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Ulcer Definition:
Localized defect in the surface epithelium exposing an inflamed connective tissue base Most common lesion of the oral mucosa May be a manifestation of many disease entities Erosion: is a superficial ulcer
Traumatic Ulceration
Mechanical Chemical Thermal Factitious Radiation Eosinophilic ulcer (traumatic granuloma)
Mechanical Ulceration
Three criteria for diagnosis
1. Define a cause 2. Fit size, shape and location of ulcer 3. Healing within 10 days of cause removal
Chemical Ulceration
Materials used in dental practice Self treatment of oral complaints, the use
of aspirin, undiluted mouth washes Reaction varies in severity: edema to necrosis
Aspirin burn
Chemical burn
Formocresol burn
Anesthetic necrosis
Thermal Ulcerations
Hot food or drink
Factitious ulcers
Factitious ulcers
Radiotherapy
Damage to the epithelium Damage to blood vessels: atrophic and necrotic
epithelium Damage to lymphatics: edema
SCC
RAD mucositis
Clinical appearance
Histopathologic features
Sheets of histiocytes and some eosinophils
No relation to eosinophilic
granuloma of bone treatment
Clinical features:
Prodromal symptoms 1-2 days before Tingling sensation Red macule
Minor RAS
Major RAS-scarring
Herpetiform Ulceration
Least common, older age group 1-2 mm On any part of the mucosa No: hundreds Heal in 2-3 weeks according to the size Scarring may occur Associated with severe discomfort-older
age group
Etiology of RAS
Most likely immune mediated Box 12.1 Co factors
Trauma
May influence the site
Emotional stress
Precipitating factor Biting of the mucosa
Hematological disorders
In 20% of patients: Iron, folic acid, B12 deficiency, Causal role?
Gastrointestinal diseases,
Celiac disease (gluten hypersensitivity) 2-4% Minor type Ulcerative colitis and Crohn`s disease
Histopathology
Infiltration by lymphocytes Damage to the epithelium and more
infiltration Decrease in lymphocytes upon healing Epithelial infiltrate is T cell cytotoxic followed by CD4 in healing phase
Pathogenesis
Genetic predisposition
HLA- B51
Vesiculbullous diseases
Meaning of the name Collection of clear fluid within or below the
epithelium Classification:
Intraepithelial Subepithelial
Intraepithelial vesiculobullous:
Acantholytic: pemphigus, breakdown of intercellular attachment Non acantholytic: herpetic infection, death of cells
Vesiculbullous diseases
History is important
duration, recurrence skin, eye, genital lesions medications, systemic manifestations
Pemphigus
Vulgaris is the most common type Female more than male Ethnic groups: Ashkenazi Jews
Pemphigus
Autoimmue: auto antibodies against
epithelial desmosomes
Pemphigus
Pathogenesis: auto Ab against
desmosomes
Desmoglein 3 Desmoglein 1 and 3 in skin and oral Activation of proteinases
Pemphigus Vulgaris
Pemphigus Vulgaris
Pemphigus vulgaris
Bullous eruptions: skin and mucous membranes intraepithelial Oral mucosa is almost always involved Fragile bullae Any part of the oral mucosa may be involved,
soft palate, buccal mucosa and lips
Desquamative gingivitis
Pemphigus vulgaris
Direct immunofluorescence:
biopsy from perilesional tissue
Indirect immunoflourescence
Disease monitoring Autoantibodies to desmosomes Titer correlates with severity Not present in early stages? Or all patients
Pemphigus Vulgaris
Pemphigus vulgaris
Histopathology Intra epithelial separation Little subepithelial inflammation Tzanck cells
Pemphigus Vulgaris
Mouthrinse
Triamcinolone acetonide
Ointment
Triamcinolone acetonide Fluocinonide (Lidex) Clobetasol
Systemic Steroids
Prednisone Contraindicated in certain systemic diseases
Intralesional Steroids
Triamcinolone acetonide, inject 10-40 mg Anesthetize area before injection of steroid
Erythema Multiforme
Wide range of clinical presentation Maculopapular, vesiculobullous, target Orally:lips and anterior parts
Target
Erythema Multiforme
Sudden onset Skin and mucous membranes
Pathogenesis is not clear
Hypersensitivity rxn, type 3 hypersensitivity And consequenses
Ag - Ab complexes have been detected in EM and HSV infn
ERYTHEMA MULTIFORME
Stevens-Johnson Syndrome:
A more severe form of erythema multiforme Lesions involve skin, conjunctiva, oral mucosa, genital mucosa
Erythema Multiforme
Microscopic features: not diagnostic Diagnosis is primarily clinical Treatment and prognosis
Remove causative drugs, if any Topical and systemic corticosteroids May be recurrent May benefit from prophylactic acyclovir
Erythema Multiforme
Pemphigoid
Autimmune disease
Auto antibodies to hemidesmosomes and basement membrane
Pemphigoid
2 clinical groups: Mucous membrane pemphigoid
Mainly mucosal
Bullous pemphigoid
Mainly skin
Nikolsky sign
MMP
MMP
Extraoral lesions
Conjunctiva: may cause blindness Nasal, pharyngeal, vaginal mucosa Skin
MMP
Bullous Pemphigoid
Subepithelial vesicle
No subepithelial inflammation first Later, inflammation and perivascular infiltrate Eosinophils are involved Release of proteases
Dermatitis Herpetiformis
Autoimmune disease Subepithelial blistering Primarly skin disease, oral manifestation
variable
Small erythema to wide necrosis
Dermatitis Herpetiformis
Biopsy shows: granular accumulation of
neutrophils
Immunofluerescence shows:
IgA deposition at the tips of CT papilla
Histopathology: subepithelial seperation D/D: dermatitis herpetiformis and MMP Immunofluorescence: linear IGA along
basement memnrane. Gluten hypersensitivity in 30%
Epidermolysis Bullosa
Complex group of syndromes Gene mutations coding for keratins in
basal layer or collagens Keratin: intraepithelial bullae Basement membrane structure: subepithelial bullae
Epidermolysis Bullosa
Clinically: at birth Extreme fragility of skin Heal slowly with scarring Several types are incompatible with life
EPIDERMOLYSIS BULLOSA
Treatment
Avoid trauma Antibiotics, corticosteroids Prognosis Simplex: good Recessive & Junctional: fatal
bullae Middle aged or elderly Soft palate, solitary Cause is unknown, trauma? Histology: subepithelial seperation Immunofluorescence: negative