6. Acute Oral Ulcers Flashcards
(105 cards)
1
Q
What is the etiology of Aphthous Ulcers (canker sores)?
A
Undetermined Etiology
- Thought to represent a Type IV T8 Cell Cytotoxic Rxn to an antigen
- Especially when mucosal barrier is compromised OR there is a hyper-immune response
2
Q
Aphthous Ulcers are ALWAYS…
A
Acutely Painful or tender
3
Q
Where do Aphthous Ulcers develop?
A
Labial, NON-keratinized mucosa (moveable) then heal
4
Q
What do Aphous Ulcers spare/not develop?
A
-
Gingiva
- If pt says its the gums, its probs the alveolar mucosa
- Hard Palate
- Dorsal Tongue
5
Q
What is the histology of Aphtous Ulcers?
A
Non-specific, non-diagnostic Ulcer
no need for biopsy for dx
6
Q
What is the most common type (20-60%) of aphtous ulcer?
A
RAU minor
7
Q
What aphtous ulcer is ocasionally seen, with most cases in females?
A
Herpetiform apthae
8
Q
What type of aphtous ulcer is rare?
A
RAU Major
9
Q
What is the clinical presentation of RAU minor?
A
- 1-5 small (3mm < 1cm) well demarcated, circular ulcers surrounded by a red border
10
Q
What is the clinical presentation of Herpetiform aphthae?
A
- Numerous (6-100) crops of small, irregular ulcers that can coalesce and become larger ulcers
11
Q
What is the clinical presentation of RAU major?
A
- Several large (1-3cm), deep (into muscle), ragged ulcers
- Painful enough to encourage suicide
12
Q
Where is RAU minor located?
A
- Confined to labile mucosa or oral cavity
- NEVER on gingiva or hard palate
13
Q
Where is Herpetiform aphthae located?
A
- Mostly on labial mucosa
- RARELY on hard palate or gingiva
14
Q
Where is RAU major located?
A
- Can occur anywhere including pharynx (pretty common location for them)
15
Q
What is the frequency of RAU minor?
A
- Episodes Every Few Months
- Triggered by trauma (cheek biting, tooth brushing, after CPR training, trauma from ortho), stress, foods, meds
16
Q
What is the frequency of Herpetiform aphtae?
A
- Frequent episodes (every couple weeks)
17
Q
What is the frequency of RAU major?
A
- Almost always present (as 1 heals another 1 starts)
18
Q
What is the healing time for RAU minor?
A
Heal w/o scars in 1-2 wks
19
Q
What is the healing time for Herpetiform aphthae?
A
Heal w/o scars in 1 wk
20
Q
What is the healing time for RAU major?
A
- Heal with SCARS in 2-6 wks
- Constriction of the oral cavity; Microstomia
21
Q
What is the preferred treatment for RAU minor?
A
Chemical Cautery
eradicates the pain but won’t prevent new ones
22
Q
What is the preffered treatment for Herpetiform aphthae?
A
Topical or Systemic Steroids
23
Q
What is the prefered treatment for RAU major?
A
- Systemic Steroids
- Intralesional Steroid Injection, around the base of the ulcer
-
Dangerous Drugs
- Bone marrow consequences
- Birth defects
24
Q
What are the features of Behcet Syndrome?
A
- Systemic vasculitis that features multiple aphtous ulcers of various size in 90% ALONG WITH:
- Genital Ulcers (75%)
-
Inflammatory Eye and Conjunctival Lesions (80%)
- Blindness (25%)
- Neurologic Sxs (10-20%)
- Assoc with poor prognosis, dementia and paralysis
- Arthritis (common but mild)
- Varied skin lesion
25
What is the etiopathogenesis of Behcet Syndrome?
* **Hyperimmune rxn** to **oral bacteria**, other infectious or environmental agents
26
Who has a predisposition for Behcet Syndrome?
**SILK ROUTE**
* **HLA** predisposition among **Turks, Japanese, Mediterranean's**
27
How is Behcet Syndrome Diagnosed?
**Pathergy Test**
* Rxn following skin injection of sterile saline
* Unique to this disease - Diagnostic
28
What must be present for the diagnosis of Behcet Syndrome?
Must have **Oral Ulcers,** **+2** other lesions (**genital, eye, skin lesions**), **+ pathergy test**
29
What is the other name for Reactive Arthritis?
Reiter Syndrome
30
In what populations are Reiter Syndrome more common in?
