Ulceration

Question 1

What can cause ulcers

Answer 1

Trauma

Immunological
-aphthous ulcers
-lichen planus
-Lupus
-vesiculo-bullous
-Erythema multiforme

Carcinoma

Infections
-bacterial
-fungal
-Viral

Gastrointestinal
-Crohn’s disease
-ulcerative colitis

Question 2

What falls under Single Episode Oral Ulceration

Answer 2

Trauma

1st episode of recurrent

Primary viral infections

Oral squamous cell carcinoma

Question 3

What are crohns ulcers like

Answer 3

Linear at the depth of the sulcus

Full of Crohn’s associated granulomas

Persist for months

Question 4

What should an oral ulceration history entail

Answer 4

Where?

Size & Shape?

Blister or ulcer?

How long for?
-More than 2 weeks is bad

Recurrent?
Same site or Different Sites?

Painful?

Question 5

What should an ulcer examination entail

Answer 5

Check the Margins are they:
-Flat? Raised? Rolled?

Check the base is it:
Soft? Firm? Hard?

Check the Surrounding tissue:
Inflamed? Normal?

Systemic Illness

Question 6

What are recurrent herpatic lesions

Answer 6

Ulceration limited to one nerve group/branch

Often Hard palate
-Lesion recurs in the same place

PAIN suggests Herpes ZOSTER rather than simplex

Treat with systemic ACICLOVIR

Question 7

What is the general rule of ulcers

Answer 7

Recurrent self healing ulcers affecting exclusively the non-keratinised mucosa are most likely to be aphthae

Question 8

If there is a recurring ulcer afecting keratinised mucosa what is the cause

Answer 8

Viral

Question 9

What are apthous ulcers

Answer 9

Immunologically generated recurring oral ulcers

Follow a set pattern depending upon the ulcer type

Genetically driven with environmental modification

Multifactorial environmental triggers and variable expression

Question 10

What are the 4 main forms of recurrent Aphthous Stomatitis (RAS)

Answer 10

Minor

Major

Herpetiform

Oro-Genital ulcer syndromes – e.g. Behçet’s syndrome

Question 11

How could you diagnose RAS

Answer 11

History and examination (yellow/gray base with erythematous margin)W

Question 12

What are minor aphthous ulcers like

Answer 12

Less than 10mm diameter

Last up to 2 weeks

Only affect non-Keratinised mucosa

Heal without scarring

Usually a good response to topical steroids

Question 13

What is the most common recurrent ulcer

Answer 13

Minor aphthous

Question 14

What are major aphthous ulcers like

Answer 14

Can last for months

Can affect any part of the oral mucosa
-Keratinised or non Keratinised or both

-May scar when healing

-Poorly responsive to topical steroids

-Usually larger than 10mm

Question 15

What is herpetiform aphthae like

Answer 15

rarest

Multiple small ulcers on non-keratinized mucosa

Heal within 2 weeks

Can coalesce into larger areas of ulceration

Nothing to do with herpes viruses
-the early stages looks like primary herpetic gingivostomatitis

Question 16

What are Oral & Genital Ulcerations like

Answer 16

Normally Behcets disease

Other Oro-genital ‘ulcerative’ conditions exist
-Vesiculobullous diseases
-Lichen Planus

Question 17

How to diagnose Behcets disease

Answer 17

three episodes of mouth ulcers in a year

At least two of the following: genital sores, eye inflammation, skin ulcers, pathergy

Question 17

What is Behcets disease

Answer 17

primarily a Vasculitis

Causes:
-Oral & genital ulceration
-Eye disease
-Anterior or posterior uveitis
-Bowel ulceration
-Heart and lungs
-Brain
-Joints

Question 18

How to treat Behcets disease

Answer 18

Treat local oral disease or RAS

Systemic immunomodulation where multisystem involvement
-Colchicine first treatment
-Azathioprine/Mycophenolate
-Biologics – infliximab and others

Managed with help of Rheumatology

Question 19

What are predisposing factors to RAS

Answer 19

Stress

Systemic disease

Genetics

Viral/bacterial infections

Microelement deficiencies

Hormonal level flunccuations

Mech. injuries

Question 20

With aphthous ulcers when does the ulcer appear

Answer 20

AFTER the damage

Question 21

How do you investigate Aphthous ulcers

Answer 21

Blood tests
-Haematinic deficiencies (Iron, B12, Folic acid)
-Coeliac Disease, TTG (tissue transgutaminase) If TTG positive test Anti-gliadin & Anti-endomysial antibodies

Question 22

How do you treat aphthae

Answer 22

Correct blood deficiencies
-Ferritin (iron), Folic Acid, Vit B12

Refer for investigation if Coeliac positive

Avoid dietary triggers
-SLS containing toothpaste

Question 23

What are drug treatments of Aphthous Ulcers

Answer 23

Non-Steroid Topical Therapy
-For inconvenient lesions

Steroid Topical Therapy
-For disabling lesions