Oral Ulceration

Question 1

What is an ulcer?

Answer 1

A full thickness breach of the epithelium”

Question 2

What sorts of questions should you ask when taking a history for oral ulceration?

Answer 2

1. Number?
2. Size?
3. Site/ Where?
4. Frequency?
5. Duration?
6. Ulcer free period?
7. Pain?
8. Habits?
9. Associations? - food/menstrual period?
10. Family history?
11. Systemic - GI, weight loss, blood in stools, abdominal pain
12. MH?
13. Medication/dose change?

Question 3

Which form of RAS commonly results in scarring?

Answer 3

Major RAS

Question 4

What medication can cause oral, ocular ulceration?

Answer 4

Nicorandil

Question 5

Why is it important to decide if the ulcer is persistent or recurrent?

Answer 5

Oral cancer can present as a single persistant oral ulcer

Question 6

if you suspect oral cancer what must you do?

Answer 6

refer that SAME day under local referral pathway

Question 7

what must you include in the referral for suspicious oral cancer lesions?

Answer 7

• clinical photos
• medical/social history

Question 8

what type of investigations might be needed in ROU?

Answer 8

FBC, haematinics and coeliac screening bloods

Question 9

what is ROU?

Answer 9

recurrent oral ulceration (refers to ANY cause for recurrent oral ulcers)

Question 10

What is RAS?

Answer 10

Recurrent aphthous stomatitis? (specific diagnosis)

Question 11

What are the 3 variants of RAS?

Answer 11

minor, major and herpetiform?

Question 12

is there a strong genetic predispostion with RAS?

Answer 12

Yes!

Question 13

What is the rough amt of ulcers you would see in minor, major and herpetiforme RAS

Answer 13

1-5
1-10
10-100

Question 14

what would you expect the size of the ulcers to be in minor, major and herpetiforme RAS?

Answer 14

<10mm
>10mm
1-2mm

Question 15

what would the duration of each ulcer be in minor, major and herpetiforme RAS?

Answer 15

4-14
>30
<30

Question 16

what type of RAS commonly leads to scarring?

Answer 16

Major RAS

Question 17

What is the most common form of RAS?

Answer 17

minor RAS

Question 18

What are some causes of persistent oral ulceration?

Answer 18

SCC (squamous cell carcinoma)
trauma
medication-related

Question 19

What are some conditions that lead to (ROU) recurrent oral ulceration?

Answer 19

IBD
Coeliac
Behcet’s
Cyclical neutropenia

Question 20

What information might a FBC give?

Answer 20

presence of anemia or if pt is suffering a clinical infection or potential hematological causes

Question 21

what information might haematinics give?

Answer 21

Deficiency in B12, folate, ferritin

Question 22

What information might serum ACE, ESR and CRP give?

Answer 22

generic markers of generalised inflammation - helpful in diagnosis/management of IBD

Question 23

When would you use the term RAS?

Answer 23

When there is no underlying pathological process or diagnosis causing the ulcers

Question 24

What are subtle clinical signs of parafunctional habits?

Answer 24

pronounced buccal ridging
linea albae
scalloped edges to the tongue
concomitant TMD secondary to clenching or grinding
NCTSL

Question 25

What would be suitable management for parafunctional ulcers?

Answer 25

Education Pain relief (topical agents - Gelclair) 2-3mm soft bite guard

Question 26

What management approach should be taken for patient with oral ulceration?

Answer 26

1. IDENTIFY CAUSE! - early decision making regarding ulcer is a presentation of oral cancer 2. Provide pt with leaflets and information 3. simple strategies to alleviate pain and functional problems from ulcers 4. Take photos!

Question 27

What are the reasons to refer to Oral Medicine for oral ulceration?

Answer 27

Doubt over diagnosis partial/non-response to topical treatments severe presentation (rapid onset), extensive mucosal surfaces ulcerated or multiple systems involved (skin, gut, eyes) Major RAS Known or suspected medication condition/medication contributing to ulcer

Question 28

Where do herpetiforme ulcers tend to appear?

Answer 28

ventral tongue, floor of mouth and lower labial mucosa

Question 29

what antibiotic can be prescribed and is supposedly good for herpetiforme RAS?

Answer 29

Doxycycline

Question 30

What is Behcet disease?

Answer 30

rare disease causes vasculitic changes in multiple body tissue

Question 31

what are other potential effects of behcet disease (apart from aphthous ulceration)

Answer 31

ocular changes, headaches, genital ulceration, acne form lesions, myalgia, arthralgia

Question 32

Who is commonly affected by Behcet disease?

Answer 32

male patients aged 20-30 most commonly

Question 33

what is neutropenia? how might it be acquired?

Answer 33

depletion of white blood cell - neutrophil acquired following chemotherapy or secondary to significant infections

Question 34

what is cyclic neutropenia?

Answer 34

inherited disorder - neutrophil count falls every 21 days

Question 35

what is the clinical presentation of oral lichen planus?

Answer 35

oral ulceration + patchy erythema = white patches

Question 36

what does primary herpetic gingiva stomatitis present as in the mouth? what site does it normally affect?

Answer 36

little tiny ulcers on the ventral surface of tongue

Question 37

what are the supportive measures of primary herpetic gingiva stomatitis?

Answer 37

- well hydrated, paracetamol, keeping everything clean, chlorhexidine mouthrinse

Question 38

if the ulcers feel firm as opposed to soft what would we be advised to do?

Answer 38

undertake an urgent biopsy (usually within 2 weeks) to confirm diagnosis

Question 39

what is bullous pemphigoid?

Answer 39

rare skin condition

Question 40

what is mucous membrane pemphigoid?

Answer 40

rare, chronic, autoimmune disorder that typically affects the mucous membranes more often than the skin

Question 41

what area of the mouth does mucous membrane pemphigoid appear?

Answer 41

soft palate

Question 42

what is pemphigus vulgaris?

Answer 42

rare long-term condition caused by a problem with the immune system

Question 43

what site in the mouth does SLE typically affect? what si the typical appearance?

Answer 43

lateral borders of the tongue = striations with a lichenoid appearance

Question 44

what is erythema multiforme?

Answer 44

skin reaction that can be triggered by an infection or some medicines

Question 45

what are classical signs of erythema multiforme?

Answer 45

widespread ulceration of the vault of the palate, ulcerated lips (dry/cracked), bullae lesions on skin, bluish ring of discolouration, painful

Question 46

what is B cell non-hodgkins lymphoma

Answer 46

cancer of the lymphatic system

Question 47

what is the typical appearance of SCC?

Answer 47

ulcerated lesion with rolled border and indurated firm base - lateral border of the tongue is a high risk site

Question 48

who is likely to have ulcerated SCC of the lower lip?

Answer 48

older pts who smoke or had a lot of sun exposure

Question 49

what type of mucosa does minor RAS tend to occur on>

Answer 49

non-keratinised (labial mucosa, floor of mouth, ventral side of tongue)

Question 50

what type of mucosa does minor RAS tend to occur on>

Answer 50

These usually appear inside the lips and cheeks, on the tongue and sometimes the floor of the mouth.

Question 51

What is the management for oral ulceration?

Answer 51

symptomatic relief, Corsodyl mouthwash, correct reversible risk factors, anti-fungals? adjusting dentures? smoothing off teeth? referral of ulcers and systemic disease

Question 52

what type of RAS might mimic a squamous cell carcinoma?

Answer 52

Major RAS

Question 53

what is nicorandil commonly prescribed for?

Answer 53

poorly controlled/ moderately severe ischaemic heart disease (eg: angina)