OP12 Ulcerative lesions of the oral mucosa

Question 1

What is an ulcer?

Answer 1

A break in the continuity of skin or mucous membrane leaving an inflamed area of exposed connective tissue. There is loss of the whole thickness of the epithelium.

Question 2

What is an erosion?

Answer 2

More superficial than an ulcer, not all the layers of the epithelium have been lost. There is no direct exposure of the connective tissue.

Question 3

What is the difference between primary and secondary ulceration?

Answer 3

Primary (de novo)
Secondary to vesiculo-bullous diseases - vesicles rupture exposing the connective tissue

Question 4

What is a vesicle?

Answer 4

A collection of clear fluid within or just beneath the epithelium measuring upto 5mm in diameter

Question 5

What is a bulla?

Answer 5

A collection of clear fluid within or just beneath the epithelium larger than 5mm in diameter (large vesicles)

Question 6

What are the different mechanisms of ulcer formation?

Answer 6

Direct trauma
Ischaemia - endarteritis obliterans (syphilus)
Altered cellular metabolism - primary haematological disease
Gastrointestinal disease - primary ulceration to secondary haematological deficiency
Cytopathic - viruses
Immunological - autoimmune, type IV hypersensitivity, altered keratinocyte expression
Neoplastic - adhesion molecules and cytokines (TNF)
Idiopathic - RAU, Behcets syndrome, erythema migrans

Question 7

What things can cause primary ulceration?

Answer 7

Traumatic
Infective
Idiopathic
Associated with systemic disease
Associated with dermatological disease
Neoplastic

Question 8

What things can cause secondary ulceration?

Answer 8

Intraepithelial bullous lesion - acantholytic, non-acantholytic
Subepithelial bullous lesions

Question 9

Ulcerations can also be solitary, multiple, or recurrent. Give aetiologies of solitary ulcerations.

Answer 9

 Traumatic: mechanical, chemical thermal factitious, radiations, eosinophilic granuloma
 Infections: TB, Syphilis, histoplasmosis, blastomycosis, candida
 Neoplastic: Squamous cell carcinoma, lymphoma, metastases

Question 10

Ulcerations can also be solitary, multiple, or recurrent. Give aetiologies of multiple ulcerations.

Answer 10

Infections: ANUG, syphilis, actinomycosis, blastomycosis, candida, herpes simplex, herpes zoster, herpangina, hand foot & mouth disease, infectious mononucleosis
Vesiculobullous diseases: pemphigus vulgaris, pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa, erythema multiforme
Dermatological diseases: lichen planus, lupus erythematosus
Haematological diseases: Fe++, folate, B12 deficiency
Gastrointestinal diseases: ulcerative colitis, Crohn’s, gluten enteropathy
Idiopathic: RAU, Behçet’s, erythema migrans

Question 11

Ulcerations can also be solitary, multiple, or recurrent. Give aetiologies of recurrent ulcerations.

Answer 11

 Traumatic: mechanical, chemical thermal factitious
 Dermatological diseases: lichen planus, lupus erythematosus
 Inadequately treated diseases: Haematological or Gastrointestinal diseases
 Recurrent neoplasms: SCC
 Idiopathic: RAU, Behçet’s, erythema migrans

Question 12

What should you do in the cause of a traumatic ulcer?

Answer 12

Identify the cause
Cause must fit the site, size and shape
Removing the cause must show improvement in about 10 days

Question 13

Why does removing the cause of a traumatic ulcer improve in 10 days?

Answer 13

Because epithelium recovers in 11 days and fibroblasts take betweem 20-40 days to produce collagen

Question 14

What should you do if the ulcer does not heal in 10 days?

Answer 14

Biopsy

Question 15

What is the histology of traumatic ulcers>

Answer 15

Non-specific chronic inflammation
Epithelium next to ulcer might show increased number of mitosis (since trying to heal)

Question 16

What are the types of trauma that cause ulcers?

Answer 16

Mechanical trauma
Chemical
Thermal
Radiation
Factitious
Eosinophilic ulcer

Question 17

What are eosinophilic ulcers?

Answer 17

From muscle trauma, attracting eosinophils and histiocytes
Commonly on tongue
Might take very long time to heal

Question 18

What things can cause bacterial infective ulceration?

Answer 18

ANUG
TB - deep undermined edges, caseous granulomas
Syphilus
Actinomycosis
Others

Question 19

What things can cause fungal infective ulceration?

Answer 19

Histoplasmosis, blastomycosis, candidosis

Question 20

What things can cause idiopathic ulceration?

Answer 20

Recurrent aphthous stomatitis (RAS)
Behcets syndrome
Erythema multiforme

Question 21

What are the 3 types of RAS?

Answer 21

Minor aphthous ulcers
Major aphthous ulcers
Herpetiform ulcers

Question 22

What is Behcets syndrome?

