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Oral Disease > Oral Mucosa: Recurrent Oral Ulceration > Flashcards

Oral Mucosa: Recurrent Oral Ulceration Flashcards

1
Q

Ulcer features?

A 
A full thickness loss of epithelium
Exposes underlying CT
Ulcer covered by slough
Underlying granulation tissue (healing tissue - endothelial cells and fibroblasts)
Mixed inflammatory infiltrate
Usually painful
Erosion = partial loss of the epithelium
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2
Q

Histology of ulcers?

A

Fibrino-purulent slough on top

Granulation tissue under

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3
Q

Primary ulcers?

A

Begin as ulcers

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4
Q

Secondary ulcers?

A

Begin as a blister/vesicle

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5
Q

Ulcer - differential diagnosis?

A

Neoplastic e.g SCC (usually floor of mouth, lateral tongue, retromolar area)
Traumatic e.g. sharp tooth
Developmental - epidermolysis bullosa
Infective - Syphilis, HSV, TB
Idiopathic - RAS
Iatrogenic - drugs
Manifestation of dermatological disease e.g. lichen planus
Manifestation of systemic disease e.g. crohn’s

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6
Q

Oral ulceration - how to take a history?

A

Drugs can cause episodes - question drugs

Single episode

  • Single ulcer e.g. SCC
  • Multiple ulcers e.g. herpes zoster

Recurrent episodes

  • Single ulcer - mucocutanous disorders
  • Multiple ulcers e.g. RAS, mucocutaneous disorders
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7
Q

Singe episode ulcers - what can cause them?

A

Trauma
- Physcial, chem, thermal factitious

Malignancy
- SCC, Salivary neoplasm, lymphoma

Infection
- TB, symphilis, HSV

Drugs
- Methotrexate (immunosuppressant)

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8
Q

Treatment of single episode traumatic ulcers?

A

Reassurance
Remove cause
Consider difflam and corsodyl
Should show signs of improvement - if not refer for biopsy

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9
Q

Malignant ulcers - how can they present?

A

Raised, ROLLED BORDERS

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10
Q

Oral malignant ulcer - what is a red flag?

A

Any ulcer that is >3 weeks duration of unexplained cause = BIOPSY

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11
Q

Causes of single episode ulcers when there are multiple ulcers?

A 
Herpes simplex
Herpes zoster
Erythema multiforme
Hand, foot and mouth = coxsackieviruses
Herpangina
Iatrogenic e.g. drugs
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12
Q

Drugs which can cause oral ulcers?

A 
Allopurinol
Cytotoxics
Gold
Indomethacin
Methotrexate
Methyldopa
Nicorandil = anti angina medication - heal very quickly when dose reduced or stopped
Penicillamine

Irradiation - head and neck radiotherapy

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13
Q

How to manage drug related ulcers?

A

Liaise with GP or consultant

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14
Q

How to manage infective causes?

A

Most are self limiting, some require anti-fungals (candidiasis) /antibiotics (syphilis) /aciclovir (herpes virus)

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15
Q

Recurrent episodes of oral ulcers?

A

Single ulcer e.g. mucocutanous disorders

Multiple ulcers e.g. RAS, mucocutaenous disorders

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16
Q

Recurrent aphthous stomatisis (RAS) - types?

A

Minor recurrent aphthous stomatitis
Major RAS
Herpetiform RAS - not linked to herpes, ulcers formed looked like herpes ulcers

17
Q

Other causes of recurrent multiple ulcers?

A

Behcet’s disease
Recurrent erythema multiforme
Muco-cutaneous disorders
Other systemic disorders

18
Q

Recurrent aphthous stomatitis features?

A 
Common, affects 20% of population
Painful
May affect eating, drinking, speech
Most common type is the minor RAS
Occasionally very disabling
FH
19
Q

Minor aphthous ulcers?

