Oral Ulcers

Question 1

What causes oral ulcers?

Answer 1

• trauma
• immunological (aphthous ulcers; lichen plants; lupus; vesicle-bulous; erythema multiforme)
• carcinoma
• infections
• gastrointestinal (chron’s disease; ulcerative colitis)

Question 2

What are the subtypes of Recurrent Aphthous Stomatitis (ulcers)?

Answer 2

1. Minor aphthous ulcers
2. Major aphthous ulcers
3. Herpetiform ulcers
4. Behcet’s Syndrome

Question 3

What is the commonest type of recurrent oral ulcerations?

Answer 3

minor aphthous ulcers

Question 4

An ulcer that is less than 10mm in diameter, goes away within 2 weeks and affects non-keratinised mucosa (dorsum of tongue, floor of mouth, soft palate, alveolar mucosa, lip cheek, etc) is what type of ulcer?

Answer 4

minor aphthous ulcer

Question 5

An ulcer that is larger than 10mm in diameter and lasts for months is usually what type of ulcer?

Answer 5

major aphthous ulcer

Question 6

Cluster of small 1-2mm in diameter ulcers on non-keratinised mucosa that goes away within 2 weeks?

Answer 6

Herpetiform ulcers

Question 7

Cluster of small 1-2mm in diameter ulcers on keratinised mucosa (hard palate, gingiva) is a sign of…?

Answer 7

herpesvirus / primary herpetic gingivostomatitis

Question 8

How can ulcers caused by Behcet’s disease be diagnosed?

Answer 8

• 3 episodes of oral ulcers in a year
• at least 2 of:
  genital sores;
  eye inflammation;
  skin ulcers;
  pathergy

Question 9

Name 3 oral and genital ulcerative conditions.

Answer 9

1. Behcet’s Disease
2. Vesiculobullous diseases
3. Lichen planus

Question 10

What are predisposing factors of recurrent aphthous stomatitis?

Answer 10

genetics
systemic diseases
stress
mechanical injuries
hormonal level fluctuations
microelement deficiencies
viral and bacterial infections

Question 11

What special investigations can we do to aid with management of RAS?

Answer 11

Blood tests
- check for haematinic deficiencies (iron ferritin, vitamin B12, folic acid)
- check for coeliac disease TTG (tissue transglutaminase)

Allergy tests
- food additives

Question 12

How can RAS be treated? (non-drug)

Answer 12

Correct blood deficiencies
- iron ferritin, folic acid, vitamin B12 supplements

Refer for investigations if coeliac positive
- endoscopy and jejuna biopsy

Avoid dietary triggers
- use SLS-free toothpaste i.e. sensodyne proenamel & kingfisher

Question 13

According to SDCEP, what drugs can we prescribe to manage RAS symptoms?

Answer 13

Warm salty mouthwash (1/2 tsp salt in glass of warm water)

NaCl mouthwash

0.2% CHX mouthwash
Rinse for 1 min with 10ml twice daily
* leave 30 min interval between rinsing and using toothpaste
* can be diluted 1:1 with water

6% hydrogen peroxide mouthwash
Rinse for 2 min with 13ml diluted in glass of warm water thrice daily
* can be used up to 3 min

100mg doxycycline dispersible tablets
Dissolve 1 tablet in water and rinse in mouth for 2 min 4x daily for 3 days
* caution with hepatic impairments, hepatotoxic drugs
* not for pregnant women, nursing mothers and children under 12 years
* can deposit on growing bone, teeth and cause staining + dental hypoplasia
* anticoagulant effect of warfarin may be enhanced

Topical corticosteroids:
Beclometasone diproprionate inhaler (Clenil modulite)
50mcg/metered inhalation
1-2 puffs directed onto ulcers twice daily

Betamethasone tablets
500mcg
1 tablet dissolved in 10ml water as mouthwash 4 times daily

Hydrocortisone oromucosal tablets
2.5mg
1 tablet dissolved next to lesion 4 times daily

Question 14

At what age does aphthous ulcers usually occur in children?

Answer 14

During periods of rapid growth
8-11 years
13-16 years

However, can also be due to genetics instead of growth.