Oral dermatology: ulcers, aphthae and aphtoses, bullous lesions of the oral mucosa
I. Histological reminders:
The mucosa consists of a lining epithelium resting on the lamina propria through a basement membrane.
II. Basic lesions
The elementary lesion is the unmodified primary lesion of the oral mucosa, as it appears to the observer.
It can be clear, permanent, but be more or less obvious depending on the evolution, the area of appearance or the therapies used. This lesion is analyzed by observation and palpation. The use of optics is often useful to specify certain characteristics.
Clinical diagnosis is based on anamnesis, topography and mainly on examination.
The primary elementary lesion must be distinguished from secondary lesions which result from a spontaneous or induced transformation of the primary lesion.
- Stains, beaches, and cupboards:
Macules correspond to a change in the color of the mucosa over a limited surface without relief or infiltration.
A plaque or spot corresponds to a change in the color of the oral mucosa whose diameter exceeds 0.5 cm in diameter.
These single or multiple lesions most often have clear limits and may be erythematous, white or pigmented, or on the contrary hypochromic or achromic.
Subjective signs include: a burning sensation, annoyance.
On histological examination, they respond to capillary dilation without extravasation of red blood cells, sometimes epithelial atrophy is observed.
2)Plaques and papules:
Raised and circumscribed lesions, solid, not containing liquid, we speak of plaque when the diameter exceeds 0.5 cm in diameter.
They may be related to an increase in the diameter of the epithelium, or an increase in the volume of the chorion;
Papules may be chorioepithelial, well-circumscribed, and may be erythematous, white, pigmented, or hypochromic.
3) Nodules:
These are round, protruding bumps, with a diameter greater than 1 cm,
correspond to a deep infiltration of the chorion by cellular proliferation
These are most often tumors, whether benign or malignant.
4) Bullous lesions:
Bullae are rounded or oval epithelial detachments of variable size, they contain a serous or hemorrhagic fluid, their presence is generally ephemeral because of the fragility of the roof, oral humidity and food trauma.
Bullous conditions may occur in isolation or in association with a skin rash.
5) Erosions:
They can be primitive or secondary:
It is a loss of superficial substance, without necrosis of the underlying tissues, the bottom of the lesion retains a more or less red color;
The well-circumscribed character with a whitish epithelial collar suggests post-bullous or post-vesicular erosion.
6) Ulcerations:
Deep loss of substance with destruction of the oral epithelium and the upper part of the chorion, unlike erosion or loss of substance only concerns the superficial part of the epithelium.
III. Mouth ulcers and canker sores
Mouth ulcers mainly pose an etiological problem that can reveal very diverse and sometimes serious local or general diseases.
Isolated ulcers; then multiple acute oral ulcers and recurrent ulcers, and finally chronic ulcers.
III.1) isolated ulcerations
Traumatic ulcers:
It is most often a single ulceration
with a contour molded on the causative agent :
a poorly fitting dental prosthesis
a bite especially after local anesthesia.
This ulceration heals in 7 to 8 days if the cause is treated. Using mouthwash with saline solution or 0.2% chlorhexidine solution can help healing.
If the ulceration persists, the lesion should be biopsied to eliminate a neoplastic cause.
III.3) Recurrent ulcerations
Of systemic origin, a certain number of patients present with a problem of recurrent oral ulcerations, sometimes extending over a period of several years.
- Aphthous ulcer (oropharyngeal aphthosis and Behcet’s disease)
- leukopenia, cyclic neutropenia
- Chemotherapy-related ulcers
- Inflammatory bowel diseases (Crohn’s-UC)
- Malabsorption syndrome (celiac disease)
- Anemia and nutritional deficiencies
- Hypogammaglobulinemia
- HIV infection
- Chronic renal failure
- Lupus erythematosus.
III.3) Recurrent ulcerations: Aphthae and aphtoses:
Aphthous ulcer Greek word “Aphta” = ulcer or burn.
Mouth ulcers are relatively common ulcers but the etiology is unknown.
The ulceration of the oral mucosa is the most painful. The patient experiences difficulty chewing, swallowing and maintaining oral hygiene.
Oral ulcers can be isolated (common or vulgar ulcers and oral-pharyngeal ulcers) or part of an ulcer affecting other organs (Behçet’s disease or major ulcer of Touraine, cutaneous and mucous membrane ulcers).
MECHANISMS OF APPEARANCE
Phase 1 : prodromal phase (painful):
Tingling + burning (less than 24 hours) (often absent in Mr. Behçet)
Phase 2 : pre-ulcerative phase (short)
Erythematous, macular or papular or even vesicular lesions
(ephemeral vesicles that most often go unnoticed.
Phase 3 : the canker sore ulcerates in a punctiform or lenticular manner, never bleeds.
