Oral Ulceration

Question 1

Define an ulcer

Answer 1

Full thickness breach of the epithelium

One of the ways the oral mucosae can respond to an insult or condition

Question 2

List some causes of oral ulcers

Answer 2

Recurrent aphthous stomatitis (RAS)

Haematinic deficiency

Anaemia

Mucous membrane pemphigoid

Pemphigus Vulgaris

Erythema Multiforme

Steven Johnson’s Syndrome

Lupus

HSV infections

Medications e.g. Nicorandil

Behcet’s

Cyclical neutropenia

Acquired immunodeficiency

HIV

Trauma

Leukaemia

Inflammatory bowel disease

Coeliac disease

Oral facial granulomatosis (OFG, variant of Crohn’s disease that only affects the orofacial tissues)

Tuberculosis

Chemotherapy

Question 3

Briefly describe the classification system for oral ulcers

Answer 3

2 sub-divisions-

Recurrent
Persistent

If an oral ulcer is persistent, consider the following differentials-
SCC or other oral cancers (often present as a single persistent oral ulcer)
Trauma
Medication related

If an oral ulcer is recurrent, consider the following differentials-

Recurrent aphthous stomatitis (RAS)-
Minor
Major
Herpetiforme

Recurrent oral ulceration (ROU) associated with-
Inflammatory bowel disease (IBD)
Coeliac disease
Cyclical neutropenia
Behcet’s etc.

Question 4

A patient presents with a single oral ulcer that has persisted for 4 weeks. What is one differential diagnosis? What should be done if this differential is suspected?

Answer 4

Oral cancer commonly presents as a single persistent oral ulcer.

If oral cancer is suspected, the patient must be referred that same day via the 2 Week Wait referral pathway to a local OMFS unit.

The dentist should take clinical photographs and record clear descriptions of the clinical problem alongside the medical/social history.

The patient should be seen within 2 weeks from referral (as oral cancer is a potentially life threatening, if not life changing diagnosis that must be acted upon rapidly to give the best possible outcomes for the patient)

Question 5

Briefly describe how a history would be taken from patients who present with oral ulcers

Answer 5

Number-
How many ulcers do you get at any one time?

Size-
How big do the ulcers get (pin head, grain of rice, size of a 5p coin)

Site-
Where in the mouth do they appear?

Frequency-
How often do you get the ulcers?

Duration-
How long does each ulcer usually last for?

Ulcer-free period-
How long a period of time do you get with no ulcers whatsoever?

Extra-oral ulcers-
Do you get ulcers anywhere else on your body (e.g., genitalia, eyes, skin)

Pain-
Are the ulcers painful and if so do they affect eating/speaking etc.?

Habits-
Do you clench or grind your teeth? Are you aware of tongue thrusting or repeatedly rubbing your tongue, lips or cheeks on your teeth?

Thorough medical history taking

Medication history-
Find out if the patient has recently started a new medication or had a dose change before the ulceration began.
Enquire about medications, especially anything that has been tried to alleviate the ulcers (whether OTC or prescribed).
Check compliance with treatment used so far.

Family history-
Do you have any first degree relatives with oral ulceration? Any inflammatory bowel disease (Crohn’s or Ulcerative Colitis) or coeliac disease in your family? Any other significant illnesses to report?

Review of systems-
Enquire about related systemic systems, especially focusing on any gastrointestinal signs e.g., abdominal pain, weight loss, blood or mucus in the stools, alterations in bowel habit

Associations-
Are the ulcers associated with any particular foodstuffs?
For women, is there any relation to your menstrual cycle?

Effect on life/schooling-
How do the ulcers affect you? What is their effect on eating and drinking? How many days of school or work have you missed because of the ulceration?

Question 6

What special investigations may be conducted when a patient presents with oral ulceration?

Answer 6

For the majority of patients with oral ulcers, tests are not necessary to make the diagnosis but for some, they can help us work out the underlying cause.

Vitamin deficiencies and anaemia are usually relatively simple to rectify and can cause the ulcers to resolve without any other treatment but for the rarer causes, or when the ulcers are not behaving as they are classically expected to, then bloods or even biopsies can reveal more complicated underlying medical issues which need treating by a suitably qualified medical doctor.

