Full-text - Polski Przegląd Otorynolaryngologiczny

Full-text - Polski Przegląd Otorynolaryngologiczny

praca przeglądowa / review
Diagnostics of stomatitis with mucosal
erosions and ulcers
Diagnostyka zapaleń jamy ustnej z nadżerkami
i owrzodzeniami błony śluzowej
Elżbieta Waśniewska-Okupniak1, Witold Szyfter1
Klinika Otolaryngologii i Onkologii Laryngologicznej Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu
Kierownik Kliniki: prof. dr hab. med. Witold Szyfter
1
Article history: Received: 22.11.2014 Accepted: 03.12.2014 Published: 28.02.2015
ABSTRACT:Ulcers and erosions of the oral mucosa may occur primarily due to various local factors or be secondary to a
lot of systemic diseases or administered drugs. Frequently, diagnostic procedures and therapy require close
cooperation of an laryngologist with doctors of other specialties: dermatologists, gastroenterologists, rheumatologists, hematologists or dentists. This study presents the most common etiological factors of oral mucosa
ulcers and erosions and determines basic rules for their differential diagnostics. Furthermore, the two forms of
secondary eruptions, that are often interchangeably used in medical literature, were defined according to the
histopathological classification.
KEY WORDS: stomatitis, ulceration, erosion
STRESZCZENIE: Owrzodzenia i nadżerki błony śluzowej jamy ustnej mogą powstawać pierwotnie w wyniku szeregu czynników
miejscowych lub wtórnie na wskutek wielu chorób ogólnoustrojowych czy przyjmowanych leków. Niejednokrotnie ich diagnostyka i leczenie wymaga od laryngologa ścisłej współpracy z lekarzami innych specjalności:
dermatologami, gastroenterologami, reumatologami, hematologami czy stomatologami. W pracy przedstawiono najważniejsze czynniki etiologiczne powstawania owrzodzeń i nadżerek na błonie śluzowej jamy ustnej oraz określono podstawowe zasady ich diagnostyki różnicowej. Ponadto zdefiniowano według terminologii
histopatologicznej obie formy wykwitów wtórnych, które niejednokrotnie w piśmiennictwie medycznym są zamiennie stosowane w wielu jednostkach chorobowych.
SŁOWA KLUCZOWE: zapalenie jamy ustnej, owrzodzenie, nadżerka
INTRODUCTION
Ulcers and erosions of the oral mucosa may develop primarily due
to various local factors or be secondary to many systemic diseases
or administered drugs. The occurrence of similar and non-specific
clinical symptoms resulting from often unknown systemic causes, usually generates the highest number of diagnostic and therapeutic difficulties and frequently requires close cooperation of
an laryngologist with doctors of other specialties: dermatologists,
gastroenterologists, rheumatologists, hematologists or dentists.
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 1 (2015), s. 15-19
It seems that the ability to differentiate erosive lesions from
proper ulcerations of the oral mucosa is vital in order to properly direct the diagnostic procedures and to make a correct
final diagnosis. It is often observed that the two types of secondary eruptions have a similar clinical picture or may occur simultaneously in the oral mucosa, which leads to great
diagnostic difficulties. Both terms, i.e. erosion/ulceration, are
also quite often used interchangeably in literature (even for
the same disease), which cannot be fully justified according
to histopathological terminology.
DOI: 10.5604/20845308.1132407
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praca przeglądowa / review
ULCERATION (ulceratio, ulcus) is an open wound of the oral
mucosa in which there is a gradual disintegration of pathological tissue and sloughing of necrotic masses, with further
development of craterlike tissue defects. This term is usually
used if the damage to the mucosa exceeds the epithelial basal
membrane and reaches the proper mucosa, and in most cases a scar forms as it heals. It develops as a result of primary
lesion (tumors, nodules, pustules) disintegration, or it can
also result from thermal, chemical and radiation injuries [1-4].
EROSION, on the other hand, is a term that denotes superficial breakage of the continuity of the epithelium that lies above
the basal membrane cell layer. A scar forms rarely as the eruption heals. It develops at places in which primary lesions could
be found (vesicles, blisters, papulae) as a result of a mechanical trauma or trophic lesions. In the beginning it is red, then,
when damage to the mucous membrane encompasses the full
thickness of the epithelium, it is covered with a layer of fibers
and becomes yellow-red in color [1-4].
