Ulcers

Question 1

What are the common causes of oral ulceration?

Answer 1

Idiopathic - RAS (minor, major, herpetiform)
Hypersensitivity - erythema multiforme
Hameatinic deficiency
Trauma (Intra oral appliance, cheek biting)

Question 2

What should you ask the patient regarding ulcer history?

Answer 2

Site of ulcer
Size of ulcer
Shape of ulcer

Duration of each
Number of ulcers
Frequency

Preceded by vesicles?

Age off onset
FH

Exacerbating or relieving factors

Question 3

What are the typical features of minor RAS?

Answer 3

3-8mm diameter
Lasting up to 2 weeks
On non-keratinised mucosa
Heals without scarring

Longer periods ulcer free

Usually single ulcers or crops of 2-5

Question 4

What are the typical features of major RAS?

Answer 4

> 1cm diameter
Can last for months
Can affect any mucosa
May scar when healing
Poor response to topical steroids

One or two ulcers at a time

Question 5

What are the features of herpetiform RAS?

Answer 5

0.2-3mm diameter
May last 7-10 days (heals within 2 weeks)

Multiple small ulcers (30-100) on non keratinised mucosa which may coalesce

Not to do with herpes virus - in HSV, keratinised epithelium is involved

Question 6

What shape are RAS ulcers?

Answer 6

Oval/ round and sharply defined (may become irregular with healing)

Question 7

What feature of an ulcer can indicate healing?

Answer 7

Slight irregular margin

Question 8

After a diagnosis of RAS, What are your next steps?

Answer 8

Consider any underlying predisposing factors eg haemantinics, GI disease, Behcets, smoking, medications

Blood test- FBC (haemantinics and TTG test)

Question 9

What is Behçet’s disease?

Answer 9

A rare auto inflammatory condition that can present with oral ulcers as the most significant problem.
Biopsy of the ulcer will show underlying vasculitis

Question 10

What is an example of mediation which can cause oral ulceration?

Answer 10

Nicorandil (management of angina)
Methotrexate (RA management)

• these ulcers do not follow typical RAS pattern

Question 11

What is the treatment options for RAS?

Answer 11

Lifestyle advice - avoid diet triggers, smoking cessation, SLS
Analgesic mouthwash - Benzydamine
Antiseptic mouthwash - chlorohexidine
Steroid mouthwash - betamethasone
Topical steroid - oralone
Systemic therapies - prednisolone etc

Question 12

What are aphthous ulcers?

Answer 12

Immunologically generated recurring oral ulcers which follow a set pattern
Can be major, minor, herpetiform

Question 13

When is treatment most effective for aphthous ulcers?

Answer 13

Most effective in prodrome period (as damage happens before the ulcer appears).
Therefore prophylactic treatment is effective eg daily steroid mouthwash

Question 14

What guidance is followed for treatment of ulcers?

Answer 14

SDCEP

Question 15

What is the characteristic of a recurrent aphthous ulcer?

Answer 15

Yellow fibrous base with surrounding erythematous halo

Question 16

What are the features of primary viral infection ulcer?
What is the treatment?

Answer 16

Herpes virus - Pattern on oral mucosa is of the innervation of maxillary nerve (limited to one nerve) - unilateral on hard palate.
Will be on the same site each time it recurs.

Pain suggests herpes zoster rather than simplex virus.

Treat with aciclovir.

Question 17

What is the differential diagnosis for recurrent ulceration?

Answer 17

Aphthous ulcer action (minor, major, herpetiform)
Lichen planus
Vesiculobullous lesions (PV, EM, MMP, Angina bulbosa haemorrhagica)
Recurrent viral lesions - HSV, VZV
Trauma
Systemic disease eg. Chrons

Question 18

What causes primary and secondary traumatic ulcers?

Answer 18

Primary - sharp edge on restoration/ tooth/ appliance
Secondary - parafunction rubbing mucosa against teeth