Ulceration

Question 1

What are the key points of ulcer histology?

Answer 1

• Loss of surface epithelium
• Replacement by slough (mixture of fibrin and acute inflammatory cells)
• Underlying lamina propria filled with granulation tissue

Question 2

Name some multiple recurrent ulcers

Answer 2

Recurrent aphthous stomatitis
Erythema multiforme
Recurrent Herpes
Ulcers related to smoking cessation
Behcets disease
PFAPA
Idiopathic

Question 3

Name some single persistent ulcers

Answer 3

Neoplasm
Chronic Infections (syphilis, TB, fungal)
Drugs

Question 4

Name some multiple persistent ulcers

Answer 4

Dermatological conditions (lichen planus, vesiculobullous conditions)
Drugs

Question 5

What are the principles to ulcer diagnosis?

Answer 5

1) History: what does it look like? What has the patient noticed? How long has it been there? Medical History. Social history (smoker, diet)
2) Examination
3) Differential Diagnosis
4) Special Investigations
5) Diagnosis

Question 6

What questions do we need to ask in the ulcer history?

Answer 6

• Age of onset of the ulcer?
• Duration of ulceration (how long do they take to heal? do they heal?)
• Frequency of attacks (pattern or random?)
• Length of ulcer free periods?
• Site (cheek, lips, palate)
• Size of ulcer (has this changed?)
• Shape of ulcer (oval is a common shape for recurrent oral ulcers, irregular ulcers are more rare)
• Do the ulcers coalesce or not?
• Prodrome (recurrent ulcers can have these)
• Relation of ulcer to menstruation or smoking?
• Change in degree of ulceration over time
• Synchronous / asynchronous

Question 7

What are the risk factors for oral malignancy?

Answer 7

• Age
• Previous malignancy
• Smoking
• Alcohol
• Smoking & Alcohol
• UV radiation

Question 8

What types of trauma can cause a persistent single ulcer?

Answer 8

1. Mechanical: sharp tooth or restoration, dental appliance, non-accidental injury , self-inflicted
2. Thermal: hot / cold
3. Chemical: aspirin burn
4. Radiation: head and neck radio-therapy
5. Electric: current applied to mucosa

Question 9

What type of cancers are oral ulcers?

Answer 9

Oral squamous cell carcinomas

Question 10

What systemic conditions are the persistent multiple ulcers secondary to?

Answer 10

Dermatological:
- Lichen planus
- Immunobullous (pemphigus and pemphigoid)
- Linear IgA disease
- Erythema multiforme

Gastrointestinal:
- Chrons and UC

Haematological disorder:
- Anaemia
- Blood malignancy

Connective tissue disorder:
- Lupus

Drugs:
- Methotrexate

Question 11

What can be seen in the histology of an oral ulcer?

Answer 11

• Multi-layered squamous epithelium
• Breach in epithelium leading to exposure of underlying connective tissue
• Production of fibrinous exudate (slough consisting of fibrin and acute inflammatory cells)
• Granulation tissue placed under fibrin (proliferating small blood vessels, acute and chronic inflammatory cells)

Question 12

What feature makes syphilis ulcers very identifiable on histology?

Answer 12

Plasma cell rich subepithelial infiltrate

Question 13

What features makes Herpetic ulcers identifiable on histology?

Answer 13

Replication of virus within infected epithelial cells leads to epithelial cell lysis forming vesicles.
Presents as pus filled ulcers.

Question 14

What is an clinical indication for a big sign of maligancy?

Answer 14

Rolled margins