory in nature
Bite yourself, hurt with dental appliance, burn with a chemical or heat
Characterized ulceration as acute or chronic Chronic - hasn’t healed in 2 weeks (2 week rule)
Example: the middle image - see the lesion and assume trauma (if there is a broken tooth cusp) - give the pt 2 weeks to come back to reevaluate . If it hasn’t gone away, it is not ____ any more (may still be trauma-induced), but you should biopsy it.
The most common differential diagnosis for a nonhealing ulceration is ____, ____, ____
Any of the patients shown above could have any of the above differential diagnosis - cannot differentiate/predict between the diagnosis just by looking if it’s non-healing
common self-induced basement membrane acute trauma infection cancer
Cannot differentiate these either if non-healing
But if acute, the best guess diagnosis for the ulceration cause is ____ (Eg. If the pt comes in saying “I’ve had this lesion for 3 days”
Different between acute and chronic will influence your differential diagnosis
Could be cancer (starts somewhere) but could be trauma or herpes or canker sore (acutely inducing ulcerations)
trauma
Injury due to denture flange Injury due to denture flange Saliva ejector injury
Cotton roll burn
Examples of ulcerations ____ to physical damage during dental procedures They don’t all look the same but common factor: loss of epitheliu
secondary
Non-specific ulcer
• Loss of ____
• Acute inflammation
• ____
Traumatic ulcerative granuloma with stromal eosinophilia (Eosinophilic granuloma)
• ____, large mononuclear cells and ____ extend deep into submucosa
• Riga-Fede disease
– Traumatic ulcer in ____ tongue due to ____ teeth
Last year: 2 types of traumatically induced ulceration
1. nonspecific ulceration (not specific - just see microsopically loss of epithelium. Eg, traumatic ulcerative granuloma (TUGSE)
TUGSE is traumatically induced with unique histology - characterized by many eosinophils (aka eosinophilia or eosinophilic granuloma)
Diagnose microscopically only on ____
Characterized by large ____ cells - not macrophages - large ____ type cells Lots of lymphocytes
Most importantly eosinophils
Variation that occurs in children/infants - those with teeth very early in life
When feeding, riga-fede is a unique clinical variant of ____ specifically on the anterior ventral tongue in area of contact with lower incisors that are ____ erupted
Simply a traumatically induced ulceration
Once biopsied, tend to go away
Nonhealing, but once you surgically affect the area and reinitiate the wound healing response, it goes awa
surface epithelium
erythema
lymphocytes
eosinophils
anterior ventral
natal
histology
mononuclear
fibroblastic
eosinophilia
prematurely
non-specific ulcer
TUGSE
Both are microscopic examples of ulceration
A region shows stratified squamous epithelium, B shows no epithelium (ulceration) - should recognize which area has ulceration for quizzes
Knowledge is cumulative (but not the quizzes)
On the right, you don’t see the ulceration specifically but you can see a lot of ____ in the infiltrate (the red cells) (highlighted only a couple)
This is definitive of TUGSE - eosinophilic granuloma
eosinophils
Spontaneous resolution
Nonspecific and TUGSE both tend to undergo ____ after biopsy (although before were nonhealing)
Spontaneous healing
Pictures left to right: a lesion, 2 weeks later after biops, 1 month after biopsy (back to normal)
resolution
Hydrogen peroxide burn
Phenol burn
The previous lesions are from mechanical sources (aka factitial trauma)
These are chemical burns (may be due to us - what we do in clinical practice)
Things like hydrogen peroxide, bleach (____ canals with bleach), phenol (used in irrigation)
Things we can do that cause ____ ulcerations
endo-irrigitating
acute
Formocresol burn
Anesthetic necrosis
Endodontically induced lesion on left (chemical used to irrigate and sterilize canals)
Acutely induect ulceration on the right - too ____ an injection into the palate (anesthetic necrosis)
We as practitioners can accidentally but frequently ulcerations
rapid
Electrical burn
Pizza roll burn
These are thermal burns
Drinking hot beverages - burning our tongue (hopefully not to this degree of tissue damage)
Young boy on the left chewed on an electrical cord and shocked himself to the extent that his lip was damaged
Seen in ER at least a couple times a year
The one on the left can take ____ to resolve completely (needs surgical intervention - plastic surgery for years to resolve the visible defect)
months or years
Recurrent aphthous stomatitis
• Etiology \_\_\_\_ • \_\_\_\_-mediated • Three types – \_\_\_\_ – \_\_\_\_ (Sutton’s disease) – \_\_\_\_
Trauma is the most common cause of ulceration (skin or oral cavity)
Recurrent Aphthous Stomatitis - next most common cause of ulceration (more than Herpes Simplex - still common (maybe 3rd most common))
Herpes has distinct pathogenesis (viral infection), aphthous has no known etiology
