Oral Med Revision - Ulcers

Question 1

causes of oral ulceration

Answer 1

traumatic
metabolic / nutritional
allergic / hypersensitivity
infective
inflammatory
immunological
drug induced
neoplastic
idiopathic

Question 2

what is oral ulceration

Answer 2

a localised defect where there is a destruction of epithelium exposing underlying connective tissue

Question 3

what to assess about an ulcer

Answer 3

site
onset
duration
number
texture
appearance
size
pain
predisposing factors
relieving factors

Question 4

traumatic ulcer

Answer 4

white keratotic borders
clear causative agent i.e. # cusp
make sure to look and feel
surrounding mucosa normal and ulcer soft
consider movement disorders, sensory impairment, chemical burns

Question 5

metabolic & nutritional

Answer 5

aphthous like ulceration
yellow/white ulcer with red border
in children/teens associated with growth
adults with occult GI/GU pathology
malnourishment of any cause
anaemia
malabsorption or blood loss in gut
iron / folate / b12 deficiency causes atrophy of mucosa predisposing it to ulceration although it may have a more causative role in recurrent aphthae

Question 6

allergic / hypersensitivity

Answer 6

sorbate i.e. baked goods, canned fruit
cinnamaldehyde i.e. chewing gum
benzoates i.e. fizzy juice
often associated with features of OFG

Question 7

inflam / immunological

Answer 7

behcet’s; mouth, skin, genitals, eyes
necrotising sialometaplasia
lichen planus
vesiculobullous disease
CT disease - SLE, RA

Question 8

common features of gut & CT disease you may want to enquire about

Answer 8

GUT - abdominal pain, PR blood/mucous, altered bowel motion, unintentional weight loss
CTD - joint pain/stiffness, photosensitive rashes, xerostomia, fatigue

Question 9

infective

Answer 9

primary or recurrent HSV
varicella zoster virus
epstein barr virus
coxsackie virus
HIV

Question 10

primary herpes simplex infection

Answer 10

generally affects children 2-5yrs
associated with fever, headache, malaise, dysphagia, cervical lymphadenopathy
short lasting vesicle effective tongue, lips, buccal, palatal & gingivae mucosa then forming ulceration

Question 11

varicella zoster virus

Answer 11

primary VZV (chicken pox) -> virus remains in sensory ganglion -> reactivation of latent virus resulting in VCZ (shingles)
will present over distribution of dermatome, reactivation often due to immunocompromisation or acute infection, liaise with pt GP as may need further investigation, provide analgesia & difflam if painful

Question 12

iatrogenic

Answer 12

chemotherapy
radiotherapy
GVHD
drug induced ulceration i.e. potassium channel blockers, bisphosphonates, NSAIDs, DMARDs

Question 13

neoplastic

Answer 13

exophytic
rolled borders
raised
hard to touch
non moveable
not always painful
sensory disturbance

Question 14

other malignancy

Answer 14

non hodgkin lymphoma - ask re fever, night sweats, weight loss
kaposi’s sarcoma - 2ndary to HIV more commonly presents as pigmented lesion

Question 15

oral ulceration local management

Answer 15

reverse the reversible !!
refer for FBC/B12/folate/ferritin/ coeliac screen
- low B12/ferritin/folate +/- anaemia may result in aphthous ulceration
- low ferritin associated with low mean cell volume; microcytic
- low b12/folate associated with high mean cell volume; normocytic
1. simple MW
2. antiseptic MW (hydrogen peroxide/CHX)
3. LA; benzydamine or lidocaine
4. steroid MW; betamethasone
5. onward referral to OM; excluding other associated pathology, explore other therapeutic options such as colchicine or dapsone