Most important etiological factors of oral mucosal ulcerations
and erosions were presented, and basic rules for their differential diagnosis were defined.
MAIN CAUSES OF ULCERATIONS AND
EROSIONS WITHIN THE ORAL CAVITY
Most ulcerations/erosions in the oral cavity are caused by local
factors such as trauma or burns. However, neoplastic lesions
and systemic diseases should always be taken into account. A
classification of lesions based on etiological factors and the development mechanism are presented in Table I [2].
Table II. Basic causes of oral mucosal ulcerations/erosions
THE CAUSES OF ULCERATIONS/EROSIONS IN THE ORAL CAVITY
I. LOCAL CAUSES
– POSTTRAUMATIC ULCERATIONS
1. Mechanical trauma
2. Burns
a. C hronic Ulcerative
Stomatitis
a. Thermal
b. Lichen planus
b. Chemical
c. Pemphigus vulgaris
c. Radiation
d. Mucous membrane pemphigoid,
d. Electric
e. A
cquired epidermolysis
II. TUMORS
III. Recurrent Aphtous Stomatitis (RAS)
1. Recurrent Aphtous Stomatitis Minor (MiRAS)
2. Recurrent Aphtous Stomatits Major (MaRAS)
3. Herpetiform Recurrent Aphtous Stomatitis
(HeRAS)
IV. DRUG REACTIONS
1.Immunosuppressants and cytostatics
2. N
onsteroidal anti-inflammatory drugs
(NSAIDs)
3. Antibiotics and sulfonamides
V. SYSTEMIC DISEASES
1. Infections
a. viral
• Gingivo-stomatitis herpetica, recurrent
Herpes simplex
bullosa
f. linear IgA bullous dermatosis – LABD
3.Lymphatic and haematopoetic system
diseases
a. Anemia
b. Congenital neutropenia
c. L ymphatic and haematopoetic
system proliferative disorders
• L eukemia
• L ymphoma
•M
yelodysplastic syndromes
4. Gastrointestinal disorders
a. Celiac disease
b. Crohn’s disease
c. Colitis ulcerosa
5. Systemic connective tissue diseases
•V
aricella, Herpes zoster
a. Reactive arthritis
• I nfectious mononucleosis
b. Lupus erythematosus
• C ytomegalovirus infection
• Herpes simplex pharyngitis; Hand, foot and
mouth disease
• Acquired Immune Deficiency Syndrome
(AIDS)
b. bacterial
• HNecrotizing ulcerative gingivitis
• S yphilis
• P rimary, postprimary tuberculosis,
BASIC PRINCIPLES OF DIAGNOSTIC
PROCEDURES IN STOMATITIS WITH
ULCERATIONS AND EROSIONS
2. Mucosa and skin diseases
tuberculosis luposa
c. fungal
•H
istoplasmosis
• C ryptococcosis
6. Vascular diseases
a. B
ehçet disease (Behçet’s syndrome)
b. G
ranulomatosis with polyangitis
=Wegener’s granulomatosis
7. Endocrine disorders
a. Diabetes
8. Disorders with unknown pathogenesis
a. P FAPA syndrome periodic fever,
aphtous stomatitis, pharyngitis and
cervical adenitis))
• P aracoccidioidomycosis
Pathological oral lesions such as erosions and ulcerations may
be of local origin or may be the symptoms of systemic diseases.
Quite often they are the first signs of diseases or pathological
syndromes such as hematological diseases, systemic connective tissue disorders or cutaneous diseases. It is crucial to relate
subjective symptoms and physical examination or clinical test
results in order to make the right diagnosis.