* **Males**
* **Young Adults**, with proper HLA profile
31
What are the clinical features of Reiter Syndrome? (3)
* Recurrent lesions:
* _Oral_
* ****Resemble Geographic tongue, BUT widespread
* _Conjunctival_
* _Genital_
* Resemble Geographic Tongue
* **Non-gonococcal urethritis** (mucopurlulent discharge)
* Prominent **Crippling Arthritis**
* **Palmar and Plantar Hyperkeratosis** and other skin lesions
32
What is the etiopathogenesis of Reiter Syndrome?
* **Autoimmune Rxn** following **GI disease** or **STI** in pts with susceptible HLA profile or HIV
33
What is the most common trigger for Reiter Syndrome?
Veneral disease
34
What do the microscopic lesions of Reiter Syndrome resemble, and what do they show?
Psoriasis
show **munro micro-abscesses**
35
What are the clinical features of Transient Lingual Papillitis "Lie Bumps"?
* Common condition of **Fungiform Papillae**
* One or several papilla become **enlarged, red,** then **ulcerates**
* ****"SALT ON A PRETZEL"
* Causes **sharp pain** and tenderness
* Tends to **resolve in days to a week**
36
How is Primary Herpes Simplex 1 (oral) transmitted?
* **80% contact virus** (antibodies forming)
* Kissing, fomites, utensils, ect.
* **20% never contact virus**
37
What are the Primary Herpes Simplex 1 presentations?
* 1% - Primary **Herpetic Gingivostomatitis**
* 99% - **Asymptomatic** Primary Infection
38
What is the clinical presentation of Primary Herpetic Gingivostomatitis?
* **Multiple painful**, **3-7mm vesicles**, which **burst into ulcers** throughout the mouth, may coalesce
39
What must be present for the diagnosis of Primary Herpetic Gingivostomatitis?
Acute, Hemorrhagic Gingivitis
40
When does Primary Herpetic Gingivostomatitis resolve?
**2 weeks** and will not return in the same form
41
What is the treatment for Primary Herpetic Gingivostomatitis? (3)
* Appropriate **antiviral** - if caught early
* **Fluids**
* pts don't want to eat or drink anything, become dehydrated
* Pt is **Contagious**
* Keep away from others and themselves
42
What percent of HSV-1 infected people get seconday herpes, due to periodic outbreaks of latent virus?
**50%**
* 1% Seondary Intraoral Herpes
* 99% Herpes Labialis (Cold Sore/Fever Blister)
43
Where does Secondary Intraoral Herpes develop?
**Gingiva** and **Hard Palate**
mucosa bound down to bone
44
What is the clinical appearance of Secondary Intraoral Herpes? (2)
* **Small, short lived vesicles**
* "stabbed with icepick"
* Little red, inflamed, sore
* **Periodic outbreak**
* Triggers: trauma, dental work, fever, colds, stress
45
When does Secondary Intraoral Herpes resolve?
Heals in **7-10 days**
46
How does Herpes Labialis occur?
* latent virus in **trigeminal ganglion** periodically reactivated by **lowered systemic** or **tissue resistance:**
* **C**olds/fever, UV or cold exposure, trauma, menstration, and stress
47
How does Herpes Labialis clincal presentation begin?
* Prodrome of **lip tingling and swelling**
* Followed in a day by **localized crop of small vesicles**
48
When does Herpes Labialis resolve, and what occurs during this period?
7-10 days
* Day 1 - vesicles
* Day 2 - vesicles with inflammtion
* Day 4 - weeping crusted ulcer
* Day 7 - dries up, will go away
49
What percent of the total population NEVER gets a herpetic lesion, with or without contact with the virus?
60%
50
What are 2 other lesions caused by HSV-1?
HSV-1 can occur anywhere above the waist
* Herpetic Whitlow
* Kaposi Varicelliform Eruption
51
What is Kaposi Varicelliform Eruption?
Herpes complicating **Eczema**
* Looks like chickenpox
* If untreated can be **Fatal**
52
What test is used for the Diagnosis of HSV-1 and HSV-2?
Tzanck Smear
* Cytologic exam of the fluid or base of an intact vesicle
* Shows **acantholytic cells**
* *Also shown in **Pemphigus***
53
What is histologically diagnostic for HSV-1 and HSV-2?
**Lipshutz Bodies**
* Cells are **multinucleate**
* Contain **intra-nuclear viral inclusions**
*Pemphigus does not have Lipshutz bodies, but is confirmed with a Tzanck Smear*
54
What diseases have an etiology of HHV-3 Varicella-Zoster Virus?
Chickenpox
Zoster/Shingles
55
How is chickenpox spread?
Primary infection with varicella virus
* Droplet infection
* Contact with lesions and fomites
56
What is the incubation period for chickenpox?
2 weeks, then generalized flulike symptoms
57
What is the clinical appearance of chickenpox?