Question 7

List some special investigations that can be conducted for patients with oral ulceration and the rationale behind their use

Answer 7

FBC (will identify whether the patient is anaemic or suffering a clinical or subclinical infection or give clues to potential haematological causes for the oral ulceration)

Haematinics (deficiency in B12, folate and ferritin may cause/worsen ROU)

Coeliac screen (endoymysial antibodies, tissue transglutaminase, gland in antibodies). If coeliac disease is suspected, the first screening test is for these autoantibodies whilst the patient is still eating adequate amounts of gluten each day and if positive, OGD will be done to obtain GIT samples to confirm diagnosis)

Serum ACE, ESR, CRP (generic markers of generalised inflammation can be helpful in the diagnosis and management of IBD)

Pathergy test, HLA typing (if Behcet’s is suspected, pathergy test of the skin and HLA typing will aid diagnosis)

MC+S (occasionally, superinfection of persistent or recurrent ulceration can be a problem and swabs or oral rinses may be indicated)

Indirect immunofluorescence (autoantibodies found in vesiculobullous conditions such as pemphigus vulgaris, can be detected indirectly by a simple blood test)

Incisional biopsy for H&E +/- direct immunofluorescence (rarely necessary in all but those cases where the diagnosis is not clear)

Except for the first 3 special investigations, we would need to refer the patient onto oral medicine to have these investigations carried out. For the first 3, a GP referral is sufficient

Question 8

What is recurrent aphthous stomatitis?

Answer 8

RAS is a very common form of ulceration which has a genetic predisposition. Will have no other underlying pathological process or diagnosis behind the ulceration (SLE, IBD etc.)

Some individuals have inherited multiple genes that make them much more susceptible to this form of oral ulceration than others. And those with a first degree relative who also has RAS will have a 90% chance of having inherited these genes.

Certain factors like trauma from parafunctional habits (clenching/grinding/nocturnal bruxism), orthodontic appliance wearing, a new denture, exam stress or being generally run down and ill can make oral ulcers more problematic.

But in essence, this form of ulceration is a genetic tendency some people have towards developing a mouth ulcer when emotionally or physiologically stressed, where others don’t.

3 types-
Major
Minor
Herpetiforme

Question 9

How would a dentist manage a patient who presents with oral ulceration?

Answer 9

In general, the role of the dentist is to identify the likely cause, provide the patient with information and start simple strategies to alleviate the pain and functional problems from the ulcer/s.

Early decision making regarding whether the ulcer(s) is potentially a presentation of oral cancer must be made and if suspected (single persistent ulcer, with rolled margins etc.), the patient needs to be referred on a 2 Week Wait pathway, with clinical photographs and records as evidence.

If a diagnosis of RAS is made, the majority of patients will not require referral to oral medicine. Sufficient to prescribe the patient with simple topical treatments/advice-

Topical anaesthetic mouthwashes and sprays

Avoidance of SLS (sodium lauryl sulphate)

Provision of a bite guard (due to ulceration, secondary to parafunctional habit)

Trial of betamethasone (500 microgram tablets dissolved in 10mls of water and held in the mouth over the ulcers for 3-4 minutes, then spat out, 4/daily)

Refer cases of RAS to oral medicine in the following situations-

Doubt over diagnosis

Partial/non-response to simple topical treatments

Severe presentation i.e., unusually rapid onset, extensive mucosal surfaces ulcerated, or multiple systems involved (e.g., skin, gut, eyes, genital tract), Major RAS

Known or suspected medical condition or medication use contributing adversely to the ulcer experience

Question 10

What advice/treatment can a GDP provide to patients with RAS?

