Recurrent oral ulceration

Question 1

What is an ulcer? (7)

Answer 1

A FULL-THICKNESS loss of epithelium
Exposes underlying connective tissue
Ulcer covered by slough
Underlying granulation tissue
Mixed Inflammatory infiltrate 
Usually painful
Erosion = partial loss

Question 2

Ulcer - histology (2)

Answer 2

Fibrino-purulent slough

Granulation tissue

Question 3

What is a primary ulcer? (1)

Answer 3

Begin as ulcers

Question 4

What is a secondary ulcer? (1)

Answer 4

Begins as a blister/ vesicle

Question 5

Single episode ulcer examples (10)

Answer 5

Single ulcer e.g. SCC			
Multiple ulcers 
- Herpes simplex
- Herpes zoster
- Erythema multiforme
- Hand, foot and mouth
- Herpangina	
- Oral lichen planus
- Vesiculo -Bullous disorders
- Iatrogenic e.g. drugs

Question 6

Recurrent episodes of ulcers examples (2)

Answer 6

• Single ulcer e.g. mucocutanous disorders

- Multiple ulcers e.g. RAS, mucocutaneous disorders

Question 7

Causes of single episode ulcers (2)

Answer 7

Trauma: physical, chemical, thermal, factitious
Malignancy: SCC, salivary neoplasm, lymphoma
Infective: TB, syphyllis, HSV
Drugs: Methotrexate

Question 8

Treatment for single episode traumatic ulcers (4)

Answer 8

Reassurance
Remove the cause
Consider Difflam and Corsodyl
Should show signs of improvement

Question 9

Oral ulceration - oral cancer (3)

Answer 9

Any ulcer that is >3 weeks duration of unexplained cause
Should be regarded as malignant until proven otherwise – BIOPSY
Don’t be afraid of being wrong!

Question 10

Drug induced oral ulcers - which drugs? (8)

Answer 10

Allopurinol
Cytotoxics
Gold
Indomethacin
Methotrexate
Methyldopa
Nicorandil
Penicillamine

Question 11

Causes of iatrogenic oral ulcers (2)

Answer 11

Drug induced

Irradiation - head and neck radiotherapy

Question 12

Types of RAS (3)

Answer 12

Minor recurrent aphthous stomatitis (RAS)
Major RAS
Herpetiform RAS

Question 13

Other causes of recurrent, multiple ulcers other than RAS (4)

Answer 13

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

Question 14

RAS epidemiology (1)

Answer 14

Common, affects 20% of population at some time

Question 15

Features of RAS (4)

Answer 15

Painful
May affect eating, drinking & speech
Occasionally very disabling
May be a familial component

Question 16

Minor aphthous ulcers epidemiology (2)

Answer 16

80% of RAS ulcers

Peak age range 10-30

Question 17

Minor aphthous ulcers features (7)

Answer 17

Usually 1-5 ulcers ~ 3-8 mm diameter
Minor RAS: must be <10mm
Last 7-10 days
Variable ulcer free period
Usually non-keratinised mucosa
Usually front of mouth
Heal without scarring

Question 18

Major aphthous ulcers features (8)

Answer 18

10% of ulcers
Ulcers may be larger (up to 1.5-2cm)
Major RAS: Must be >10mm
Last longer: 3wks - 3 months
Single or multiple 
Often affect back of mouth
Often non-keratinised mucosa, but can affect masticatory mucosa
May heal with scarring

Question 19

Herpetiform oral ulceration features (5)

Answer 19

<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
Last 7-10 days

Question 20

Contributory factors to aphthous ulcers (4)

Answer 20

Stress
Trauma
Hormones
Smoking –ve relationship

Question 21

Predisposing/ underying factors for aphthous ulcers (6)

Answer 21

Haematological deficiencies (Fe, B12, Folate)
Neutropaenia
Immune deficiency (e.g. HIV+)
GI tract disease (Coeliac, Crohn’s, UC)
Vitamin deficiency (B1, B2, B6)
Food intolerance (e.g. chocolate, benzoates, cinnamon)

Question 22

Investigations for aphthous ulcers (not always needed)

Answer 22

FBC, Ferritin, B12 & Folate
Coeliac screen
Other tests according to history
-e.g. for food allergens

Question 23

Treatment for aphthous ulcers (3)

Answer 23

Preventative
Symptomatic
Suppressive

Question 24

Preventative treatment for aphthous ulcers (4)

Answer 24

Correct haematological deficiencies
Treat underlying systemic disease
Remove Trauma
Dietary elimination

Question 25

Symptomatic treatment (local) for aphthous ulcers (3)

Answer 25

Corsodyl (Chlorhexidine) mouthwash Difflam (Benzidamine) mouthwash Covering agents e.g. Gengigel, Orobase paste

Question 26

Suppressive treatment (local) for aphthous ulcers (3)

Answer 26

Topical Steroids - Hydrocortisone pellets (Corlan) - Beclometasone spray (Clenil Modulite inhaler) - Betamethasone mouthwash (Betnesol)

Question 27

Suppressive treatment (systemic) for apththous ulcers (3)

Answer 27

Prednisolone (Steroid) Thalidomide Azathioprine

Question 28

Treatment for herpetiform oral ulceration (2)

Answer 28

Symptomatic | Doxycycline mouthwash

Question 29

Behçet's disease can lead to (5)

Answer 29

``` Serious systemic disease: Blindness Neurological damage Severe oro-genital ulceration Vasculitis Death ```

Question 30

Behçet's disease epidemiology (3)

Answer 30

Mainly young adult males ~30yrs Male:Female ratio = 2.3:1 Increased Incidence in Japan and Turkey

Question 31

Behçet's disease features (3)

Answer 31

Recurrent oral aphthous ulceration Plus two 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 Other Common Features: -arthritis, GI lesions, CNS involvement, Vascular lesions etc.

Question 32

Management of Behçet's disease (4)

Answer 32

``` Multi-disciplinary approach oral medicine dermatology rheumatology ophthalmology ```

Question 33

A biopsy of an ulcer (3)

Answer 33

If a biopsy of an ulcer is undertaken, it is usually because the clinician wants to exclude malignancy Many non-malignant ulcers look identical under the microscope Clinical history and findings therefore crucial