OM-Oral ulceration and Apthous ulcers

Question 1

Name some immunological causes of oral ulcers ?

Answer 1

Apthous ulcers
lichen planus
Lupus
Vesiculo-bullous
Erythema multiforme

Question 2

What are the main causes of ulcers?

Answer 2

Trauma.
Immunological
Infection
Gastrointestinal
Carcinoma
Drug induced.

Question 3

What Gastrointestinal diseases can cause oral ulceration?

Answer 3

GORD.
Ulcerative colitis
Chron’s disease
(these problems affect absorption of nutrients)

Question 4

What do we want to ask about the history of the ulcer?

Answer 4

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?

Question 5

What do we examine when looking at the ulcer?

Answer 5

Margins-flat/raised/rolled
Base- soft?firm? Hard?
Surrounding tissue- Inflamed? Normal?

Question 6

What are the important questions to ask yourself when looking at an ulcer?

Answer 6

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?

Question 7

What situations can cause a single episode of ulceration?

Answer 7

Trauma,
First episode of a recurrent ulcer
Primary viral Infection
Oral squamous cell Carcinomas

Question 8

What can cause recurrent oral ulceration?

Answer 8

Trauma.
Apthous ulceration
Lichen planus
Vestibulobullous lesions
Recurrent viral lesions
Systemic disease

Question 9

Describe the oral ulcer presentation shown by patients with Chron’s disease?

Answer 9

Chron’s ulcers- a linear fissured ulcer along the depth of the sulcus
Apthous ulcers due ot haematninc deficiency from the chron’s itself.

Question 10

Describe the oral ulcer presentation shown by patients with recurrent herpetic ulceration?

Answer 10

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.

Question 11

What is the classification of recurrent aphtous stomatits based on?

Answer 11

The worst ulcer that the patient experiences.

Question 12

What are the 4 main forms of recurrent aphtous stomatits?

Answer 12

Major
Minor
Herpetiform
Oral genital

Question 13

Name this type of ulcer and describe its characteristics?

Answer 13

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.

Question 14

Name this type of ulcer and describe its characteristics?

Answer 14

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.

Question 15

Name this type of ulcer and describe it’s characteristics.

Answer 15

Herpetiform ulcer.
Found on non-keratinised mucosa.
Collection of small ulcers (around 2mm in size)
Can coalesce into large areas of ulceration

Question 16

What parts of the oral cavity are keratinised?

Answer 16

Mastigatory mucosa- so we want stronger mucosa.

Gingivae
Hard palate
Dorsal of tongue (top surface)

Question 17

What parts of the oral cavity are non-keratinised?

Answer 17

Lip
Cheek
Floor of mouth
Soft palate
ventral of tongue (underside of tongue)

Question 18

Compare herpeiform apthae and Primary herpetic gingivostomatitis?

Answer 18

In primary herpetic gingivostomatitis the patient also has a fever (systemic problems)

Question 19

What is Behcet’s?

Answer 19

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)

Question 20

How do we treat Behcet’s disease?

Answer 20

We treat the oral ulcers as recurrent apthous stomatitis

And then refer for systemic immunomodulation if there is multisystem involvement.

Question 21

List some predisposing factors to apthous ulceration

Answer 21

iron/ Vit B12 Deficiency.
Mechanical injury
Hormone fluctuations.

Question 22

Describe the immunopathology of an ulcer

Answer 22

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.

Question 23

Why does the application of topical steroid on an ulcer provide little benefit?

Answer 23

Because when the ulcer appears it is in the process of healing already- So application of topical steroid cannot prevent the ucler from producing.

Question 24

How can we use topical steroids to prevent oral ulceration?

Answer 24

Apply topical steroid to the area daily to catch the ulcer during the prodromal period

Question 25

How can we investigate apthous ulcers?

Answer 25

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.

Question 26

How can we manage recurrent apthae?

Answer 26

Correct blood deficincies.
Avoid dietary triggers and SLS toothpastes.
Drugs
Refer for investigation

Question 27

Discuss apthous ulcers in children?

Answer 27

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.

Question 28

How do we treat infrequent ulcers?

Answer 28

Non-steroidal therapy

Question 29

How do we treat more disabling, more frequent ulcers?

Answer 29

Steroidal therapy.

Question 30

What is the issue with treating ulcers in children?

Answer 30

Betnesol mouthwash is not licensed for any use in patients under 12.
It is also problematic if the patient cannot spit out.

Question 31

what drugs are known to cause ulceration

Answer 31

NSAID
Nicorandil
Mexotrexate.

Question 32

What red flags are more indicative of oral cancer?

Answer 32

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.

Question 33

Compare the presentation of an apthous ulcer to a traumatic ulcer?

Answer 33

Traumatic ulcers have a white border.
Apthous ulcers have an erythematous border with a yellow fibrinous surface

Question 34

When do we refer ulcers to oral medicine?

Answer 34

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.