Answer 10

Topical anaesthetic mouthwashes and sprays (Gelclair, Gengigel, Difflam)

Avoidance of SLS (sodium lauryl sulphate)

Provision of a biteguard (due to ulceration, secondary to parafunctional habit)

Trial of betamethasone (500 microgram tablets dissolved in 10mls of water and held in the mouth over the ulcers for 3-4 minutes, then spat out, 4/daily)

Question 11

If a diagnosis of RAS is made, the majority of patients will not require referral to oral medicine. Sufficient to prescribe the patient with simple topical treatments/advice. But there are some situations which would indicate the need for referral. List these situations:

Answer 11

Doubt over diagnosis

Partial/non-response to simple topical treatments

Severe presentation i.e., unusually rapid onset, extensive mucosal surfaces ulcerated, or multiple systems involved (e.g., skin, gut, eyes, genital tract), Major RAS

Known or suspected medical condition or medication use contributing adversely to the ulcer experience

Question 12

What clinical signs would indicate that a presenting oral ulcer is due to parafunction as opposed to other causes?

Answer 12

Will tend to present as ulcers along the occlusal plane, on the lateral borders of the teeth and along the occlusal plane level to the buccal mucosae or lips

Will see clinical signs of parafunction-
Pronounced buccal ridging
Linea albae (frictional thickening of the buccal mucosa, white horizontal streak on the buccal mucosa, level with the occlusal plane)
Crenulated/scalloped edges to the tongue
Concomitant TMD secondary to clenching and grinding

If the sole cause is parafunction, there will be no ulcers on the palate, floor of mouth or gingivae as the teeth can’t cause trauma here

Parafunction is often a stress response, so worth asking how the patient is generally and if there is something in their life causing extra pressure or stress

Question 13

A patient presents with complaints of a persisting oral ulcer. On examination, you notice the ulcer sits in the buccal mucosa, along the occlusal plane. There is also evidence of buccal ridging and the tongue appears scalloped. On further inquiry, the patient reports they have been quite stressed as it is currently exam season. What is the likely diagnosis and management protocol for this patient?

Answer 13

Ulcer secondary to parafunctional habit.

Explanation of the cause of the ulcer and reassurance to the patient.

Pain relief through topical agents (e.g. Gengigel, Gelclair or Difflam)

Provision of a 2-3mm soft bite guard to protect the soft tissues from the patient’s parafunction

Question 14

Describe the features of minor recurrent aphthous stomatitis

Answer 14

1-5 ulcers located in the labial mucosa, buccal mucosa, tongue or FoM

<10 mm in size

Last around 4-14 days

Occur in the age bracket of 5-19 years

Recur every 1-4 months

Unlikely to result in scarring

Most RAS sufferers are affected by this subtype (75-85%)

Males and females equally affected

Question 15

Describe the features of major recurrent aphthous stomatitis

Answer 15

1-10 ulcers located in the labial mucosa, buccal mucosa, tongue, palate or pharynx

> 10mm in size

Last for more than 30 days

Occur in the age bracket of 10-19 years

Recur < monthly (high and frequent recurrence)

Commonly result in scarring

10-15% of RAS sufferers will have this subtype

Males and females equally affected

Question 16

Describe the features of herpetiforme recurrent aphthous stomatitis

Answer 16

10-100 ulcers located in the labial mucosa, buccal mucosa, tongue, FoM, palate, pharynx or gingivae

1-2mm in size (although, may coalesce to form larger ulcers)

Last for less than 30 days

Occur in the age bracket of 20-29 years

Recur > monthly

Unlikely to result in scarring

5-10% of RAS sufferers will have this subtype

Females more commonly affected than males

Question 17

Which RAS subtype has the highest, most frequent recurrence rate

Answer 17

Major RAS

Question 18

Which RAS subtype affects more females than males?

Answer 18

Herpetiforme RAS

Question 19

Which RAS subtype is most common?

Answer 19

Minor RAS

Question 20

Which RAS subtype can result in 10-100 ulcers?

Answer 20

Herpetiforme RAS

Question 21

Which RAS subtype results in the smallest number of ulcers at any one time?

Answer 21

Minor RAS

Question 22

Which RAS subtype commonly causes scarring?

Answer 22

Major RAS

Question 23

Which RAS subtype can affect the pharynx?