Answer 22

RAS +2 of:
- Genital ulcers (recurrent)
- Eye lesions (uveitis, eye pain, redness, blurred vision)
- Skin lesions
- Skin hypersensitivity to needle puncture

Strong genetic link HLA-B51, ‘silk road’ distribution

Question 23

When does RAs usually start>

Answer 23

In childhood

Question 24

What do RAS ulcers look like clinically?

Answer 24

Round or ovoid, yellow-greyish, erythematous halo
Recurrent
No diagnostic test
Prodromal symptoms

Question 25

What are the prodromal symptoms for RAS?

Answer 25

Soreness, burning, prickling sensation, erythematous macules 1-2days before ulceration

Question 26

Compare minor, major and herpetiform RAS in terms of age, no of ulcers, size (mm), duration (days) and main sites

Answer 26

Minor - teens, 1-5 ulcers, <10mm, last 7-14 days, mainly on lips, cheeks, tongue Major - teens, 1-10 ulcers, >10mm, lasts >30 days, same but also palate, pharynx Herpetiform - 20-29yrs, 10-100 ulcers, 1-2 coalescing, lasts 10-30 days, same locations plus FoM, palate, pharynx, gingiva

Question 27

Aetiology of RAS is unknown but what factors could contribute?

Answer 27

Familial history Trauma Stress Associated with smoking cessation Hypersensitivity to S. sanguis cross reaction ep. Antigens Haematological disorders ~20% of RAS patients, mostly ferritin deficiency (also folate and B12) Gastrointestinal disorders association with coeliac disease but low in RAS patients, Crohn's & ulcerative colitis Allergies (anecdotal evidence of food allergies, increased levels of IgE in some patients)

Question 28

What is the histology of RAS?

Answer 28

- Pre-ulcerative stage: predominant lymphocytic infiltration in lamina propria + some in epithelium. CD4:CD8 2:1 - Ulcerative stage: ↑ inflammatory infiltration, especially cytotoxic lymphocytes in epithelium, ulceration. CD4:CD8 1:10 - Healing stage: CD4:CD8 10:1 - Epithelial antigens triggering this reactions are unknown but likely to be cross reacting streptococcal antigens.

Question 29

What is erythema migrans?

Answer 29

- Lesions evolve with time - In the tongue: geographic/migratory glossitis - Partial loss of filiform papillae - Margins of lesion outlined by a white line

Question 30

What is the histology of erythema migrans?

Answer 30

Neutrophil infiltration in the borders of lesion, chronic infiltrate in the centre + desquamation of epithelium, no association with candida

Question 31

What systemic diseases cause ulceration?

Answer 31

Haematological diseases - primary (iron, folate, B12 deficiencies) or secondary to gastrointestinal disease

Question 32

What gastrointestinal diseases can cause ulceration?

Answer 32

UC Crohns Gluten enteropathy (Coeliac disease)

Question 33

What is the general mechanism by which systemic diseases cause ulceration?

Answer 33

Altered metabolism --> epithelial atrophy

Question 34

What might cause iron deficiency?

Answer 34

- Reduction in diet due to nutritional deficiencies - Chronic blood loss (menstrual, GI), malaria - Increased requirement during growth, pregnancy, dialysis

Question 35

How does iron deficiency present in the mouth?

Answer 35

Sore mouth, ulceration, angular stomatitis, glossitis, burning mouth

Question 36

How does folate deficiency occur?

Answer 36

No storage, so most due to nutritional deficiencies Leads to anaemia

Question 37

How does folate deficiency present in the mouth?

Answer 37

Sore mouth, ulceration, angular stomatitis

Question 38

How does B12 deficiency occur?

Answer 38

Pernicious anaemia (autoimmune), vegans, malabsorption, some drugs

Question 39

How does B12 deficiency present in the mouth?

Answer 39

'beefy red' glossitis Ulceration

Question 40

What is UC?

Answer 40

Inflammatory bowel disease of the larger intestine. Causes intestinal ulcers and pseudopolyp formation. Anaemia, colon carcinoma (risk x30)

Question 41

How does UC present orally?

Answer 41

Chronic ulceration, pyostomatitis vegetans or gangrenosum, avoid NSAIDs

Question 42

How does Crohn's present orally?

Answer 42

Fissures, cobblestone pattern of oral mucosa, polypoid tags, linear ulcers, RAU swelling of lips and cheeks

Question 43

What is Coeliac disease?

Answer 43

Genetic hypersensitivity to gluten's gliadin in wheat, rye or barley --> villous atrophy of jejunal mucosa --> malabsorption

Question 44

How does Coeliac present orally?

Answer 44

4-20% have RAU. Remove of gluten improves ulceration and villi in gut.

Question 45

What dermatological diseases are associated with ulceration?

Answer 45

Lichen planus Chronic lupus erythematous Several vesiculobullous diseases: pemphigus, pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa, erythema multiforme