What is an ulcer?
A break in epithelial continuity usually in association with underlying damage to the lamina propria.
What is erosion?
It refers to superficial break in epithelial continuity with the underlying lamina propria being intact. It's technically an ulcer but very superficial, often extending over a wide area.
What is desquamation?
It's used to describe thinning (generally secondary to inflammation) of the epithelium with a consequent red(der) appearance. It's NOT an ulcer but if you apply pressure the epithelium can shed off and leave an ulcer.
What are the causes of oral ulceration?
• Systemic Disease
What is the clinical approach to the patient with oral ulceration?
• Detailed history outlining pattern, frequency, natural history of ulcer
• Detailed medical and drug history
• Presence or absence of associated features
What are the questions you should ask yourself when you see oral ulceration?
• Is this an isolated ulcer?
• Could this be a malignant ulcer?
• Is this part of a recurrent pattern of ulceration? (if so and there's no disease between appearances it's unlikely to be malignant)
• Is this part of, or is it an exacerbation of a chronic ulcerative condition of the oral mucosa?
• Is this an isolated oral lesion or is it related to systemic disease?
What are the common causes of recurrent oral mucosal ulceration? (so should be a part of your differential diagnosis when you hear a history of recurrent oral ulceration)
• Recurrent aphthous ulceration
• Aphthous like ulceration
• Erythema Multiforme
• Recurrent intraoral herpetic ulceration
What is this a picture of?
What are the immunological causes of recurrent oral ulceration?
• RAU/ALU (recurrent apthous ulceration)
• OLP (oral lichen planus)
• MMP (Membrane Pemphigoid)
• PV (Pemphigus vulgaris)
• EM (erythema multiforme)
What is this an image of?
Pemphigus where blisters have developed and burst to leave an area of ulceration.
What is the most common cause of recurrent ulceration?
Apthous like ulceration (also called apthous stomatitis). 1/5 of us will have it at some point. Most patients with recurrent apthous ulceration do not have an associated underlying systemic disease. May be a family history of RAU. Mostly present in childhood and adolescence and will resolve with age.
(Apthous like ulceration is identical to idiopathic recurrent apthous stomatitis so terms can be used interchangeably.)
What does recurrent aphthous ulceration (RAU) look like?
• Well defined margins
• Greyish or yellowish ulcer base
• Erythematous halo surrounding the ulcer
What can recurent apthous ulceration be classified into?
RAS can be classified into 3 groups based upon their clinical charachteristics:
o 2-6 per episode
o Last up to 10 days
o Generally involve non keratinized mucosa
o Heal without scarring
o Small pinpoint
o Coalesce to form larger ulcers
o May involve keratinized mucosa
o Heal without scarring
o Large (>1cm diameter)
o Involve both non and keratinized mucosa
o May last a month or even longer
o Heal by secondary intention often with scarring
What cuases recurrent apthous ulceration?
Unknown. But it is an immunologically mediated- T cell action with a humoral component (antibody dependent cytotoxicity reaction).
What are possible predisposing factors for RAU?
• Trauma: itself does not cause RAS but may help instigate or localize RAS in a predisposed patient
• Stress: RAS frequency and severity increase during times of stress
• Chemical- SLS (detergent found in many products including toothpaste)
• Food allergies- Food additives such as benzoates and flavouring agents such as cinnamonaldehyde
• Smoking cessation- It is well known that smokers who stop may suddenly experience RAS.
• Systemic disease- RAS may occur in association with different systemic disease as a direct consequence to this disease (eg. Behcet’s Syndrome) or because the disease predisposes to oral ulceration eg. anaemia.
What are apthous like ulcers?
• Ulceration which is clinically identical to idiopathic RAU, which however:
• Does not start in childhood
• Does not resolve with age
• Occurs in association with signs and symptoms unusual for RAU
• Occurs in association with systemic disease
• Occurs in association with drugs eg. NSAIDs
What are some systemic diseases associated with RAU/ ALU? (systemic diseases where patients may present with apthous like ulceration)
-IBD which includes Crohns Disease & Ulcerative Colitis.