- The base ⇒ slightly edematous, flexible, not indurated, except in necrotizing varieties .
- The canker sore makes eating and speaking difficult.
- The very painful, well-defined, shallow, rounded or oval lesion with a necrotic base, covered with a pseudomembrane and surrounded by an erythematous halo with a raised edge.
Phase 4: pain ↓, the lesion flattens + re-epithelializes.
- isolated canker sore:
The initial lesion is an erythematous macule
Round or oval ulceration, surrounded by an erythematous halo, with a yellowish background
Location: lips, palate, inner side of cheeks, gingivolabial groove, etc.
Non-infiltrated lesion, without satellite adenopathies.
The differential diagnosis is made with traumatic ulceration, oral syphilis chancre
b) Common aphthosis:
The thrust consists of one to three elements measuring from 3.6 to 10 mm.
Spontaneous evolution towards healing in 8 days.
Triggering circumstances are mentioned and are specific to each patient: food, dental care, stress, fatigue, etc.
Outbreaks are rare, with latency periods of several months.
The assessment of common aphthosis is essentially etiological
Treatment is symptomatic.
Canker sore outbreaks are relieved by the application of topical agents: antiseptics, topical anesthetics, analgesics.
Localized only at the level of poorly keratinized mucous membranes.
c) Multiple aphthosis:
Rare, made of 4 to 10 well-individualized elements;
Sometimes confluent, they take on a herpetiform appearance.
The assessment is essentially etiological; trying to find the triggering circumstances in order to be able to avoid them;
The general condition is preserved,
Treatments are symptomatic but do not reduce the duration of the outbreak.
d) Milliliary aphthosis:
Special form of multiple aphthosis
The elements are numerous from 10 to 100, rarely confluent;
Extremely painful
This form must be differentiated from primary infection herpetic stomatitis,
Miliary aphthosis must be differentiated from primary infection herpetic stomatitis, clinical diagnosis is sometimes difficult, but certain elements can point towards viral infection: confluence of elements, alteration of the general condition, fever, perioral lesions
Treatment of miliary aphthosis remains symptomatic.
e) Giant aphthosis:
Size greater than 1 cm
The lesion is most often unique;
The ulceration is sometimes infiltrated with edema, sometimes necrotic, and develops over several weeks, sometimes several months;
Functional signs are important, such as dysphagia, dysphonia, hypersalivation.
Treatment: Thalidomide at a rate of 100mg per day and causes in a few days a spectacular sedation of the pains which had been developing for several weeks, but it remains an old drug which causes serious congenital malformations in pregnant women. Treatment with local corticosteroids has demonstrated its effectiveness.
f) Behçet’s disease:
Turkish dermatologist (Hulusi Behçet) 1937.
It is a vasculitis with various systemic manifestations, the most frequent of which are cutaneous, ophthalmological, articular and neurological. The diagnosis is clinical and based on a set of criteria, essentially those defined by the International Study Group on Behçet’s Disease.
| TABLE II: DIAGNOSTIC CRITERIA FOR BEHCET’S DISEASE (MB) “Lancet, 1990” | |
| Criteria | Comments |
| 1. Recurrent mouth ulcers | Common, giant or miliary aphthae, observed by the doctor or the patient, with a recurrence of at least 3 times in 12 months |
| 2. Plus 2 of the following 4 criteria: | |
| 2.1 Recurrent genital ulcers | Aphthous ulceration or scar, observed by the physician or patient |
| 2.2. Eye injuries | Anterior or posterior uveitis, cells in the vitreous, retinal vasculitis diagnosed by an ophthalmologist |
| 2.3. Skin lesions | Erythema nodosum, pseudofolliculitis, papulopustular lesions, acne nodules. |
| 2.4. Pathergy-test positive | Read by the doctor after 24-48 hours |
Investigations and diagnosis of Behçet’s disease:
Diagnosis is made primarily on the basis of the patient’s reported history of the condition; and by looking for clinical criteria
There is no specific laboratory test
The interview is done in order to recognize or detect other disorders such as Crohn’s disease, celiac disease, neutropenia, HIV and Behcet’s syndrome.
ABs are classified according to 5 clinical criteria:
- the size,
- the number,
- the duration of the lesions’ development,
- the frequency of recurrences,
- and associations with a pathological context.
- This diagnostic step guides any additional investigations and therapeutic choices.
- Recurrent aphthosis is characterized by a frequency of flare-ups greater than 4 per year , regardless of the number of elements, their size, or their duration. Remission periods vary from 2 to 3 months to a few days , and flare-ups are sometimes subitent.
III.3) Recurrent ulcerations: Aphthae and aphtoses: Therapeutic methods:
Mouthwashes :
Mouthwashes prescribed in ABR cases are intended to control microbial contamination and secondary infections.
