Oral Mucosa: Recurrent Oral Ulceration

Question 1

Ulcer features?

Answer 1

A full thickness loss of epithelium
Exposes underlying CT
Ulcer covered by slough
Underlying granulation tissue (healing tissue - endothelial cells and fibroblasts)
Mixed inflammatory infiltrate
Usually painful
Erosion = partial loss of the epithelium

Question 2

Histology of ulcers?

Answer 2

Fibrino-purulent slough on top

Granulation tissue under

Question 3

Primary ulcers?

Answer 3

Begin as ulcers

Question 4

Secondary ulcers?

Answer 4

Begin as a blister/vesicle

Question 5

Ulcer - differential diagnosis?

Answer 5

Neoplastic e.g SCC (usually floor of mouth, lateral tongue, retromolar area)
Traumatic e.g. sharp tooth
Developmental - epidermolysis bullosa
Infective - Syphilis, HSV, TB
Idiopathic - RAS
Iatrogenic - drugs
Manifestation of dermatological disease e.g. lichen planus
Manifestation of systemic disease e.g. crohn’s

Question 6

Oral ulceration - how to take a history?

Answer 6

Drugs can cause episodes - question drugs

Single episode

• Single ulcer e.g. SCC
• Multiple ulcers e.g. herpes zoster

Recurrent episodes

• Single ulcer - mucocutanous disorders
• Multiple ulcers e.g. RAS, mucocutaneous disorders

Question 7

Singe episode ulcers - what can cause them?

Answer 7

Trauma
- Physcial, chem, thermal factitious

Malignancy
- SCC, Salivary neoplasm, lymphoma

Infection
- TB, symphilis, HSV

Drugs
- Methotrexate (immunosuppressant)

Question 8

Treatment of single episode traumatic ulcers?

Answer 8

Reassurance
Remove cause
Consider difflam and corsodyl
Should show signs of improvement - if not refer for biopsy

Question 9

Malignant ulcers - how can they present?

Answer 9

Raised, ROLLED BORDERS

Question 10

Oral malignant ulcer - what is a red flag?

Answer 10

Any ulcer that is >3 weeks duration of unexplained cause = BIOPSY

Question 11

Causes of single episode ulcers when there are multiple ulcers?

Answer 11

Herpes simplex
Herpes zoster
Erythema multiforme
Hand, foot and mouth = coxsackieviruses
Herpangina
Iatrogenic e.g. drugs

Question 12

Drugs which can cause oral ulcers?

Answer 12

Allopurinol
Cytotoxics
Gold
Indomethacin
Methotrexate
Methyldopa
Nicorandil = anti angina medication - heal very quickly when dose reduced or stopped
Penicillamine

Irradiation - head and neck radiotherapy

Question 13

How to manage drug related ulcers?

Answer 13

Liaise with GP or consultant

Question 14

How to manage infective causes?

Answer 14

Most are self limiting, some require anti-fungals (candidiasis) /antibiotics (syphilis) /aciclovir (herpes virus)

Question 15

Recurrent episodes of oral ulcers?

Answer 15

Single ulcer e.g. mucocutanous disorders

Multiple ulcers e.g. RAS, mucocutaenous disorders

Question 16

Recurrent aphthous stomatisis (RAS) - types?

Answer 16

Minor recurrent aphthous stomatitis
Major RAS
Herpetiform RAS - not linked to herpes, ulcers formed looked like herpes ulcers

Question 17

Other causes of recurrent multiple ulcers?

Answer 17

Behcet’s disease
Recurrent erythema multiforme
Muco-cutaneous disorders
Other systemic disorders

Question 18

Recurrent aphthous stomatitis features?

Answer 18

Common, affects 20% of population
Painful
May affect eating, drinking, speech
Most common type is the minor RAS
Occasionally very disabling
FH

Question 19

Minor aphthous ulcers?

