7 Ulcerative and Inflammatory Conditions
Most cases of recurrent aphthae are idiopathic; however, aphthous-like lesions are seen in Behçet disease, Crohn disease (often linear in the sulcus), hematinic deficiencies, some hypersensitivity reactions (to food, sodium lauryl sulfate found in toothpaste), cyclic neutropenia, and HIV infection. Complex aphthosis is often used to describe lesions associated with syndromes affecting the skin. Ulcers in children may be part of periodic fever, aphthosis, pharyngitis, and adenopathy (PFAPA) syndrome. Trauma and stress bring on episodes in susceptible individuals. Minor aphthous ulcers do not tend to be biopsied because of the typical history and presentation, whereas major ulcers are biopsied to rule out vesiculobullous disease. Chemotherapy-induced ulcerations are much larger, resolve predictably over 1 to 2 weeks, and are not aphthous ulcers.
Traumatic ulcers are caused by trauma—usually on buccal mucosa, tongue, and lower lip (also on sites of morsicatio mucosae oris)—and are indistinguishable histologically from recurrent aphthous ulcers. They also occur secondarily on lesions that protrude (e.g., fibromas and gingival nodules).
• Recurrent aphthous ulcers begin in the second and third decades of life and diminish in severity with age; ulcers are episodic or continuous and only on the nonkeratinized mucosa, although tongue dorsum may be involved in hematinic deficiency; a yellow fibrin membrane with surrounding erythema is present (Fig. 7-1, A-C).
• Minor ulcers are the most common, are smaller than 1 cm in size, and last 1 to 2 weeks; major ulcers are the least common, are larger than 1 cm in size, last for weeks or months, and often are associated with scarring—this form is often seen in HIV/AIDS. Herpetiform ulcers are uncommon and number more than 10 minor ulcers at each episode; severe aphthous ulcers present as continuous ulcerations.
• Fibrin membrane with enmeshed neutrophils and underlying granulation tissue with acute and chronic inflammatory cells confined to the lamina propria; adjacent epithelium exhibits spongiotic pustules and reactive atypia (such as multinucleated epithelial cells and basal cell hyperplasia) (Fig. 7-2); traumatic ulcers often show adjacent hyperparakeratosis and surface bacterial colonies.
FIGURE 7-2 Traumatic ulcer. A, Loss of epithelial integrity and acute and chronic inflammation. B, Fibrin membrane containing many neutrophils with adjacent frictional hyperparakeratosis, acanthosis, and spongiotic pustules. C, Reactive epithelial atypia.
• Topical or systemic steroid therapy or other immunosuppressive agents (see Appendix A) and topical analgesia are indicated.
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