Although their benefits have not been confirmed, several ATB-based BBs have been used to treat ABR (Tetracycline, Cephalexin);
A solution can be prepared with 250 to 500 mg: 1 to 2 capsules of Vibramycin dissolved in 30 to 50 ml of sterile water.
Compresses can also be soaked and applied directly to the lesion.
Chlorhexidine: Chlorhexidine gluconate acts on healing by reducing the duration of ulceration, but it has no effect on recurrence.
Corticosteroids
Topically, corticosteroids have the effect of limiting the inflammatory process associated with canker sores. The effectiveness of topical corticosteroids in the treatment of canker sores is indisputable; which explains their wide use.
This is supported by the absence of side effects. Dermal creams are however not suitable for intraoral use.
Corticosteroid mouthwashes have the added benefit of not being swallowed and not entering the circulation.
To optimize the effect of corticosteroids, it is recommended to:
Massage with your finger or cotton pad for 30 to 60 seconds.
To keep the product at the level of the ulceration
Avoid eating or drinking for at least 30 minutes afterwards.
Prolonged use of corticosteroids may promote the occurrence of candidiasis.
IV. Bullous lesions:
Clinically, a bubble is a superficial fluid collection with clear or serohaematic content, several millimeters in diameter.
It can be located on the skin or on the mucous membranes.
It is necessary to know how to evoke an elementary bullous lesion in the face of post-bullous erosion.
IV.1) non-autoimmune bullous dermatosis:
- erythema multiforme:
Bullous disease in young adults and children,
It is a development of an immune response against various infectious agents, often HSV is incriminated.
Manifestations of postherpetic erythema multiforme usually appear 7 to 10 days after herpetic recurrence, with a sudden onset.
- Curative damage is characteristic and leads to the diagnosis
- These cockade-shaped lesions, 1 to 3 cm in diameter, form papules centered by a vesicle and surrounded by an erythematous halo.
- A pseudo-flu syndrome may be associated
Mucosal lesions are observed in 50% of cases.
Clinical
Endo-oral examination reveals large post-bullous erosions, covered with fibrin, very extensive, on the anterior part but also on the inner side of the cheeks, the veil and the tongue, hindering eating, mouth opening and examination. Crusted and hemorrhagic cheilitis is very common. Spontaneous remission without sequelae occurs in 2 to 3 weeks.
What to do
A liquid or semi-liquid or substitute diet (Renutryl, Fortimel) is necessary. Proper oral hygiene will be resumed as soon as possible, with gentle brushing using a surgical brush.
Local symptomatic treatment: In all forms, local treatment includes:
– Xylocaine gel applied to erosions;
– compound mouthwashes, with the addition of a bottle of 5% Xylocaine in the preparation. They are prescribed before meals to anesthetize the mucous membranes;
In the major forms, add a tablet of Solupred 20 mg or Célestène dispersible 2 mg to each glass of mouthwash.
IV.2) autoimmune bullous dermatosis:
a) Bullous pemphigoid
- This is the most common, mainly affecting elderly people.
- May begin with generalized pruritus, eczematous or urticarial patches
- The characteristic eruption consists of tense, clear-content blisters, often large, sitting on an erythematous base.
- Mucosal involvement is rare.
B) Pemphigus vulgaris:
It is a rare disease that affects middle-aged adults.
The onset is incisive with erosive mucosal lesions, especially oral , leading to dysphagia and sometimes weight loss.
The typical rash is characterized by flaccid blisters in healthy skin that rapidly rupture leaving non-healing erosions, with a Nikolski sign.
- the mortality rate is around 10%, in progressive or extensive forms general corticosteroid therapy constitutes the initial treatment.
- Prednisone 1 to 1.5 mg/kg/day.
- Cicatricial pemphigoid:
- Characterized by selective involvement of the mucous membranes
- Mainly affects the elderly
- Gingivitis, bullous or erosive stomatitis in the mouth
- Conjunctivitis with risk of blindness due to corneal opacification
- Inconsistent skin involvement
- The potential severity of ocular involvement justifies treatment with immunosuppressants.
Conclusion :
Oral ulcers and canker sores remain a very broad area in Odontostomatology, sometimes requiring multidisciplinary collaboration so that the treatment is comprehensive.
In oral medicine, the primary aim of treating these patients is analgesic. However, the dentist contributes to the early diagnosis of certain aphthous lesions and oral ulcers, since he is the only observer of the oral cavity, and this through his precise clinical examination.
Good oral hygiene Regular scaling at the dentist Dental implant placement Dental x-rays Teeth whitening A visit to the dentist The dentist uses local anesthesia to minimize pain