Medical history
First of all, during history-taking one should obtain information concerning the moment of time at which eruptions de16
veloped and their duration. Short-lasting, usually self-limiting
oral erosions or ulcerations with sudden onset are normally
related to a trauma, burn or viral infection. Long-lasting ulcerations may mean that a potential cause of the disease is neoplastic process, chronic trauma, chronic skin disease or chronic infection, e.g. syphilis or tuberculosis. It is also important
to determine whether a given ulceration occurs as a single lesion or whether there are multiple lesions. A single ulceration
or erosion present for more than 3 weeks, without apparent
healing symptoms, should be considered seriously, as it may
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be a neoplastic lesion. Multiple long-lasting ulcerations are
most frequently caused by chronic skin diseases (e.g. pemphigus, pemphigoid, lichen planus), hematological disorders,
gastro-intestinal disorders or immune disorders [5]. Multiple
short-lasting ulcerations are usually of viral origin (most frequently caused by herpes virus, Coxsackie) or may be caused
by aphtae – in such cases they heal spontaneously, usually within a week, to a month [2,6]. While taking medical history
one should also take into account whether the lesions occurred for the first time or whether it is one of recurrent episodes. Recurrent erosions and ulcerations are characteristic for
e.g. aphtous stomatitis. It should also be determined whether
the patient uses prosthetic restorations – if he/she does, then
one should inquire for how long and whether he/she relates
any symptoms with them.
An important clue is the information whether oral eruptions
are accompanied by similar cutaneous lesions or whether systemic symptoms are observed, such as e.g. fever, chronic cough,
gastro-intestinal disorders, weight loss, fatigue, cachexia and/
or other clinical symptoms suggesting a chronic infection (e.g.
tuberculosis, syphilis, HIV), hematological disorder, systemic
connective tissue disorder, inflammatory bowel disease or neoplastic process. It is also important to determine what drugs
are taken by the patient, as some of them (mainly cytostatics,
immunosuppressive drugs and non-steroid anti-inflammatory
drugs) frequently lead to the development of painful erosions
and ulcerations of the oral mucosa [7-9].
Physical examination
Laryngological physical examination – while performing an
oral examination (visual or with palpation), one should first
of all evaluate pathological lesions in detail, i.e. note down the
amount of ulcerations/erosions, their location and their characteristic features: shape, size, characteristic features of margins, the structure of the bottom, exudate, painfulness, the state of the surrounding mucosa and the reaction of neighboring
lymph nodes (Table II) [2,4,10-12].
After examining pathological lesions visually and with palpation (increased firmness of the lesion may suggest malignant
nature of the ulceration!), one should examine the state of patient’s teeth, paying close attention to the presence of carious
cavities, improper restorations, sharp teeth edges and misaligned prosthetic restorations that quite often constitute the local
cause of painful oral erosions and ulcerations [2,3]. Frequently,
the diagnosis of the cause, due to which the ulceration develops, is determined by the state of the surrounding mucosa and
other oral pathological lesions – e.g. paleness of the mucous
membrane, petechiae, gingival bleeding – in acute myeloid or
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 1 (2015), s. 15-19
Table II. Detailed features of oral mucosal ulcerations and erosions
FEATURE
EROSION
ULCEROSIS
Shape
Round, oval (e.g. Recurrent
Aphtous Stomatitis Minor
(MiRAS))
Irregular (drug reactions)
Oval (eg. Recurrent Aphtous
Stomatits Major (MaRAS))
Irregular (drug reactions)
Small lesions (e.g. Postprimary
tuberculosis)
Size
Small lesions (e.g. Recurrent
Aphtous Stomatitis Minor
(MiRAS))
Large lesions (e.g. Pemphigus
vulgaris, pemphigoid)
Margin
Even, smooth (e.g. Recurrent
Aphtous Stomatitis)
Uneven (e.g. Pemphigus
vulgaris)
Even, smooth (eg. Primary
syphilis)
Uneven, lacerated (e.g.
Postprimary tuberculosis)
Floor
Most commonly smooth
Smooth (eg. Primary syphilis)
Granulated ((eg. Postprimary
tuberculosis)
Basis
Free from infiltration
Soft (e.g. Postprimary
tuberculosis)
Hard and infiltrated (tumours,
Primary syphilis, Recurrent
Aphtous Stomatitis Major
(MaRAS))
Secretion
Serous, serofibrinous (e.g.
Recurrent Aphtous Stomatitis)
Serosanguineous (e.g.
