Oral Ulceration Flashcards
What are ulcers?
- Ulcers are breaks in the continuity of the epithelium exposing the CT
- All are covered by a grey/yellow fibrin slough
- May have sharp well-defined border or ragged margins
- Rapid turnover of the oral mucosa allows ulcers to heal rapidly (few days - 2 weeks)
Classification of ulcers
- clinically, useful to divide ulcers into those that are persistent and those that are recurrent
- recurrent ulcers have few common causes
Clinical presentation of traumatic ulcers
- usually caused by biting, denture trauma or chemical trauma at trauma prone sites (lips, buccal mucosa or near denture flange)
- yellow-grey floor of fibrin slough and red margins
- variable inflammation, swelling and erythema depending on cause and time since trauma
- no induration (hardening) unless the site is scarred
- Should heal in 10 days after elimination of cause - if not then biopsy
What is an eosinophilic ulcer and what is the clinical presentation?
- Cause is unknown but suspected to be response to trauma
- Presents as deep ulcer usually on the tongue often resemble carcinomas and exceeding 10mm
- Heals spontaneously within 3-10 weeks
- Biopsy usually taken to exclude carcinoma
What is a factitious ulcer and what is the clinical presentation?
- Unintended factitious injury can follow repetitive habits such as picking at gingival margin with finger-nail
- Usual presentation is a non-healing ulcer in anterior of mouth caused by repeated physical trauma
What are the typical features of recurrent aphthous stomatitis?
- Most common oral mucosal disease (25% of population) and onset peaks in adolescence
- Ulcers have smooth sharply defined margin with erythematous rim in enlarging phase which reduces once ulcer is full size
- Attacks at variable intervals
- Often have prodromal phase (prickling/sensitivity before ulcer forms)
- Ulcers almost never occur on keratinised mucosa
- Usually self-limiting
Three types of recurrent aphthous ulcer and what are their typical features
Minor aphthae
- Most common type
- 2nd decade
- Non-keratinised mucosa
- Shallow rounded 3-7mm with erythematous margin and yellowish floor
- 1-5 ulcer crops
Major
- 1st decade
- Masticatory mucosa (dorsum of tongue)/any surface
- Ulcer persist for several months and scarring may follow healing
- > 10mm with indurated edge
- 2-10 ulcer crop
Herpetiform
- 3rd decade
- Non-keratinised mucosa
- 0.5-3mm, rounded with bright erythema
- 5-40-100 ulcer crop which may coalesce to form irregular ulcers
Aetiology of recurrent aphthous ulcers
Haematological deficiencies e.g. b12, folate, iron
Genetic predisposition
Exaggerated response to trauma
Immunological abnormalities
GI disorder
Hormonal disturbances e.g. luteal phase of menstrual cycle
Stress
HIV infection
After quitting smoking - nicotine supplements prevent
Investigations to help diagnose RAU
- Anaemia, B12, red cell folate and iron deficiencies
- History of diarrhoea, constipation or blood in stools suggesting GI
- Biopsy plays no role in diagnosis except to exclude carcinoma
Management of RAU
- Treatment is empirical (based on observation) and palliative only
- Before tx exclude underlying causes (iron deficiency etc.) and exclude Bechet’s
- Refer when minor/herptiform not responding to tx and major RAS
1. reassurance and education
2. corticosteroids - hydrocortisone 2.5mg oromucosal tablets dissolved next to ulcer to reduce inflammation
3. tetracycline mouth rinse antiseptic may reduce healing time and discomfort
4. chlorhexidine to reduce duration
5. topical salicylate preparations which is anti-inflammatory (Bonjela)
6. local analgesics - topical lidocaine
What are the clinical presentations of Behçet’s Disease
- Pts usually young males between 20-40 yrs and can be triggered by infection
1. Mucocutaneous: oral aphthae and often genital ulceration and other rashes (erythema nodosum and vasculitis)
2. Arthritic: large weight-baring joints
3. Neurological: usually late stage. Vasculitis within the brain causes sensory/motor disturbances, confusion and fits
4. Ocular: Uveal inflammation or vasculitis and thrombosis of the retinal arteries which can lead to blindness
What are the diagnosis criteria for Behçet’s Disease
4 or more points is Behçet’s Disease
2 points each
- Oral Ulceration
- Genital Ulceration
- Ocular Manifestations
1 point each
- Skin lesions
- Neurological manifestations
- Vascular manifestations
- Positive Pathergy (exaggerated skin injury)
Management of Behçet’s Disease
treatment is difficult
ciclosporin or tacrolimus (immunosuppressants) are the main treatments, with steroids for acute exacerbations
Which ulcers are HIV patients more susceptible to?
How should they be treated?
- Severe recurrent aphthae - most are major or herpetiform
- Ulcers whose presentation does not match any of the three patterns are just called ‘HIV ulceration’
- Biopsies should be taken to exclude opportunistic infections (EBV, lymphoma, fungal infections)
- Topical steroids is effective
- Antiretrovirals reduce severity and incidence
Which drug can induce ulcers? And what is the clinical appearance of these ulcers?
- The K+ channel activator Nicorandil used to dilate arterioles in angine causes ulcers in 5% of pts on the drug (usually at high doses)
- Usually on lateral tongue, buccal mucosa or gingivae
- Painful and deep with punched-out or overhanging margin
- Persist for several months unless drug is withdrawn
