Oral Ulceration Flashcards
What is an ulcer?
A full thickness breach of the epithelium”
What sorts of questions should you ask when taking a history for oral ulceration?
- Number?
- Size?
- Site/ Where?
- Frequency?
- Duration?
- Ulcer free period?
- Pain?
- Habits?
- Associations? - food/menstrual period?
- Family history?
- Systemic - GI, weight loss, blood in stools, abdominal pain
- MH?
- Medication/dose change?
Which form of RAS commonly results in scarring?
Major RAS
What medication can cause oral, ocular ulceration?
Nicorandil
Why is it important to decide if the ulcer is persistent or recurrent?
Oral cancer can present as a single persistant oral ulcer
if you suspect oral cancer what must you do?
refer that SAME day under local referral pathway
what must you include in the referral for suspicious oral cancer lesions?
- clinical photos
- medical/social history
what type of investigations might be needed in ROU?
FBC, haematinics and coeliac screening bloods
what is ROU?
recurrent oral ulceration (refers to ANY cause for recurrent oral ulcers)
What is RAS?
Recurrent aphthous stomatitis? (specific diagnosis)
What are the 3 variants of RAS?
minor, major and herpetiform?
is there a strong genetic predispostion with RAS?
Yes!
What is the rough amt of ulcers you would see in minor, major and herpetiforme RAS
1-5
1-10
10-100
what would you expect the size of the ulcers to be in minor, major and herpetiforme RAS?
<10mm
>10mm
1-2mm
what would the duration of each ulcer be in minor, major and herpetiforme RAS?
4-14
>30
<30
what type of RAS commonly leads to scarring?
Major RAS
What is the most common form of RAS?
minor RAS
What are some causes of persistent oral ulceration?
SCC (squamous cell carcinoma)
trauma
medication-related
What are some conditions that lead to (ROU) recurrent oral ulceration?
IBD
Coeliac
Behcet’s
Cyclical neutropenia
What information might a FBC give?
presence of anemia or if pt is suffering a clinical infection or potential hematological causes
what information might haematinics give?
Deficiency in B12, folate, ferritin
What information might serum ACE, ESR and CRP give?
generic markers of generalised inflammation - helpful in diagnosis/management of IBD
When would you use the term RAS?
When there is no underlying pathological process or diagnosis causing the ulcers
What are subtle clinical signs of parafunctional habits?
pronounced buccal ridging
linea albae
scalloped edges to the tongue
concomitant TMD secondary to clenching or grinding
NCTSL
What would be suitable management for parafunctional ulcers?
Education
Pain relief (topical agents - Gelclair)
2-3mm soft bite guard
What management approach should be taken for patient with oral ulceration?
- IDENTIFY CAUSE! - early decision making regarding ulcer is a presentation of oral cancer
- Provide pt with leaflets and information
- simple strategies to alleviate pain and functional problems from ulcers
- Take photos!
What are the reasons to refer to Oral Medicine for oral ulceration?
Doubt over diagnosis
partial/non-response to topical treatments
severe presentation (rapid onset), extensive mucosal surfaces ulcerated or multiple systems involved (skin, gut, eyes)
Major RAS
Known or suspected medication condition/medication contributing to ulcer
Where do herpetiforme ulcers tend to appear?
ventral tongue, floor of mouth and lower labial mucosa
what antibiotic can be prescribed and is supposedly good for herpetiforme RAS?
Doxycycline
What is Behcet disease?
rare disease causes vasculitic changes in multiple body tissue
what are other potential effects of behcet disease (apart from aphthous ulceration)
ocular changes, headaches, genital ulceration, acne form lesions, myalgia, arthralgia
Who is commonly affected by Behcet disease?
male patients
aged 20-30 most commonly
what is neutropenia? how might it be acquired?
depletion of white blood cell - neutrophil
acquired following chemotherapy or secondary to significant infections
what is cyclic neutropenia?
inherited disorder - neutrophil count falls every 21 days
what is the clinical presentation of oral lichen planus?
oral ulceration + patchy erythema = white patches
what does primary herpetic gingiva stomatitis present as in the mouth? what site does it normally affect?
little tiny ulcers on the ventral surface of tongue
what are the supportive measures of primary herpetic gingiva stomatitis?
- well hydrated, paracetamol, keeping everything clean, chlorhexidine mouthrinse
if the ulcers feel firm as opposed to soft what would we be advised to do?
undertake an urgent biopsy (usually within 2 weeks) to confirm diagnosis
what is bullous pemphigoid?
rare skin condition
what is mucous membrane pemphigoid?
rare, chronic, autoimmune disorder that typically affects the mucous membranes more often than the skin
what area of the mouth does mucous membrane pemphigoid appear?
soft palate
what is pemphigus vulgaris?
rare long-term condition caused by a problem with the immune system
what site in the mouth does SLE typically affect? what si the typical appearance?
lateral borders of the tongue = striations with a lichenoid appearance
what is erythema multiforme?
skin reaction that can be triggered by an infection or some medicines
what are classical signs of erythema multiforme?
widespread ulceration of the vault of the palate, ulcerated lips (dry/cracked), bullae lesions on skin, bluish ring of discolouration, painful
what is B cell non-hodgkins lymphoma
cancer of the lymphatic system
what is the typical appearance of SCC?
ulcerated lesion with rolled border and indurated firm base
- lateral border of the tongue is a high risk site
who is likely to have ulcerated SCC of the lower lip?
older pts who smoke or had a lot of sun exposure
what type of mucosa does minor RAS tend to occur on>
non-keratinised (labial mucosa, floor of mouth, ventral side of tongue)
what type of mucosa does minor RAS tend to occur on>
These usually appear inside the lips and cheeks, on the tongue and sometimes the floor of
the mouth.
What is the management for oral ulceration?
symptomatic relief, Corsodyl mouthwash, correct reversible risk factors, anti-fungals? adjusting dentures? smoothing off teeth? referral of ulcers and systemic disease
what type of RAS might mimic a squamous cell carcinoma?
Major RAS
what is nicorandil commonly prescribed for?
poorly controlled/ moderately severe ischaemic heart disease (eg: angina)