Lots of things induce canker sores (many people have/had it)
Lesions that come and go
Some things that may induce these in certain people:
____
Certain foods
Drinking certain ____ (Orange juice)
Local ____
Menstruation
No common link but many things can cause canker sores in a person
These are T-Cell mediated lesion (they drive pathogenesis of these lesion)- don’t know what triggers the T Cells
3 clinical subtypes of aphthous
Minor (____ people get)
Major (____ get)
Herpetiform (hopefully no one in the room gets) - this last one is a lot of ____ for a long time
All 3 have the same way they look (no including size)
Well ____ ulcerations
Zone of ____ surrounding
What differentiates the 3 forms is____ of the lesions, the amount of ____, ____ of the lesion itself
unknown T-cell minor major herpetiform
stress
juices
trauma
many
few
pain
circumscribed erythema size discomfort duration
Minor aphthous
• On ____ mucosa
• Heal without ____ in 7-10 dayss
Comes and goes, lasts about 7-10 days, minor and major occur on non-keratinized tissue only (in healthy pts)
Minor - rather ____
Herpeteform happens in ____ tissues (distinguishing feature)
Question (couldn’t hear)
Answer - “yes” - you can say for now that it is a canker sore but if it doesn’t go away within 2 weeks (it should go away in days) then biopsy
Confidently say canker sore - appear quickly with no warning where trauma is not a likely suspect (ventral tongue, posterior buccal mucosa, soft palate)
non-keratinized
scarring
small
non-keratinized and keratinized
• R: the ulceration is located on the left-hand side
• Doesn’t have a diagnostic appearance microscopically
○ Clinical-pathologic correlation
§ Need a microscopic and clinical picture
○ 100% of time is ____
atheroma-stomatitis
Major aphthous
• > ____ cm in diameter and painful
• ____ to heal and with scarring
– Tendency to ____
• Same location, still non-keratinized tissue, but much \_\_\_\_ lesion • Longer to heal ○ 3-4 weeks in some places • Tend to recur frequently and in the same area ○ Every healing-recurrence § \_\_\_\_ in the area where lesions tend to occur • Harder to characterize as being aphtous • Keratinized tissue in oral cavity ○ \_\_\_\_ ○ \_\_\_\_ ○ Parts of \_\_\_\_ ○ Tells difference between AP and herpes § Diagnosis includes these and traumatic ulceration • Recurrent herpes occurs on \_\_\_\_ tissues ○ Occurs less on dorsum of tongue ○ If a lesion like this is on hard palate > \_\_\_\_ • Rules only apply in healthy patients ○ Underlying sickness - rules don't apply > can get AP on \_\_\_\_ tissues and recurrent herpes on \_\_\_\_ tissues
1 longer recur large scarring attached gingiva hard palate dorsum tongue keratinized recurrent herpes keratinized non-keratinized
major aphthous
* MA in floor of mouth, soft palate * \_\_\_\_ * \_\_\_\_ and zone of \_\_\_\_
large
circumscribed
erythema
major aphthous
• Can become deeper ○ Typically \_\_\_\_ ulcerations ○ Major lesions may be a bit \_\_\_\_ § May seen bone or \_\_\_\_ being exposed • R: history of recurrent MA ○ Occurring in that same area > over time develops scar tissue • Treatment: ○ Avoid certain \_\_\_\_ (spicy, citric, crunchy) ○ Once the lesion goes away, but may come back later ○ In patients with major lesions, may need to go through therapy § Topical \_\_\_\_ spray > numb them transiently § \_\_\_\_ - may accelerate the healing process
superficial deeper salivary gland foods lidocaine/benzocaine steroids
Herpetiform aphthous • Usually in \_\_\_\_ • More common in \_\_\_\_ • Numerous \_\_\_\_ 1-3 mm ulcers • Both \_\_\_\_ mucosa
• Same category of disease - lesions look the exact same, but it is very different • The others start at around of puberty, these start in \_\_\_\_ • No sex predilection of the others • Numerous, small and clustered in one area or diffuse around the cavity • Given name herpetiform ○ Mimics \_\_\_\_ infection § Acute viral infection that we've all been exposed to, but not everyone has had lesions § Lesions in oral cavity look no different than HA □ \_\_\_\_ required before initiating therapy □ If prescribe \_\_\_\_ for these patients, and if they had herpes then the steroid is going to result in the disease becoming worse § Quick diagnosis without surgery (within 48 hours): □ Can swab patient ® By time send to laboratory it may be too long □ Gold standard for HSV is \_\_\_\_ test □ Smear ® Take a tongue blade, and scrape a lesion and wipe on slide, stain and see if there are herpetically infected cells □ Same applies for difference between \_\_\_\_ and minor aphtous
adulthood
females
small
non-keratinized and keratinized
adulthood primary simplex herpes diagnosis steroids PCR major
Treatment
- Spontaneous ____
- ____ if necessary
- Topical ____ if necessary• Each lesion will resolve on it’s own
○ As one is resolving, another one is forming
○ If not treated properly, may have weeks of disease
