Aphthous Ulcers

Question 1

What is do an ulcer?

Answer 1

Breach of the epithelium

Question 2

What are apthous ulcers?

Answer 2

self healing ulcers that affect non-keratinised mucosa only

Question 3

How can we investiager aphthous ulcers?

Answer 3

Blood tests

Coeliac testing

Allergy testing

Question 4

What bloods can we get for investigation of aphthous ulcers?

Answer 4

Haemitinic levels - ferritin, B12, folate

Coeliac testing - TTG testing (can have high false positive results)

Question 5

What allergy tests can we do?

Answer 5

Contact allergy testing

Immediate hypersensitivity testing

pts may be allergic to food additives - best thing is to avoid common diet triggers such as cinnamon and chocolate for 3 months and check affect

Question 6

How can we manage apthous ulcers when pt has blood deficiencies?

Answer 6

Replace iron, folic acid or b12 as needed - but GP must do follow up for reason why there is deficiency (if unexplained GI investigations)

Question 7

What in toothpaste can trigger ulceration?

Answer 7

SLS - we can get SLS free toothpastes such as sensodyne proenamel or also Aldi and lidl have available

Question 8

How do we manage recurrent and self limiting oral aphthous ulceration?

Answer 8

CHX 0.2% mouthwash

in children - soft diet, analgesia and usually resolve within 1-2 weeks

Diflam mouthwash = used to treat pain and inflammation

Question 9

What mouthwash can we recommend for pts with self limiting ulcers?

Answer 9

CHX 0.2%
Difflam 0.15%w/v Oral Rinse - anti-inflammatory analgesic oral rinse (over 12 only - 15 ml every 1-3 hours)

Question 10

When can ulcers occur in children?

Answer 10

Commonly occur during periods of rapid growth (Unusual for children under 12 to get ulcers - consider referral)

Question 11

What can be done for ulceration in children?

Answer 11

3 months iron supplements
assess diet

Question 12

What is the main trigger for ulceration in children?

Answer 12

Low iron levels - nutrients used rapidly during growth periods - provide iron supplements for 3 months

Question 13

What are some viral infections that can cause oral ulceration?

Answer 13

Herpes
Cokksaky virus
HIV
Hand foot and mouth

Question 14

What are some bacterial infections that can case oral ulceration?

Answer 14

Syphyliss
TB

Question 15

What mucocutaneous diseases can cause oral ulceration?

Answer 15

Lichen Planus
Erythema Multiforme
Pemphigoid
Pemphigus
Behcets syndrome

Question 16

What haematological disease can cause oral ulceration?

Answer 16

Anaemia
Leukemaa

Question 17

What GI problems can cause oral ulceration?

Answer 17

Crohns
UC
Coeliac disease

Question 18

Wha are apthous ulcers?

Answer 18

These are immunologically generated recurring oral ulcers that follow a set pattern depending on the type

Question 19

WHat is the histology of apthous ulcers?

Answer 19

Immunological process occurs in epithelium and connective tissue, initially as a genetic base, at the epithelial connective tissue junction cells in the basement layer can’t produce new epithelium cells resulting in breach of epithelium and exposure of CT (once ulcer is present in mouth healing process has already began and immunological process is reversed and cells in basement membrane produce new epithelial cells)

Question 20

What are the types of recurrent apthous stomatitis?

Answer 20

Minor
Major
Herpetiform
Behcets SYndrom

Question 21

What does a standard minor oral ulcer look like?

Answer 21

Fibrin base yellow in colour and erythematous halo margin (inflammatory change)

Question 22

What are the features of Minor apthous ulcers?

Answer 22

<10mm in size
last up to two weeks
NOn K mucosa - wont be seen on attached gingival or hard palate
will heal without scarring
pt can have 1-20

Question 23

Why do ulcers have perilesional erythema?

Answer 23

Inmmunolgical change in epithelium has caused inflammatory change but not enough to cause breach of epithelium

Question 24

What are major aphthous ulcers?

