Exodontia.Info
Angina Bullosa Hæmorrhagica
(Oral Blood Blisters)
What is Angina Bullosa Hæmorrhagica (ABH)?

Angina Bullosa Hæmorrhagica (Angina 'painful',
bullosa 'a blister' & hæmorrhagica 'blood-filled'),  
(initially termed as
traumatic oral hæmophlyctenosis)
is the term used to describe benign and generally,
sub-epithelial oral mucosal blisters filled with blood,
which are not attributable to a systemic disorder or
hæmostatic defect (clotting disorder).
The blood blisters may be confused with other more
serious disorders (e.g.,
dermatitis herpetiformis,
epidermolysis bullosa acquisita, mucous membrane
pemphigoid, cicatricial pemphigoid, pemphigoid
gestationis
, linear IgA disease, bullous lichen planus,
amyloidosis, blood dyscrasias) however, the isolated
nature, rapid healing and rare recurrence of
ABH blisters
generally are sufficient findings to rule out the previously
mentioned conditions.

The lesions maybe indistinguishable from blood blisters
related to low level of platelets (
thrombocytopænia)
however blood tests and the absence of areas of bruising
(
ecchymosis), nose bleeds (epistaxis) or bleeding from the
gums are helpful signs to rule it out.

Angina bullosa hæmorrhagica (ABH) is a rare acute and
benign blood blistering oral disorder that predominantly
affects middle-aged or elderly people (60% of the patients
in the range of 45 - 70 years).  Both sexes are equally
affected.


What are the signs and symptoms of Angina Bullosa
Hæmorrhagica
(ABH)?

Some patients describe a stinging pain or burning
sensation immediately before the appearance of the blood
blister.  The blisters last only few minutes and then
spontaneously rupture, leaving a shallow ulcer that heals
without scarring, discomfort, or pain.

Patients do not report a tendency to bleed at other sites.

Family history generally is non-contributory (though there is
a suggestion that it can be associated with type II
diabetes, hyperglycemia or a family history of diabetes
however there is no conclusive evidence of a cause-and-
effect relationship between the presence of
ABH and
glucose metabolism).

Physical:

•        The lesions reach an average size of 1 - 3 cm in
diameter.
•        The soft palate is the most commonly affected site.  
Occasional lesions have been reported in the buccal
mucosa and tongue (the anterior third is most commonly
affected in the tongue).
•        Approximately one third of the patients exhibit blood
blisters in more than one location.
•        The oral mucosa attached to bone (ie, ‘
masticatory
mucosa
’ represented by the hard palate and gums) is not
affected.
•        Similar lesions in other mucous membranes or the
skin have not been reported.
Photo of ABH on the left lateral border of the tongue
What are the causes of Angina Bullosa Hæmorrhagica
(
ABH)?

  • Slightly more than 50% of the cases described are
    related to the minor trauma of hot foods, restorative
    dentistry (fillings, crowns etc) or periodontal therapy
    (treatment of gum disease).

  • Other potential causes that have been mentioned in
    the literature are dental injections of anæsthetics and
    steroid inhalers.

  • A causative factor is not identified in almost 50% of
    patients.


Investigations:

Lab Studies:

  • Platelet counts and coagulation tests are within normal
    limits.

Procedures:

  • Performing a biopsy of an intact bulla is difficult
    because of the short duration of the lesion.

Histologic Findings:

  • The diagnosis is essentially clinical; however, in the
    cases in which a biopsy has being taken, the
    microscopic examination reveals a sub-epithelial bulla
    filled with blood and an underlying mild and non-
    specific mono-nuclear inflammatory cell infiltrate that
    generally is limited to the region of the lamina propria.

  • Performing a biopsy of an intact bulla is difficult
    because of the short duration of the lesion.  
    Otherwise, a biopsy of a ruptured bulla exhibits just a
    non-specific ulceration. According to Scully et al,
    direct immuno-staining for immunoglobulin G (IgG),
    immunoglobulin A (IgA), or C3 consistently are non-
    contributory.

  • However, laboratory tests are sometimes necessary
    to rule out any other bullous diseases.


Treatment:

Medical Care:

  • No treatment is required because the blood blisters
    spontaneously rupture and heal. Coagulation tests and
    platelet count may be indicated to rule out a blood
    dyscrasia.

Prognosis:

  • ABH is a benign condition.


Useful Websites:

Emedicine

New Zealand Dermatological Society (DermNZ)

British Medical Journal

Wikipedia

Index Medicus / PubMed
Last Updated 30th August 2010