• Can give topical anesthetic for palliative care
○ Maintain hydration, eat properly
§ If cannot eat solid foods: OTC ____ and smoothies
resolution
palliation
steroids
milkshakes
Aphthous lesions may be associated with
____ disease
____
____ disease
____ deficiencies
• Could be a sign of something more significant ○ Systemic disease: § Lupus □ Increase risk for apthous stomatitis § \_\_\_\_ disease § Ulcerative cholitis and \_\_\_\_\_ § Same looking lesions, but the underlying predisposition is from \_\_\_\_ inflammation ○ Aphthous is not diagnostic of these diseases or definciencies, but it is diagnosit for \_\_\_\_ disease
behcet
systemic lupus erythematosus
inflammatory bowel
nutritional
chron’s
systemic
behcet
Behҫet disease
• ____ inflammatory disease of unknown etiology
• ____ – Mediterraneans, Japanese
• ____, genital ulcers, skin and ____ lesions
• Systemic findings
– ____
– Neurologic
• Systemic chronic inflammatory disease • \_\_\_\_ predisposition ○ Not gentically inherited, but the DNA does dictate risk § Especially from middle east and Mediterranean (Israel, Turkey, Spain, Greece) □ Endemic to these areas ○ HLA B-51 § Variant in coding in DNA > increases risk of developing disease ○ Caucasian in western have different \_\_\_\_ • All patients need to have \_\_\_\_ as a clinical symptom ○ Several lesions, not of herpiform subtype, but likely the major lesion ○ Affects \_\_\_\_ § \_\_\_\_ and hard palate affected here ○ Genital lesions ○ Non-specific inflammation lesions in skin ○ And lesions in the eyes § Burning, irritated eyes ○ May have joint pain and neurologic findings
chronic HLA B-51 RAS ocular arthritic
genetic risk factors AS non-keratinized and keratinized soft palate
Behcet disease
• Aphthous stomatitis plus two of following – Recurrent \_\_\_\_ ulcerations – \_\_\_\_ lesions – \_\_\_\_ lesions – Positive \_\_\_\_ test
• Several criteria to diagnose ○ AS and: § + pathergy test □ Inject sterile \_\_\_\_ under skin, if a couple days later you develop a bump > + pathergy test □ 40-90% of patients with this have positive pathergy • Aphthous is multiple lesions, and recurring multiple times in a given year (recurrent) ○ Would resolve, and return in a few months with new lesions • This disease warrants intervention and therapy ○ Systemic therapy: systemic \_\_\_\_ • Only disease where AS is a \_\_\_\_ criteria for this disease ○ Can occur in others, but not diagnostic
genital
ocular
skin
pathergy
saline
prednisone
diagnostic
Pathergy test
If positive, you see a s a ____-like skin reaction 1 -2 days later
Positive reaction seen in 40 – 90% of patients with s a ____ disease
tuberculin
behcet
Crohn disease
• \_\_\_\_ inflammatory bowel disease – Weakened \_\_\_\_ immunity – \_\_\_\_ mutations in subset of patients • May involve single or \_\_\_\_ anatomic segments • Peak incidence in \_\_\_\_ decades
• \_\_\_\_ disease ○ Differentiates Chron's from ulcerative cholitis • \_\_\_\_ is increased in prevalence • Inability to regulate commensal organisms ○ Defect in innate immune system § Regulates response to microflora § Mutation in protein that is involved in innate immune system § \_\_\_\_ is more prone to break down by those bugs □ In skin □ Mouth to rectal canal ® Multi-segment disease ® Not a continuous stretch of disease, can be in different \_\_\_\_: skip areas ® May get oral cavity before developing GI disease • Occurs in young people primarily; teenager or young-adult
chronic innate CARD15 multiple 2nd and 3rd
granulomatous
AS
mucosa
spots
Crohn disease
• Oral manifestations in majority of patients
– ____
– Erythema
– ____ lesions
• ____ inflammation seen in 50% of cases
• Characterized as a GI disease ○ First symptom may be chronic diarrhea and rectal \_\_\_\_ ○ \_\_\_\_ manifestations may be one of the first manifestations before going onto this § Puts dentists in a unique position to stop spread • \_\_\_\_ of mucosa ○ Pebbley type tissue • Pathogneumonically: \_\_\_\_ ulceration (bottom pictures) ○ Sliced into \_\_\_\_ (upper or lower) ○ Still warrants a \_\_\_\_ to confirm diagnosis • Not \_\_\_\_ granulomatous ○ Not always seen microscopically
ulcerations cobblestone granulomatous bleeding oral cobblestoning linear buccomucofold biopsy always
Lichen planus
____ hypersensitivity reaction
____ and erosive forms
Most common cause of ____
• Commonly occurring ulcerating disorder • Type IV hypersensitivity reaction ○ \_\_\_\_ mediated inflammatory condition ○ Two subtypes: § Reticular □ Characterized by lace-like appearance (\_\_\_\_) anywhere in the oral cavity § Erosive • \_\_\_\_ ○ Red, peeling gums • Go through the pathway ○ Don't inow what T cells are responding to; some foreign antigen that responding to, and once recognized, and responded via a T-cell mediated process § Causes a reticulated pattern in the mucosa (buccal mucosa, and dorsum tongue)
type IV
reticular
desquamative gingivitis
T-cell
wickham’s striae
desquamative gingivitis