Answer 23

Major RAS

Herpetiforme RAS

Question 24

List the ages of onset for each RAS subtype

Answer 24

Minor RAS (5-19 years)

Major RAS (10-19 years)

Herpetiforme RAS (20-29 years)

Question 25

A patient comes in with minor recurrent aphthous stomatitis. Describe the clinical features you would observe that confirm this diagnosis

Answer 25

1-5 circular or ovoid ulcers (that are more than 5mm but less than 10mm in size)

Found on the buccal mucosa, labial mucosa, lateral borders of the tongue or the FoM

Will have a regular outline and a fairly narrow border of erythema surrounding them.

Will be covered with slough (yellow creamy colouration centrally) and if this was to come off, it would reveal an intense red and erythematous base to the ulcers.

Question 26

What subtype of oral lichen planus can present in ulcers?

Answer 26

Erosive/ulcerative lichen planus

Question 27

Describe the clinical features of erosive lichen planus

Answer 27

Patchy erythema with bilateral striations (lacey white lines) which are fairly diffuse and extend almost to the full height of the buccal mucosae on both sides.

In and amongst these areas of red and white patches, some superficial ulceration will be observed.

If we palpate these lesions, we would observe them to be soft, with no evidence of induration and rolling of the borders.

Can also present as large white plaques with some areas of erythema on the dorsum of the tongue. These plaques can take a creamy yellowish colour transitioning into an ulcer slough just before the ulcer forms

Question 28

Describe the features of primary herpetic gingivostomatitis

Answer 28

An infection caused by the herpes simplex virus, that produces little tiny ulcers (from pin head size to 2-3mm in width)

Predominantly affect the ventral surface of the tongue

May observe the small ulcers coalescing (ulcers have started to join together and form larger islands)

Can also result in very red, angry, inflamed gums

Self-limiting condition (usually lasts no more than 7-10 days)

Question 29

How would you treat a patient with primary herpetic gingivostomatitis

Answer 29

Self-limiting condition.

Whilst it’s unpleasant, usually lasts no more than 7-10 days

Put in place simple supportive measures-

Advising the patient to stay well hydrated

Advising the patient to take paracetamol

Encouraging the patient to maintain good OH, keeping everything clean with Chlorhexidine or hot, salty mouthwashes to prevent super infection

Question 30

Which drug is known to cause oral, ocular and anal ulceration in some patients?

Answer 30

Nicorandil (use to treat poorly controlled or moderate/severe ischaemic heart disease e.g. angina)

Question 31

Describe the features of drug induced ulceration following the use of Nicorandil

Answer 31

Persistent painful oral ulcer

Often smooth, circular/ovoid shaped, with a white border around it (which evidences hyperkeratosis)

Can take a punched out appearance (clinically concerning appearance, think cancer?)

May feel a little indurated or thickened and fibrous when palpated (as these ulcers tend to be quite large and deep)

Can observe associated ulcers in the eye and anus.

Forms due to the use of Nicorandil for the treatment of ischaemic heart disease. This drug has a threshold. Some patients will be able to tolerate the drug with ease with no ulcerations whatsoever, but when the dose is increased (i.e., the heart disease has become more severe etc.), they develop these persistent painful ulcers that can take many months to heal. Conversely, if the dose is decreased, these ulcers will resolve or improve without the need for any further intervention.

Question 32

Why does the use of Nicorandil cause oral ulceration?

Answer 32

The drug has a threshold. Some patients will be able to tolerate the drug with ease with no ulcerations whatsoever, but when the dose is increased (i.e., the heart disease has become more severe etc.), they develop these persistent painful ulcers that can take many months to heal. Conversely, if the dose is decreased, these ulcers will resolve or improve without the need for any further intervention.

Question 33

How do we treat a patient with Nicorandil induced oral ulceration?

Answer 33

Withdraw the drug and give the patient an alternative

OR lower the drug dose if the oral ulceration presented after a dosage increase

If the ulcer is in a clinically concerning region (lateral borders of the tongue) or has a clinically concerning appearance (pearly border, punched out appearance, rolled margins, feels a little indurated and hardened when touched), refer patient to oral medicine for an incisional biopsy to assess for dysplastic/malignant features

Question 34

Describe the features of bullous pemphigoid

Answer 34

Uncommon in the dental setting

Typically targets the skin of elderly patients more so than it does the mouth

Will result in extra-oral ulcers / blisters on the skin where we may observe excoriated or scratched ulcers, that have burst, leaving a scaly erythematous appearance

Intra-orally, we will see large islands of ulceration, with ulcer sloughs covering the area where the epithelia has been breached and broken down.