* **Vesicles fold** onto themselves becoming **umbilicated pustules** and then **crusts**
* Oral lesions common
58
Where does the varicella-zoster virus remain latent?
Nerve ganglia
59
What are the complications of chickenpox? (3)
* Reye Sx (aspirin)
* Encephalitis
* Pneumonia
60
How is chickenpox prevented?
Immunization with **Varivax**
61
What is the treatment for chickenpox?
Antivirals = **Valtrex** or **Famvir**
* if caught early, they help **shorten the duration** and **decrease number of lesions**
62
How does zoster/shingles occur?
* Reactivation of **latent chickpox virus** occuring when **resistance is lowered:**
* Stress, HIV, **Internal Malignancy** **(Lymphoma/Leukemia)**, debilitating ds, old age
63
What is the clinical presentation of Zoster/Shingles? (5)
* Intense **prodromal pain** followed by **painful coalescing vesicles**
* _DON'T CROSS MIDLINE_
* **Post-Herpetic Neuralgia**
* Can be incapacitating and last years after the rash and clisters disappear
* **Jaw** and **Pulpal Necrosis**
* Zoster affects the blood supply
* May cause **Facial Paralysis**
* Involvement of **tip of nose** predicts **Eye Involvement**
* ****Can cause **blindness**
64
What is the treatment for Zoster/Shingles?
* If tx early with **Valtrex** or **Famvir** - can abort the lesions
* **Vaccine for pts \> 60 yrs**
* Dire consequences over age 60
65
What is caused by Herpes 6, 7?
Roseola (childhood disease)
66
What is caused by HHV8?
**Kaposi Sarcoma**
opportunistic for severe immunosuppression
67
What occurs in Ramsey Hunt Syndrome?
* **Herpes** in **geniculate ganglion**
* Will cause **Bell's Palsy**
68
How is Herpes Labialis (Cold Sores/Fever Blisters) prevented?
* Protection from elements
* Prophy antivirals prior to exposure to elements
* **L-lysine 1000mg supplement** and **avoid arginine** (chocolate, nuts, dried fruit)
* Have to take it min **1 month**
* **Vegans** are typically deficient in this EAA
* Herpes virus needs arginine to replicate
* L-lysine competes with arginine
69
What is the treatment for Herpes Labialis?
* **Denavir cream**
* Famvir or Valtrex @ onset of outbreak
70
What is the treatment for Primary Herpes (chickenpox) or Zoster?
* **Famvir** or **Valtrex capsules** as soon as clinical diagnosis is made
* Will not prevent post-herpetic pain, but it will **reduce the duration** of it and the lesions
71
What is shown in the histology of Varicella-Zoster Virus diseases?
Viral inclusion bodies
72
What is caused by Coxsackieviruses? (3)
* Hand, Foot, and Mouth Disease
* Herpangina
* Acute Lymphonodular Pharyngitis
73
What is shown in the histology of coxsackieviruses?
**NO viral inclusion bodies**
*unlike HSV-1, HSV-2, HHV-3*
74
What is the clinical presentation fo HFM Ds?
* Multiple, acute oral vesicles breaking into ulcers
* *Resemble **Primary Herpes***, but **NO GINGIVITIS**
* _Ulcer Stage_, *resembles **Herpetiform Aphthae,*** but **NO RECURRENCE**
* Hand/foot lesions present but may be delayed
* Also get **lesions on buttocks**
* *aka primary herpes but include lesions on hands, feet, and butt*
75
What is the clinical presentation of Herpangina?
* **Small number** of acute oral vesicles & ulcers confined to **Soft Palate and Pharynx**
* *Pharynx is a common location for _RAU major_, but it will have several lesions*
76
What is the clinical presentation of Acute Lymphonodular Pharyngitis?
* **Soft**, shiny, yellow/red, **nodules** on **soft palate**
* Representing **_inflamed lymphoid tissue_**
77
What is the etiopathogenesis of Necrotizing Ulcerative Gingivitis (NUG)?
* Opportunistic **fuso-spirochetal anaerobic** infection
* Triggered by: **poor oral hygiene** in a setting of **stress, smoking, debilitation**
78
What does NUG affect?
Gingival Papillae
79
What is the diagnostic triad of NUG?
* Pain
* Bleeding
* Necrotic ulceration of inter-dental papillae
* "punched out" papillae
* doesn't look like gingivitis at all
80
What symptoms/signs occur in NUG in addition to the diagnositc triad?
* Excessive salivation
* **Metallic taste** (from blood)
* Fever and Lymphadenopathy
81
What are the complications of NUG?