A 
80% of RAS ulcers
Peak range 10-30
Usually 1-5 ulcers, 3-8mm diameter
Minor RAS must be less than 10MM
Last 7-10 days 
Variable ulcer free period
Usually non-keratinised mucosa
Usually front of mouth
Heal without scarring
20
Q

Major aphthous ulcers?

A 
10% of ulcers
May be larger - up to 1.5-2cm
Major RAS must be over 10mm
Last longer - 3 weeks to 3 months 
Single or multiple
Often affect back of mouth
Often non-keratinised mucosa, but can affect masticatory mucosa
May heal with scarring
21
Q

Herpetiform oral ulceration?

A

Less than 5% of ulcers
Dozens of small 1-2mm ulcers
May coalesce to form larger irregular ulcers
Mainly floor of mouth, margins and ventral surface of tongue
Lasts 7-10 days
Not associated with herpes infection (no vesicles)

22
Q

Contributory factors of aphthous ulcers?

A

Stress
Trauma
Hormones
Smoking - negative relationship

23
Q

Predisposing/underlying factors for aphthous ulcers?

A

Haematological deficiencies (Fe, B12, folate)
Neutropenia
Immune deficiency (HIV)
GI tract disease (coeliac, crohn’s, UC)
Vitamin deficiency (B1, B2, B6)
Food intolerance - chocolate, cinnamon, benzoates

24
Q

Investigations for aphthous ulcers?

A

Not always needed
FBC, ferritin, B12 and folate
Coeliac screen
Other tests according to history e.g. food allergies

25
Q

Treatment for aphthous ulcers?

A

Preventative

  • Correct haematological deficiencies
  • Treat underlying systemic disease
  • Remove trauma
  • Dietary elimination
  • OHI/diet advice

Symptomatic tx (local)

  • Corsodyl MW
  • Difflam MW
  • Covering agents e.g. gengigel, orobase paste

Suppressive tx (local)

  • Topical steroids
  • Hydrocortisone pellets (corlan)
  • Beclometasone spray (clenil modulite inhalter)
  • Betamethasone MW (betnesol) = most common
  • Flixonase nasules

Suppessive tx (systemic)

  • Prednisolone (steroid)
  • Thalidomide
  • Azathioprine
26
Q

Tx for herpetiform oral ulceration?

A

Doxycycline MW

27
Q

Behcet’s disease symptoms? Who/where is it more common?

A

Serious systemic disease

  • Blindness
  • Neurological damage
  • Severe oro-genital ulceration
  • Vasculitis
  • Death

Mainly young adult males - 30yrs
Incidence higher in japan and Turkey

28
Q

How to diagnose someone with Behcet’s disease?

A

Recurrent oral aphthous ulceration
PLUS 2 of the following:
- Recurrent genital ulcers
- Uveitis, cells in the vitreous or retinal vasculitis
- Skin lesions: erythema nodosum, acne like papulopustular lesions
- Positive pathergy test = large crusty lesions

Other common features
- Arthritis, GI lesions, CNS involvement, vascular lesions

29
Q

Management of Behcet’s disease?

A 
Multi-disciplinary approach
Oral med
Dermatology
Rheumatology
Opthalmology
30
Q

Other causes of oral ulceration?

A

Muco-cutaneous disorders

  • Lichen planus
  • Pemphigus
  • Pemphigoid
  • Erythema multiforme

Haematological disorders
Gastro-intestinal disorders

31
Q

When is a biopsy undertaken?

A

Usually because a clinician wants to exclude malignancy
Many non-malignant ulcers look identical under the microscope
= Clinical history and findings are crucial

32
Q

Ulcer history?

A 
Size 
Shape
Number
Location
Duration
Periodicity - how often they're getting them
Pain
Precipitating factors
Relieving factors
33
Q

Ulcer examination?

A 
Size
Shape
Site
Number
Base - malignant are hard
Edge
Discharge
Consistency - lumpy
Nodes - attached/do not move, hard if cancerous 
Other features

Oral Disease (42 decks)

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