-Coeliac Disease (RAS/ALU are more frequent and severe in patients with Coeliac Disease compared to a comparable population without coeliac disease.)
Drugs and RAS
-Anaemia and haematinic deficiencies (deficiency of iron, B12 and folic acid) may be a factor.
-Behcet’s Syndrome (discussed below)
-Systemic Lupus Erythematosus
-RAS/ALU ulcers may be seen in HIV. The ulceration can be extremely severe and troubling.
Which drugs have been associated with the development of apthous like ulceration?
• Angiotensin converting enzyme inhibitor captopril
• Gold salts
How is recurrent apthous like ulceration managed?
The diagnosis is clinical but before it's diagnosed predisposing factors such as trauma and underlying systemic disease must first be excluded. Only then can the medical management begin.
How is recurrent apthous like ulceration investigated?
• Full blood count
• Haematinic assays (ferritin, folate, B12) Other investigations (depending on clinical findings): coeliac disease screen, auto antibody profile.
What is the medical management of RAU?
• Corlan pellets: hydrocortisone hemisuccinate pellets 2.5mg allowed to dissolve close to the ulcer up to four times per day.
• Beclometasone diproprionate spray: 2 puffs directed onto the ulcer three times/day
• Betnesol Mouthwash: Betamethasone Phosphate 500mcg tabs dissolved in 10 mls water and used as a mouthwash on a swish and spit basis, three times per day.
• Chlorhexidene M/W may help prevent secondary infection of the RAU
• This is reserved for severe cases of RAU in specialist care. Drugs that may be used range from systemic steroids such as prednisolone to immunosuppressants such as Azathioprine.
Very little evidence in terms of the efficacy of topical steroids and antiseptic preparations but they are the standard treatments of RAU for the moment.
What is this?
Orofacial Granulomatosis: a systemic disease that is presenting with oral ulceration.
What is this?
This is a patient with irritable bowel disease who's presenting with apthous like ulceration.
What can ulcerative colitis present with orally?
• Pyostomatitis Vegetans (see image. It is a highly specific marker for inflammatory bowel disease)
• Aphthous type ulceration
• Atypical ulceration
What is this?
Oral ulceration secondary to systemic disease- Behcet’s Syndrome ( BS):
• Triad of oral, genital ulceration and uveitis (eye inflammation).
• Oral ulceration tends to be apthous like with a mixture of minor, herpetiform and major type ulcers.
• Compared to RAU or ALU these ulcers occur at an increased ulcer frequency, involve the soft palate and oropharynx.
• BS is more common in eastern Mediterranean and east Asian countries and has HLA and MHC associations.
• Immune complex mediated disease.
What is this?
Oral ulceration secondary to systemic disease- Systemic Lupus Erythematosus (SLE). Presenting with:
• lichenoid mucositis
• ALU (apthous like ulceration)
What is erythema multiforme?
• EM is an immunologically mediated disease with involvement of one or more mucous membrane and possibly skin.
• Pathophysiology is thought to involve cell mediated immunity with destruction of epithelial cells and also deposition of immune complexes and complement activation causing a vasculitis.
What are possible predisposing triggers for erythema multiforme?
oMicrobial : HSV (herpes simplex virus) is the most common trigger of EM (90% of EM minor) Other microbial triggers-Mycoplasma pneumonia.
oDrugs: Drugs ranging from penicillin to carbamazepine have been reported to cause EM. oFoods: such as food additives such as benzoic acid.
How does EM present?
• The presentation ranges from limited disease possibly involving the oral mucous membrane to severe widespread disease involving multiple mucous membranes such as eyes, genital, pharynx, mouth and skin.
• Oral involvement generally is with widespread ulceration and blistering. A desquamative gingivitis may be present.
• Skin lesions classically have a target appearance. • Eye involvement is particularly dangerous as it can lead to blindness.