* _HIV-association NUG_ (much worse)
* _Noma_
* Lack of treatment of NUG leads to the spread of infection into soft tissue sites
* Causing **extensive intraoral destruction**, which can **expose alveolar bone** and teeth
* **Palatal destruction**
82
What are the similarities between NUG and Primary Herpetic Gingivostomatitis (primary herpes)? (3)
* Children/young adults
* Painful ulcers
* Fever and lymphadenopathy
83
What are the differences between NUG and Primary Herpetic Gingivostomatitis (primary herpes)? (4)
* Acute Hemorrhagic Gingivitis must be present for herpes dx, so the papillae will be swollen (**inflammation vs. necrosis**)
* **Contact virus vs. bacterial infection**
* Throughout the mouth vs. gingival papillae (**generalized vs. localized**)
* **NUG is non-contagious**
84
What is the etiology of Measles?
**Paramyxovirus**
85
How is measles spread?
Droplets, very contagious
86
What is the incubation period of Measles?
**10-12 days**, followed by **flu-like symptoms**
87
What is the 1st lesion shown in measles?
**Koplik Spots**
* Blue-white papules on _buccal mucosa_
* Appear and disappear frequently
88
What is the clinical presentation of measles?
* **Red maculopapular rash** of: **face** --\> **trunk** --\> **extremities**
* Accompaning **painful gingivitis**
89
In what population is measles a very serious disease?
* \< 5 yrs
* \> 20 yrs
90
What are the complications associated with measles? (6)
* **Fatal Encephalitis**
* **Delayed symptoms of CNS disease**
* **Pneumonia** (can be fatal, especially in children)
* Appendicitis due to lymphoid swelling
* Severe, sometimes fatal infections and Noma
* **Vitamin A Deficiencies**
* Can lead to **blindness and deafness**
* Fatal
91
What is the prevention for measles?
Vaccine
92
What is the classic lesion of Oral Hairy Leukoplakia?
* **Bilateral white**, ragged, lesions that **don't scape off**
* Classicly on the **Lateral Tongue**
93
What does Oral Hairy Leukoplakia clinically resemble? (3)
* Tongue Biting
* Cinnamon Stomatitis
* Candidiasis
94
What do Oral Hairy Leukoplakia lesions frequently show?
**Candidiasis**, especially in **HIV pts**
95
What is the prognosis of Oral Hairy Leukoplakia?
Not a terrible disease, just an **indicator of something serious** that is going on
96
What is the treatment for Oral Hairy Leukoplakia?
Anti-virals
97
What is the histology of Oral Hairy Leukoplakia?
* Hyperparakeratosis and clusters of **koilocytic clear cells** with **beaded nuclei** (dark beads around periphery of nucleus)
98
How can you confirm the diagnosis of Oral Hairy Leukoplakia?
With **ISH studies**, can conclusively identify **EBV** to confirm ds
99
What is the etiology of Infectious Mononucleosis and how is it spread?
* **EBV**
* Spread through **intimate contact** with **saliva**
100
What are the signs of Infectious Mononucleosis? (6)
* Kids are usually asymptomatic
* Fever, cough, runny nose
* **Cerival Lymphadenopathy**
* **Whopping Tonsillitis** they can get so big that they may touch
* Painful Pharyngitis
* 30% get classic **_Palatal Petechiae_**
101
How long does it take Infectious Mononucleosis to resolve?
4-6 weeks
102
What occurs in those with Infectious Mononucleosis that doesnt resolve?
* Manifests as a **systemic disease** that likes to **grow in liver & spleen**
* In spleen, it gets into & **weakens the splenic capsule**, causing **tenderness**
* Can cause **splenic rupture** **with trauma**, which can be **fatal**
103
How is Infectious Mononucleosis diagnosed?
DIAGNOSTIC if **peripheral smear** shows: **\> 10% large lymphocytes**
(Lymphocytes are so big they look like monocytes)
* Test for **Paul Bunnell Heterophile Antibody (IgM)**
* **Mono Spot Test** (rapid results)
104
What are the complications associated with Infectious Mononucleosis? (3)
* Splenic rupture
* **Bell's Facial Palsy**
* Chronic Fatigue Syndrome
105
What is in the Differential Diagnosis of: Acute, Recurrent Aphthaeform Lesions? (12)
* RAU minor
* Default dx
* RAU major
* Herptiform Apthae
* Behcet Sx
* Chron's Ds
* GI complaints, and sudden increase/appearance of oral aphthae
* Ulcerative Colitis
* HIV
* Neutropenia
* Gingival ulcers, so kinda doesn't fit
* IgA Deficiency
* MAGIC Sx
* Nutritional Deficiency
* Fe, Zn, B-complex
* Secondary Intraoral Herpes