Minimal trauma from eating sharp foods or brushing teeth or accidentally biting the lip would be sufficient to cause the shearing of the mucosa and the blistering to burst, forming subsequently large ulcerated lesions

These features would usually be evoked by trauma

Question 35

Describe the features of mucous membrane pemphigoid

Answer 35

More commonly seen in the dental setting as it predominantly targets the oral mucosa

Large areas of ulceration with a predilection for the soft palate. Can affect other areas like the lateral borders of the tongue/buccal mucosa

These ulcers have a fairly irregular border, with lots of erythema and ulcer slough over the affected areas.

Can also present as a nodular area (pink, smooth, raised area). Less commonly found.

These blisters form in a submucosal location and are a bit more resistant to bursting than the more superficial blisters seen in pemphigus.

But still unusual to see an intact blister in this condition, more likely to see the ulcers that remain once the blisters have burst in pemphigoid

Very painful to eat

Very easy for a super infection to take hold with such large areas of raw breached epithelium

Question 36

Describe the features of pemphigus vulgaris

Answer 36

Large areas of ulceration that can extend to the hard and soft palate

These ulcers have a fairly irregular border, with lots of erythema and ulcer slough over the affected areas

May observe superficial ulceration to the lower lip

These ulcers are far more fragile and the mucosa will very easily tear away, blister and ulcerate with very minimal trauma.

Almost impossible to find an intact blister in this condition, because they form in such a superficial area of the epithelium.

Typically will occur in much younger patients.

Has a fairly dramatic acute presentation with other bodily sites affected at the same time.

Question 37

Describe the intra-oral features of systemic lupus erythematous (SLE)

Answer 37

Little striations with a lichenoid appearance that may contain small ulcers within the striae

Can affect the lateral borders of the tongue, the ventral surface etc.

SLE can result in lichenoid features and the potential presence of non-specific oral ulceration that doesn’t fit any particular pattern.

May also observe a dry mouth due to salivary gland involvement (as some of the oral manifestations of SLE)

Question 38

Describe the features of erythema multiforme

Answer 38

Widespread intra-oral ulceration to different mucosal surfaces, including the vault of the palate.

Ulcer sloughs on a background of erythema in affected areas

Lips are often also ulcerated (labial mucosa, external lip), appearing fairly dry and cracked

Ulcers will present as bullae or targetoid lesions on the skin. Considered targetoid lesions as they resemble a Bull’s eye with concentric circles of pallor, erythema and sometimes, a bluish ring of discolouration

These blisters can be very painful on the skin. And ARE very painful in the mouth.

Question 39

An edentulous elderly patient presents to your clinic with a solitary non-healing ulcer, that has persisted for months. It is located just under the denture bearing area. On inquiry, the patient reports it causes her no pain. And on examination, you notice some evidence of bony expansion of the maxilla in the region of the ulcer. What is one differential diagnosis? What should a dentist do if this diagnosis is suspected?

Answer 39

Oral cancer

Refer patient via the 2 Week Wait referral pathway for an oral assessment and incisional biopsy by the OMFS unit to assess for malignancy

Question 40

A patient presents with a little ovoid ulcer on the lateral border of the tongue at the level of the occlusal plans. You notice several very sharp restorations that sit next to this region when the tongue is at rest. On inquiry, the patient states he often feels that the teeth next to the area are sharp. On palpation, the area feels quite firm. What is the differential diagnoses and management protocol for this patient?

