Oral Ulceration

Question 1

How would you know if an ulcer is likely to be caused by trauma?

Answer 1

Look in the mouth and see if anything sharp or jaggy matches up with this ulcer.

Usually a single ulcer episode.
Remove the cause and healed in 2 weeks- review.

If it does not heal or is unexplained- refer for biopsy.

Question 2

What kind of ulcers occur in Crohn’s disease?

Answer 2

Crohn’s specific ulcers-
- Linear at the depth of the labial sulcus
- Persist for months
Full of Crohn’s associated granulomas.

Aphthous type ulcers
- Haematinic deficiency associated.

Question 3

What are recurrent herpetic lesions?

Answer 3

Ulceration limited to one nerve group/branch- where the virus has remained dormant.
- in the oral cavity, this is the trigeminal nerve.

Usually the hard palate, lesion recurs in the same place.
Patient will have prodromal period and then recurrence.

Presents with prodromal symptoms, such as tingling or a burning sensation followed by vesicle formation within an area of a sensory nerve distribution.
Unilateral ragged ulceration with surrounding erythema is observed

Question 4

If you suspect someone has recurrent herpetic ulceration and they complain of pain, what is it likely to be?

Answer 4

Zoster virus.

Question 5

How would you treat recurrent herpetic lesions?

Answer 5

Systemic Acyclovir
- Herpes- 200mg, 1 tablet 5 times a day for 5 days.
- Zoster virus- 800mg, 1 tablet 5 times a day for 7 days.

Question 6

When taking a history of a patient complaining of ulcers, what questions would you want to ask?

Answer 6

Where is the ulcer?
How long has it been there?
Do you have ulcers anywhere else?
Has it got any bigger or smaller?
What shape is it?
Do the ulcer burst and then grow back?
Does it come and go in the same spot?
How long do the ulcers last?
How long in between episodes?
Are they painful?

Question 7

When examination an ulcer, what aspects of the ulcer are important to note?

Answer 7

Are the margins flat, rolled or raised?
Is the base soft, firm or hard?
Is the surrounding tissue inflamed or normal?
Is the patient systemically unwell?

Question 8

What is primary herpetic Gingivostomatitis?

Answer 8

Acute infectious disease caused by Herpex Simplex virus.
Transmission by droplet formation with 7 day incubation period.
Can be on keratinised or non-keratinised.

Question 9

What are the signs and symptoms of Primary Herpetic Gingivostomatitis?

Answer 9

Fluid filled vesicles, rupture to painful ragged ulcers on the gingivae, tongue, lips, buccal mucosa and palatal mucosa.
Severe oedematous marginal mucosa.
Fever
Headache
Malaise
Cervical lymphadenopathy.

Question 10

What is the treatment for Primary Herpetic Gingivostomatitis?

Answer 10

Bed rest
Soft diet
Stay hydrated
Paracetamol
Antimicrobial gel/mouthwash- Chlorhexidine 0.2%, 300ml, 10ml 3 times a day to be rinsed around mouth and spat out.
Acyclovir in immunocompromised individuals.

Question 11

How is Herpes Labials treated?

Answer 11

Topical Aciclovir- 5%. Applied to lesion every 4 hours for 5 days.

Question 12

What are Aphthous ulcers?

Answer 12

Immunologically generated recurring oral ulcers.
Genetically driven with environmental modification.
Variable expression.

Question 13

What are minor aphthous ulcers?

Answer 13

Less than 10mm in diameter
Last up to 2 weeks
Only affect non-keratinised mucosa.
Heal without scarring.
Ulcer free period is a good guide to morbidity.

Question 14

What does recurrent aphthous stomatitis look like?

Answer 14

Yellow/grey base with red erythematous margin.

Question 15

How does recurrent herpetic lesions occur?

Answer 15

Herpes Simplex virus or Zoster virus remains dormant within the nerve, until a stimuli re-activates it.

Stress, immunosuppression, illness, menstruation.

Question 16

What do recurrent herpetic lesions look like intra-orally?

Answer 16

Uni-lateral ragged ulceration with erythematous surrounding.
Ulcers occur along the area that is supplied by the same nerve.

Question 17

What are major Aphthous ulcers?

Answer 17

Can last for months
Affect any part of the oral mucosa- keratinised or non-keratinised.
May scar after healing.
Poorly responsive to topical steroids.
Usually larger than 10mm.