Answer 24

Can last for months
>=10mm in size
non k and k mucosa - hard palate and attached gingiva
may scar when healing

Question 25

How do we dx if pt has major or minor aphthous ulcer?

Answer 25

Dx from biggest ulcer present

Question 26

What can cause stricter at back of throat?

Answer 26

Healing of major aphthous ulcer which can case scarring if ulcers persist

Question 27

What is herpetiform ulcer?

Answer 27

Appears viral but no viral cause (looks like primary herpetic gingivostomatitis)
Non-K mucosa
heals within two weeks
can join to form larger areas of ulcer

Question 28

What is primary herpetic gingivostomatitis?

Answer 28

Primary herpetic gingivostomatitis (PHGS) typically has a prodrome of 2-4 days, and consists of fever, malaise, headaches, and cervical lymphadenopathy before generalised gingival inflammation and ulceration occur
PHGS is often a self-limiting infection that resolves in 10-14 days. Be aware of more serious complications of a herpes simplex infection, including erythema multiforme, aseptic meningitis, and encephalitis
Treatment with oral aciclovir is recommended within five days of prodromal signs and symptoms

Question 29

Difference between primary herpetic gingivostomatitis and herpetifrom ulcer?

Answer 29

PHG usually has systemic effects - pt all have fever, malaise, headaches and lymphadenopathy before ulcers become present on non-K mucosa whereas in herpetiform Althea there is no systemic affect

herpes infections also affect keratinised mucosa

Question 30

What is behcets disease?

Answer 30

This is where pt has 3 or more episodes of oral ulceration in one year along with ulceration present on the genitals, eye inflammation, skin ulcers and

Question 31

What are some examples of oral genital ulcerative conditions?

Answer 31

Behcets - must meet criteria
Vesicobullous diseases
LP

Question 32

How does behcets disease occur?

Answer 32

It is primary a vasculitis - there is inflammation of BVs leading to inflammation throughout the body

it can lead to significant disability such as blindness

Question 33

How is behcets disease treated?

Answer 33

Immunosuppressants used to treat Behçet’s disease include azathioprine, ciclosporin, methotrexate, mycophenolate mofetil and thalidomide.

Question 34

What triggers ulcers?

Answer 34

Trigger unknownn - immunological process occurs at the basement membrane where there is damage to basal cells resulting in them unable to produce epithelial cells resulting in loss of epithelium

Question 35

When do ulcers show?

Answer 35

3 to 4 days after immunological period has began

Question 36

How do ulcers form (histology)

Answer 36

There is an immunological process which results in cells in the basement membrane being unable to produce new epithelial cells and as upper cells fall away there is exposure of CT due to no new replacement epitehoal cells resulting in ulcer - this is the prodromal period and is when best to tx ulcer before appearance in mouth

Question 37

When is ulcer tx most effective?

Answer 37

In the prodromal period - this is when the immunological process is occurring in the CT at the epithelial junction and cells in the basement membrane are not producing epithelial cells due to damage resulting in exposure of CT = ulcer

topical steroids best when pt is in prodromal phase - can reverse or lessen damage of ulcer

Question 38

What may prodromal period feel like?

Answer 38

Tingy feeling pt will be aware of - this is when to apply topical steroids

Question 39

What is first line for oral ulceration tx?

Answer 39

CHX 2% 300ml - rinse for 1min with 10ml 2x day
- spit out after and use until lesions resolved

Question 40

What can be used to treat recurrent aphthous stomatitis?

Answer 40

Doxycycline 100mg tablts - send 48 - dissolve 1 tablet in water and rinse for 2 mins for 4x day for 3 days after onset of ulcer

Question 41

How can pts reduce mucosal discomfort?

Answer 41

Lidocaine gel - 5% or 10% solution as a spray to ulcer

benzydamine mouthwash - 0.15% 300ml rinse 15ml every 1hr 30 as req

benzydamina spray - 0.15% 30ml - 4 sprays on affected area every 1.5 hrs

Question 42

When do we consider steroid topical therapy?

Answer 42

when ulcer is disabling, can be used in prodromal period before ulcer present