Answer 40

Traumatic ulce

Oral cancer (as it was quite firm to palpate and located on the lateral borders of the tongue, it could raise suspicions for a cancer diagnosis)

To get to the definitive diagnosis-
Further inquiry to the patient’s complaint of the teeth next to the area feeling sharp is necessary.
Ask the patient if the teeth rub against the tongue in this region
Query whether he accidently bites the region repeatedly
Ask whether there’s been other form of trauma in the region in the past

All of the above would indicate a traumatic ulcer rather than oral cancer

But if in doubt, the patient should be referred via the 2 Week Wait referral pathway for a biopsy to confirm non-malignancy/non-dysplasia in the region

As this is likely a traumatic ulcer, the dentist should smooth down these sharp restorations and take the region of the tongue out of the way of the occlusion by, for example, making the patient a bite guard, to protect the soft tissues from the teeth. This would completely resolve the ulcer

Question 41

Describe the features of squamous cell carcinoma (SCC) in the mouth

Answer 41

Variable presentation, but classically an ulcerated lesion with a rolled border and an indurated firm and thickened base that is fixed to the underlying tissues.
Some lesions present as poorly defined patchy pigmentation, with erythema, whiteness and central ulceration. If these lesions are palpated, they would feel very firm, thickened, and quite fixed to the tissues underlying the area.

Others present as punched out ulcers with some hyperkeratosis/whitening surrounding them, surface of these ulcers may be raw where there’s been loss of epithelium. There may not be a lot of erythema but again, these ulcers would feel very thickened and indurated when palpated

May also see tissues within the ulcer begin to break down and become necrotic centrally

Often coupled with an expansion of bone (clinically presents as a swelling)

Common affected surfaces include the lateral borders of the tongue, buccaneering mucosa, lip

Question 42

Describe the features you would observe if a patient presents with a SCC of the lower lip. What is the likely age of the patient? What risk factor, other than age, could make this diagnosis more likely for this patient?

Answer 42

Nodular SCC that may have begun to break down and ulcerate (yellow/creamy colour). May see a slightly redder area where there’s been loss of epithelium

Very irregular and large ulcer

May see some expansion in the region

Patient likely to be older (therefore has had a lot of sun exposure throughout their lives) and have a smoking habit

Question 43

A 25 year old female patient presents with tiny 1-2mm ulcers gathered in crops that are beginning to join together to form large ulcers. The ulcers are located on the ventral surface of the tongue, FoM and lower labial mucosa. The patient reports they have been there for 25 days and occur many times throughout the year. What is the likely diagnosis and management protocol for this patient?

Answer 43

Herpetiforme RAS

Unlike other subtypes, a prescription of doxycycline mouthwash can be used to control Herpetiforme RAS

Thought that the anti-inflammatory properties of the doxycycline prevent the ulcers forming.

Should be prescribed as 100mg capsules that need to be opened, with their contents mixed in warm water and used as a mouthwash for at least 2 minutes 4/daily as soon as the ulcers appear. Should not be swallowed but spat out

Question 44

Describe the features of Behçet’s disease

Answer 44

Rare condition that causes vasculitic changes in multiple bodily tissues that can have the following features/symptoms-

Aphthous oral ulceration (Minor, Major or Herpetiforme RAS), as well as genital ulceration.

Ocular changes (uveitis, retinal vasculitis etc.)

Acne-form lesions (papulopustular rashes)

Pain in the form of headaches, arthralgia and myalgia

Life-threatening neurological system involvement (e.g., strokes).

Severe GI involvement

Severe thrombotic events like DVTs

Ethnic predisposition (Mediterranean, Middle Eastern, Japanese or South-East Asian descent).

Gender predisposition (most commonly affects males aged 20-30 but children, older patients and females can also be affected.

Condition has a long latency period from first expression of clinical signs and symptoms to time of diagnosis

Question 45

Describe the intra-oral features of cyclical neutropenia

Answer 45

Neutropenia refers to the depletion of the white blood cell, the neutrophil.

Inherited disorder characterised by falls in neutrophil counts every 21 days (polygenic inheritance pattern)

Predisposes patients to RAS which has a similar pattern of cycling through periods of ulceration for 21 days followed by a brief period of remission.

Rare with a varied presentation with regards to impact-
Some patients have ulcers which are easy to control and others with ulcers which are far more challenging.

May, however, improve and settle as the child enters adulthood.