Aphthous Ulcers Flashcards
What is do an ulcer?
Breach of the epithelium
What are apthous ulcers?
self healing ulcers that affect non-keratinised mucosa only
How can we investiager aphthous ulcers?
Blood tests
Coeliac testing
Allergy testing
What bloods can we get for investigation of aphthous ulcers?
Haemitinic levels - ferritin, B12, folate
Coeliac testing - TTG testing (can have high false positive results)
What allergy tests can we do?
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
How can we manage apthous ulcers when pt has blood deficiencies?
Replace iron, folic acid or b12 as needed - but GP must do follow up for reason why there is deficiency (if unexplained GI investigations)
What in toothpaste can trigger ulceration?
SLS - we can get SLS free toothpastes such as sensodyne proenamel or also Aldi and lidl have available
How do we manage recurrent and self limiting oral aphthous ulceration?
CHX 0.2% mouthwash
in children - soft diet, analgesia and usually resolve within 1-2 weeks
Diflam mouthwash = used to treat pain and inflammation
What mouthwash can we recommend for pts with self limiting ulcers?
CHX 0.2%
Difflam 0.15%w/v Oral Rinse - anti-inflammatory analgesic oral rinse (over 12 only - 15 ml every 1-3 hours)
When can ulcers occur in children?
Commonly occur during periods of rapid growth (Unusual for children under 12 to get ulcers - consider referral)
What can be done for ulceration in children?
3 months iron supplements
assess diet
What is the main trigger for ulceration in children?
Low iron levels - nutrients used rapidly during growth periods - provide iron supplements for 3 months
What are some viral infections that can cause oral ulceration?
Herpes
Cokksaky virus
HIV
Hand foot and mouth
What are some bacterial infections that can case oral ulceration?
Syphyliss
TB
What mucocutaneous diseases can cause oral ulceration?
Lichen Planus
Erythema Multiforme
Pemphigoid
Pemphigus
Behcets syndrome
What haematological disease can cause oral ulceration?
Anaemia
Leukemaa
What GI problems can cause oral ulceration?
Crohns
UC
Coeliac disease
Wha are apthous ulcers?
These are immunologically generated recurring oral ulcers that follow a set pattern depending on the type
WHat is the histology of apthous ulcers?
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)
What are the types of recurrent apthous stomatitis?
Minor
Major
Herpetiform
Behcets SYndrom
What does a standard minor oral ulcer look like?
Fibrin base yellow in colour and erythematous halo margin (inflammatory change)
What are the features of Minor apthous ulcers?
<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
Why do ulcers have perilesional erythema?
Inmmunolgical change in epithelium has caused inflammatory change but not enough to cause breach of epithelium
What are major aphthous ulcers?
Can last for months
>=10mm in size
non k and k mucosa - hard palate and attached gingiva
may scar when healing
How do we dx if pt has major or minor aphthous ulcer?
Dx from biggest ulcer present
What can cause stricter at back of throat?
Healing of major aphthous ulcer which can case scarring if ulcers persist
What is herpetiform ulcer?
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
What is primary herpetic gingivostomatitis?
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
Difference between primary herpetic gingivostomatitis and herpetifrom ulcer?
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
What is behcets disease?
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
What are some examples of oral genital ulcerative conditions?
Behcets - must meet criteria
Vesicobullous diseases
LP
How does behcets disease occur?
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
How is behcets disease treated?
Immunosuppressants used to treat Behçet’s disease include azathioprine, ciclosporin, methotrexate, mycophenolate mofetil and thalidomide.
What triggers ulcers?
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
When do ulcers show?
3 to 4 days after immunological period has began
How do ulcers form (histology)
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
When is ulcer tx most effective?
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
What may prodromal period feel like?
Tingy feeling pt will be aware of - this is when to apply topical steroids
What is first line for oral ulceration tx?
CHX 2% 300ml - rinse for 1min with 10ml 2x day
- spit out after and use until lesions resolved
What can be used to treat recurrent aphthous stomatitis?
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
How can pts reduce mucosal discomfort?
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
When do we consider steroid topical therapy?
when ulcer is disabling, can be used in prodromal period before ulcer present
