Aphthous ulcers & oral thrush Flashcards
What is the definition of aphthous ulcers (7)
- A superficial, grey/white, painful oral lesion. Clearly defined, round or ovoid and only in the mouth
- Typically heal within 10-14 days without scaring
- Perhaps 20% of UK will get them
- 9% in children
- Most common 10-40 y/o
- 66% of young adults
- 80% of patients go to community pharmacy
What is the most likely cause of aphthous ulcers
Minor aphthous ulcer (MAU)
What are the likely causes of aphthous ulcers (2)
- Major aphthous ulcer
- trauma
What are the unlikely causes of aphthous ulcers (4)
- Herpetiform
- herpes simplex
- oral thrush
- medicine-induced
What are the very unlikely causes of aphthous ulcers (4)
- Oral carcinoma (cancer)
- erythema multiforme (SJS)
- Behcet’s syndrome
- hand foot and mouth disease
what are the factors that seem to be linked with minor aphthous ulcers (7)
- Genetic (40% have a family history)
- Stress
- Food sensitivity
- Nutritional deficiency (iron, zinc, Vit.B12)
- Infection
- More common in non-smokers
- Biting cheek, tongue etc
What are the visual diagnoses of aphthous ulcers and the history (8)
- White/grey lesions
- Under 1 cm in diameter
- Under 5 of them
- If 1 and near a tooth, suspect trauma
- Only in the mouth
- Lasted under 14 days
- Painful
- Not immunosuppressed
What are the differential diagnoses of aphthous ulcers (2) and their symptoms (5)
- Herpes simplex
- Small and large in number
- prior to ulcers may have had fever and sore throat
- often children
- Oral thrush
- Creamy white, soft elevated patches
- can be scraped off
When should aphthous ulcers be referred (SPAIND)
Size over 1 cm in diameter
Pain not present - potentially dangerous pathology
Age under 10 years old - suspect hand, foot and mouth disease
Immunodeficient
Number over 5 - other underlying cause
Duration over 14 days - other underlying cause
What advice is given for aphthous ulcers (3)
- Self-limiting <14 days with no treatment
- Avoid food/drink making it feel worse (coffee, chocolate, peanuts…)
- Trauma? → see dentist if needed (broken tooth, denture etc)
What safety netting is there for aphthous ulcers (3)
See doctor if:
- Lasts over 14 days
- More appear
- Feel unwell
What therapies are there for mouth ulcers (6)
- Protectorants - Gelatine/pectin/carmellose (GSL)
- Local anaesthetic - Benzocaine, lidocaine (GSL/P)
- Choline salicylate (GSL) - 16 +
- Benzydamine (Difflam) (P) 12+
- Antibacterials - Chlorhexidine (Corsodyl mouthwash) (POM)
- Corticosteroids - Hydrocortisone (P/POM) 12+
what is the definition and epidemiology of oral thrush (6)
- Oropharyngeal candidiasis
- Opportunistic oral mucosal fungal infection of Candida albicans
- causing sore raised white patches in the mouth
- Very young and very old
- 5% new born infants, 10% debilitated elderly
- Uncommon in healthy adults- unless a reasonable cause
- Requires change in normal environment to proliferate
What are the local factors causing oral thrush and is referral needed (10)
- Impaired local defence mechanisms - refer
- Reduced saliva production - treat
- smoking - treat
- atrophic oral mucosa - refer
- mucosal disease (e.g. oral lichen planus) - refer
- Topical medication (e.g. corticosteroids) - treat
- Decreased blood supply (e.g. caused by radiotherapy or vasculitis) - refer
- Poor oral hygiene - treat
- Dental prosthetics or dentures - treat
- Altered or immature oral flora - treat
What are the systemic factors causing oral thrush and is referral needed (8)
- Impaired systemic defence mechanisms - refer
- Immunodeficiency (e.g. AIDS) - refer
- Immunosuppressive medications (e.g. azathioprine) - refer
- Endocrine disorders - refer
- Malnutrition - refer
- Cancers - refer
- Some congenital conditions - refer
- Broad-spectrum antibiotic therapy - treat
what are the typical presentations of oral thrush (9)
- Sore raised white patches, small or large irregular shapes
- Can be removed by scraping (leaving behind a red/bleeding sore)
- Some soreness/ pain. No pain → referral (potential malignancy)
- Located on tongue, cheeks and hard palate
- Back of mouth/ throat if a S/E of inhaled steroid
- Taste disturbance
- In children may be associated by malaise
- Very young very old
- If healthy adult and no cause → refer
What are other diagnoses similar to oral thrush needing referral (4)
- Leucoplakia
- Lichen planus
- Herpetiform ulcers
- Major way to tell apart: if the white can be wiped off → thrush
What is the pharmacy treatment for oral thrush (6)
- Miconazole oral gel (Daktarin 2%)
- Infants 4-24 months: 1.25 mL QDS after food
- Over 2 y/o: 2.5 mL QDS after food
- Continue for 7 days after cleared, up to 14 days
- If on warfarin refer
- Hold on area for as long as possible
How is Nystatin used to treat oral thrush (4)
- 100,000 units (1mL) QDS usually for 7 days, and continued for 48 hours after lesions have resolved
- Hold on area for as long as possible- 1 minute
- Sticks less, major reason Daktarin typically more effective
- side effects: nausea, local irritation
What advice is given for people using inhaled corticosteroids for the management of oral thrush (3)
- Rinse mouth after use
- Use spacer
- Good oral hygiene
What advice is given for denture wearers for the management of oral thrush (6)
- Ensure sterilisation of dentures
- Air dry dentures
- Leave out for at least 6 h/day
- Brush gums with soft brush
- Ensure dentures fit
- Refer to dentist
What advice is given for infants for the management of oral thrush
Sterilise dummies and bottles
