OM-Oral ulceration and Apthous ulcers Flashcards
Name some immunological causes of oral ulcers ?
Apthous ulcers
lichen planus
Lupus
Vesiculo-bullous
Erythema multiforme
What are the main causes of ulcers?
Trauma.
Immunological
Infection
Gastrointestinal
Carcinoma
Drug induced.
What Gastrointestinal diseases can cause oral ulceration?
GORD.
Ulcerative colitis
Chron’s disease
(these problems affect absorption of nutrients)
What do we want to ask about the history of the ulcer?
Where?
are there any present on genitals/eyes?
Size and shape?
Is it a blister that bursts or initially an ulcer?
Ho wlong does it last?
Is it recurrent- in the same place or a different place.
Does it cause discomfort?
What do we examine when looking at the ulcer?
Margins-flat/raised/rolled
Base- soft?firm? Hard?
Surrounding tissue- Inflamed? Normal?
What are the important questions to ask yourself when looking at an ulcer?
Location- Is it on keratinised or non keratinised mucosa?
Is the patient showing any other systemic symptoms? e.g. fever/ GI symptoms
Is there anything that could be causing trauma?
What situations can cause a single episode of ulceration?
Trauma,
First episode of a recurrent ulcer
Primary viral Infection
Oral squamous cell Carcinomas
What can cause recurrent oral ulceration?
Trauma.
Apthous ulceration
Lichen planus
Vestibulobullous lesions
Recurrent viral lesions
Systemic disease
Describe the oral ulcer presentation shown by patients with Chron’s disease?
Chron’s ulcers- a linear fissured ulcer along the depth of the sulcus
Apthous ulcers due ot haematninc deficiency from the chron’s itself.
Describe the oral ulcer presentation shown by patients with recurrent herpetic ulceration?
Recurrent ulcers in the same place.
Limited to one nerve branch/group.
Often seen on hard palate
Patient experiences vesicles that burst to form ulcers.
What is the classification of recurrent aphtous stomatits based on?
The worst ulcer that the patient experiences.
What are the 4 main forms of recurrent aphtous stomatits?
Major
Minor
Herpetiform
Oral genital
Name this type of ulcer and describe its characteristics?
Minor apthous ulcer.
<10mm in size.
Erythemtous halo around the ulcer.
Found on non- keratinised mucosa.
Heals without scarring
Lasts 2 weeks
Responds well to topical steroids.
Name this type of ulcer and describe its characteristics?
Major apthous ulcer
>10mm.
May also be other smaller ulcers too.
Does not respond well to topical steroids.
Found on keratinised and non keratinised mucosa.
May scar when healing.
Name this type of ulcer and describe it’s characteristics.
Herpetiform ulcer.
Found on non-keratinised mucosa.
Collection of small ulcers (around 2mm in size)
Can coalesce into large areas of ulceration
What parts of the oral cavity are keratinised?
Mastigatory mucosa- so we want stronger mucosa.
Gingivae
Hard palate
Dorsal of tongue (top surface)
What parts of the oral cavity are non-keratinised?
Lip
Cheek
Floor of mouth
Soft palate
ventral of tongue (underside of tongue)
Compare herpeiform apthae and Primary herpetic gingivostomatitis?
In primary herpetic gingivostomatitis the patient also has a fever (systemic problems)
What is Behcet’s?
Primarily a vasculitiis
Condition characterised by 3 occasions of ulceration within a year
And at least two of the following (genital sores/eye inflammation/skin ulcers/ pathergy- exaggerated skin injury following minor trauma)
How do we treat Behcet’s disease?
We treat the oral ulcers as recurrent apthous stomatitis
And then refer for systemic immunomodulation if there is multisystem involvement.
List some predisposing factors to apthous ulceration
iron/ Vit B12 Deficiency.
Mechanical injury
Hormone fluctuations.
Describe the immunopathology of an ulcer
Basal cells are damaged at the basement layer & epithelial replacement cells are no longer produced.
So as skin cells shed this moves up to the surface .
It presents 3/4 days after the immunological process presents.
Why does the application of topical steroid on an ulcer provide little benefit?
Because when the ulcer appears it is in the process of healing already- So application of topical steroid cannot prevent the ucler from producing.
How can we use topical steroids to prevent oral ulceration?
Apply topical steroid to the area daily to catch the ulcer during the prodromal period
How can we investigate apthous ulcers?
Blood tests
-checking for haematinic deficiencies
-Hormone indicators of coeliac disease.
Allergy tests
-For immediate or delayed after contact hypersensitivity.
-Food additives
Get patient to avoid certain foods for 3 months and if this shows no benefit- it isn’t the cause.
How can we manage recurrent apthae?
Correct blood deficincies.
Avoid dietary triggers and SLS toothpastes.
Drugs
Refer for investigation
Discuss apthous ulcers in children?
These are most common during a child’s rapid growth- as it affects their nutritional state. (e.g. low iron levels/ peculiar diet)
But if the ulcers are not related to growth it could be a genetic problem.
How do we treat infrequent ulcers?
Non-steroidal therapy
How do we treat more disabling, more frequent ulcers?
Steroidal therapy.
What is the issue with treating ulcers in children?
Betnesol mouthwash is not licensed for any use in patients under 12.
It is also problematic if the patient cannot spit out.
what drugs are known to cause ulceration
NSAID
Nicorandil
Mexotrexate.
What red flags are more indicative of oral cancer?
Duration- ulcer lasting longer than 2 weeks.
Site- lateral border of the tongue higher risk site.
No other causes can be found
Other high risk factors- Drinking/smoking.
Growing in size.
Compare the presentation of an apthous ulcer to a traumatic ulcer?
Traumatic ulcers have a white border.
Apthous ulcers have an erythematous border with a yellow fibrinous surface
When do we refer ulcers to oral medicine?
If we have not achieved a good results after:
Referal to GP for haematinics
Topical treatments/
If the ulcer is non healing after 2 weeks (Oral medicine will decide re biopsy)
Any children under age 12 - malnutrition may have other cause.