Pemphigus vulgaris, Herpes
zoster)
Serous (e.g. Primary syphilis)
Purulent (Stomatitis ulcerosa)
Soreness
Changeable symptom
Severe pain (e.g. Recurrent
Aphtous Stomatitis, Pemphigus
vulgaris)
Common with the majority of
ulcerations (e.g. Traumatic, drug
and neoplastic ulcerations)
Surroundings
Normal (e.g. Primary syphilis),
inflammatory (e.g. Recurrent
Aphtous Stomatitis)
Normal (e.g. Primary syphilis)
Inflammatory (e.g. Stomatitis
ulcerosa)
Local
lymphatic
reaction
Enlarged and painful lymph
nodes (e.g. Recurrent Aphtous
Stomatitis)
Often normal
Enlarged and painful lymph
nodes (e.g. Recurrent Aphtous
Stomatitis Major (MaRAS))
Enlarged, hard, painless (e.g.
Primary syphilis, metastases)
Healing
Without leaving a scar
Leaves a scar
Large lesions (e.g. Recurrent
Aphtous Stomatitis Major
(MaRAS))
lymphoblastic leukemia, lesions such as hairy leukoplakia or
Kaposi’s sarcoma– in HIV/AIDS infections, etc. [8,13].
Additional tests
Apart from correctly taken medical history and an appropriately performed physical examination, appropriately conducted
and interpreted additional tests are also important in order to
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make the right diagnosis in oral ulcerations. Additional, frequently performed tests include:
– Blood test
• Complete blood count with differential count
• Measurement of iron, B12 vitamin and folic acid levels
– if deficiency anemia is suspected
• Glucose serum concentration measurement – in order
to exclude diabetes
• Serological tests – in ulcerations of autoimmune origin
or in infectious diseases
– Microbiological tests – performed when an infection is suspected. They involve bacteriological and mycological diagnostics, as well as viral cultures.
– Biopsy – it may be necessary, especially if:
• A single ulceration is present for a time period
exceeding 3 weeks
• Traumatic ulcer is present for a time period exceeding 3
weeks after a traumatic injury
• Solid lesion with increased firmness in palpation
• The presence of cutaneous lesions outside the oral
cavity
Mucosal biopsies are in most cases excisional or incisional,
performed under local topical anesthesia [2]. Correctly col-
lected biopsy material should contain both the pathological
and the physiological tissue. In cases of oral mucosa ulcerations, the tissues surrounding the lesion provide the doctors
with the majority of histopathological data, as, according to
the definition, ulceration is the loss of a greater part of the
epithelium.
– Diagnostic imaging – in selected cases, e.g. chest CT or
radiograph if tuberculosis, sarcoidosis or neoplasm is suspected
– SPECIALIST CONSULTATION – if systemic causes of
erosions and ulcers are suspected, interdisciplinary diagnostic-therapeutic procedures, which require consultation and cooperation of i.a.: dermatologists, gastroenterologists, rheumatologists, hematologists or dentists,
are inevitable.
Understanding the etiology and pathogenesis of inflammatory oral diseases, in which ulcers and erosions develop, has
changed significantly over the last years thanks to constant
development of clinical research in the field of basic sciences, immunology, microbiology and genetics. We can detect
the relationship between many systemic diseases and ulcerations within the oral cavity early enough and prevent the development of their severe local and systemic complications.
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Word count: 1329 Tables: 2 Figures: – References: 13
Access the article online: DOI: 10.5604/20845308.1132407 Full-text PDF: www.otorhinolaryngologypl.com/fulltxt.php?ICID=1132407
Corresponding author: dr n. med. Elżbieta Waśniewska-Okupniak, Klinika Otolaryngologii i Onkologii Laryngologicznej, Uniwersytetu
Medycznegoim. K. Marcinkowskiego, ul. Przybyszewskiego 49, 60-355 Poznań, te. +48618691387, faks. +48618691690, e-mail: [email protected]
Copyright © 2015 Polish Society of Otorhinolaryngologists Head and Neck Surgeons. Published by Index Copernicus Sp. z o.o. All rights reserved Competing interests: The authors declare that they have no competing interests.
Cite this article as: Waśniewska-Okupniak E., Szyfter W.: Diagnostics of stomatitis with mucosal erosions and ulcers. Pol Otorhino Rev 2015; 4(1): 15-19
POLSKI PRZEGLĄD OTORYNOLARYNGOLOGICZNY, TOM 4, NR 1 (2015), s. 15-19
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