Answer 19

80% of RAS ulcers
Peak range 10-30
Usually 1-5 ulcers, 3-8mm diameter
Minor RAS must be less than 10MM
Last 7-10 days 
Variable ulcer free period
Usually non-keratinised mucosa
Usually front of mouth
Heal without scarring

Question 20

Major aphthous ulcers?

Answer 20

10% of ulcers
May be larger - up to 1.5-2cm
Major RAS must be over 10mm
Last longer - 3 weeks to 3 months 
Single or multiple
Often affect back of mouth
Often non-keratinised mucosa, but can affect masticatory mucosa
May heal with scarring

Question 21

Herpetiform oral ulceration?

Answer 21

Less than 5% of ulcers
Dozens of small 1-2mm ulcers
May coalesce to form larger irregular ulcers
Mainly floor of mouth, margins and ventral surface of tongue
Lasts 7-10 days
Not associated with herpes infection (no vesicles)

Question 22

Contributory factors of aphthous ulcers?

Answer 22

Stress
Trauma
Hormones
Smoking - negative relationship

Question 23

Predisposing/underlying factors for aphthous ulcers?

Answer 23

Haematological deficiencies (Fe, B12, folate)
Neutropenia
Immune deficiency (HIV)
GI tract disease (coeliac, crohn’s, UC)
Vitamin deficiency (B1, B2, B6)
Food intolerance - chocolate, cinnamon, benzoates

Question 24

Investigations for aphthous ulcers?

Answer 24

Not always needed
FBC, ferritin, B12 and folate
Coeliac screen
Other tests according to history e.g. food allergies

Question 25

Treatment for aphthous ulcers?

Answer 25

Preventative - Correct haematological deficiencies - Treat underlying systemic disease - Remove trauma - Dietary elimination - OHI/diet advice Symptomatic tx (local) - Corsodyl MW - Difflam MW - Covering agents e.g. gengigel, orobase paste Suppressive tx (local) - Topical steroids - Hydrocortisone pellets (corlan) - Beclometasone spray (clenil modulite inhalter) - Betamethasone MW (betnesol) = most common - Flixonase nasules Suppessive tx (systemic) - Prednisolone (steroid) - Thalidomide - Azathioprine

Question 26

Tx for herpetiform oral ulceration?

Answer 26

Doxycycline MW

Question 27

Behcet's disease symptoms? Who/where is it more common?

Answer 27

Serious systemic disease - Blindness - Neurological damage - Severe oro-genital ulceration - Vasculitis - Death Mainly young adult males - 30yrs Incidence higher in japan and Turkey

Question 28

How to diagnose someone with Behcet's disease?

Answer 28

Recurrent oral aphthous ulceration PLUS 2 of the following: - Recurrent genital ulcers - Uveitis, cells in the vitreous or retinal vasculitis - Skin lesions: erythema nodosum, acne like papulopustular lesions - Positive pathergy test = large crusty lesions Other common features - Arthritis, GI lesions, CNS involvement, vascular lesions

Question 29

Management of Behcet's disease?

Answer 29

``` Multi-disciplinary approach Oral med Dermatology Rheumatology Opthalmology ```

Question 30

Other causes of oral ulceration?

Answer 30

Muco-cutaneous disorders - Lichen planus - Pemphigus - Pemphigoid - Erythema multiforme Haematological disorders Gastro-intestinal disorders

Question 31

When is a biopsy undertaken?

Answer 31

Usually because a clinician wants to exclude malignancy Many non-malignant ulcers look identical under the microscope = Clinical history and findings are crucial

Question 32

Ulcer history?

Answer 32

``` Size Shape Number Location Duration Periodicity - how often they're getting them Pain Precipitating factors Relieving factors ```

Question 33

Ulcer examination?

Answer 33

``` Size Shape Site Number Base - malignant are hard Edge Discharge Consistency - lumpy Nodes - attached/do not move, hard if cancerous Other features ```