Question 18

What do major aphthous ulcers look like?

Answer 18

Area of epithelial loss and a fibrous edge covering the connective tissues- ulceration.
Erythematous halo.

Question 19

What are Herpetiform Aphthae?

Answer 19

Rarest form of Aphthous ulcer.
Multiple small ulcers on non-keratinised mucosa.
Small ulcers can coalesce and look like HSV.
Heal within 2 weeks.

Question 20

What is Behçet’s disease?

Answer 20

Diagnosis given when the patient doesn’t meet the criteria for another diagnosis.

Primarily a vasculitis- inflammation of blood vessels.

Question 21

How do you diagnose Behçet’s disease?

Answer 21

Three episodes of mouth ulcers in a year.
At least two of the following- Genital sores, eye inflammation, skin ulcers, pathergy.

Question 22

What might the patient notice if they have Behçet’s disease?

Answer 22

Oral and genital ulceration
Eye disease
Bowel ulceration- pain and cramping
Heart and lungs
Brain
Joints

Question 23

How is Behçet’s disease managed?

Answer 23

Systemic immunomodulation
- Colchicine
- Azothioprine/Mycophenolate
- Biologics.

Question 24

What are the predisposing factors to recurrent aphthous stomatitis?

Answer 24

Genetic predisposition
Stress
Mechanical injuries to the oral mucosa
Hormonal level fluctuations
Haematinic deficiency
Viral and bacterial infections.
Cessation of smoking
Allergies to food
SLS

Question 25

What is the immunological response in Recurrent aphthous ulceration?

Answer 25

Hyperactivity of neutrophils
Increase in number of NK cells
COmplement system activation
Increase number of B cells
Decreased activity of regulatory T cells.
Decreased number of CD4 lymphocytes

Question 26

Describe the process by which the ulcer develops?

Answer 26

Damage happens before the ulcer develops.

Immunological reaction starts at the epithelial-connective tissue junction.
Ulceration occurs within the stem cells of the basement membrane, cells are unable to produce more epithelial cells, upper cells fall away and there is no replacement.
- loss of full thickness epithelium and fibrin formation over the top.

Question 27

When is treatment most likely to be successful?

Answer 27

In the prodromal period- better to treat prophylactically.

Patient may feel a tingling sensation in the area, prior to ulceration developing.

Question 28

What investigations might you request, if you suspect aphthous ulcers?

Answer 28

FBC- haematinics
Coeliac disease- TTG and if positive then use the anti-gliadin and anti-endomyseal antibodies.
Allergy tests.

Question 29

How would you manage recurrent aphthous ulcers?

Answer 29

Correct blood deficiencies- B12, folate, ferritin.
If related to trauma to the mucosa- stick to a soft diet and brush teeth atraumatically.
Refer for investigation if coeliac positive.
Avoid dietary triggers
Avoid SLS toothpaste (sensodyne pronamel)
Non-steroid topical therapy
Steroid topical therapy

Question 30

What non-steroidal topical therapies may be utilised in oral aphthous ulceration?

Answer 30

Chlorhexidine mouthwash 0.2%, 300ml, Rinse with 10ml for 1 minute twice a day.

Leave an interval of at least 30 minutes after brushing- may interact with toothpaste.

If in pain- Benzdamine mouthwash- 0.15%, 300ml, rinse and gargle 15ml every 1.5 hours as required.
- Advise patient to spit out once they have rinsed their mouth, it can be diluted in water if it stings and don’t use for more than 7 days.

Benzdamine spray, 0.15%.

Use for infrequent ulcers.

Question 31

What steroidal therapies may be utilised in oral aphthous ulceration?

Answer 31

Betamethosone soluble tablets, 500 micrograms, 100 tablets, 1 tablet dissolved in 10ml of water and rinsed 4 times a day.

Beclometasone pressured inhaler- 1-2 puffs directed at the ulcer twice daily.
- risk of candida.

Use for more frequent, disabling lesions.

Question 32

When should you refer ulceration to oral medicine department?

Answer 32

After all treatment avenues have been explored and not achieved a good result.
Children under 12.

Question 33

What conditions might have apthous ulceration as part of a more systemic issue?

Answer 33

Coeliac
Crohn’s
Behcet’s
PFAPA syndrome
Viral infections- EBV, HIV