Oral Ulceration Flashcards
What is an ulceration
An ulceration is the loss or erosion of the mucous membrane layer
How does an apthous ulcer look?
Yellow fibrinous base, surrounding erythematous halo
Why is there no standard tx for oral ulceration?
degree of morbidity of ulcer varies from pt to pt and episode to episode - tx is tailored to pt
What advice can we give to pt who has ulcer that wants us to see it?
take picture - ulcer may be gone when they visit us but this allows us to see lesion
What are the causes of oral ulceration? (5)
Trauma
Immunological
Carcinoma
Infections
GI causes
What falls under immunological ulceration?
Apthous ulcers
lichen Planus
lupus
vesicle-bullous
erythema muliforme
What infections can cause oral ulceration?
Bacterial
Fungal
Viral
What GI conditions can cause ulcerations?
Crohns
UC
What is the difference between crohns and UC?
Chrons disease can affect the full thickness of the GI tract - most commonly small and large intestine but anywhere from mouth to anus
UC affects/causes inflammation in the lining of the large intestine(colon and rectum)
What history do we ask a pt with ulcer?
Where is the ulcer?
What size is the ulcer?
What shape is the ulcer?
Does the ulcer begin as a blister and then bursts to produce ulcer? or is it always just been an ulcer?
How long does ulcer last for? - when did it begin (can last several weeks or months if ulcer episode but individual ulcer should last 2 weeks or less if aphthous ulcer)
Does the ulcer recur in same site?
are u having discomfort?
What do we ask the pt with regards to whether ulcer is recurrent or not?
We want to determine if the ulcers recur?
and if they recur do they recur in same place
What would be a sign the ulcer is caused by lichen Planus?
If oral ulceration occurs in same site every time - lichen planus doesn’t move
What would be a sign ulcer is just a apthous ulcer?
Moves location - diff areas of mucosa depending on trigger factors
What must we determine with regards to duration of ulcer?
How long pts ulcer free period is - how long they go with no ulcer? - this tells us how inconvenient condition is
What do we look at with regards to the margin of an ulcer?
Is the margins
FLAT
RAISED
ROLLED - if rolled, or irregular rather than well defined margins this is more sus
What do we look at in terms of the base of an ulcer?
is it soft? - good sign its nothing nasty
hard?
is it firm and hard?
is it fixed in position?
keratotic - in traumatic ulcer
What do we check in ulcer surrounding tissue?
We look for inflammation or normal mucosa?
What else do we check when examining ulcer?
Is pt systemically unwell? - inc in temp?
What may cause single episode oral ulceration?
Trauma
Why may trauma cause ulcers?
Appliance such as denture (if so then when dente is removed tissue will heal until re wearing denture), brace, URA, sharp tooth, restoration edge, fractured filling
When might we dx single episode oral ulceration?
Pts first presentation with ulcer, no history of recurrence
How do we tx traumatic ulcers?
Remove traumatic cause
Review pt
In interim we can suggest salt water rinses
What primary viruses can cause single episode ulceration?
Herpes
Coccsaky Virus
How does herpes virus ulceration look?
It tends to follow the innervation pattern of the oral mucosa - one side of mouth only
If an ulcer is in fact more sinister what may it be?
oral squamous cell carcinoma (SCC)
What are the types of aphthous ulcers?
Minor
Major
Herpetifrom
What are the potential causes of rsingle episode oral ulceration?
- TRauma
- First ep of RAU
- Viral - herpes or cokksaky virus
- Orsal SCC
Define minor apthous ulcers
Less than 10mm in size
Normally 2-5 lesions but can be up to 20
Mainly affect non-keratinised mucosa
Heal within 14 days
Heal with no scar
Define major apthous ulcer
> 10mm in size
<5 lesions at a time (1-5)
Affects both keratinised and non-keratinised mucosa
Can take several weeks(6-12 to heal)
Often scar - due to depth of erosion
What are herpetiform ulcers?
<5mm in size
can have 1-200 ulcers affecting non keratinised mucosa
dont have viral aetiology
dont scar
heal within 14 days
What are different types of recurrent oral ulceration?
Aphthous ulcers (major, minor, herpetifrom)
Lichen planus
Vesicobullous lesions - pemphigoid, pemphigus, EM
Recurrent viral lesion - herpes
trauma - sharp tooth, resto, denture
systemic disease - crohns, UC
What are some vesiculobullous ocniditons that can cause ulceration?
Pemphigus
Pemphigoid
Angina bulls HAemorrhagica
Erythema Multiform - TARGET LESIONS (type IV)
What are the types of recurrent apthous stomatitis? (RAS)
Major
Minor
Herpetifrom
Behcets syndrome
What is a RAS?
This is a form of conditions where there is immunological damage to the oral mucosa and presents in different patterns dx by history and findings of clinical exam
What are triggers of recurrent aphthous stomatitis?
Haematinic deficiencies
Systemic diseases - crohns
What are the 3 haematinics?
Ferrin
B12
Folate
What ulcers can crohns disease cause?
It can cause a mix of apthous type ulcers usually due to HCT deficiency and also crohns specific ulcers
What are crohns specific ulcers?
These are lesions that are LINEAR FISSURED ULCERS ALONG SULCUC DEPTH - often seen alongside typical apthous ulcers with oval appearance due to HCT deficiency from crohns itself
last for month s
What are the 4 features of a traumatic ulcer?
Identifiable cause
Single episode
Lesion will heal once we remove causative factor (not necessarily heal fully just begin to heal and be less prominent)
Halo of keratosis surrounding ulceration with fibrinous cover over the top - trauma due to white change around ulcer suggesting trauma has exceeded tissues capacity for repair and ulcer has occurred as epithelial cells are removed quicker than body can replace them
Why do traumatic ulcers have yellow fibrin base and often keratotic halo?
There is loss of epithelial cells by trauma which is quicker than the body natural ability to replace ep cells resulting in keratin production
What can cause recurrent herpetic lesions?
Herpes simplex 1 or 2
Herpes zoster
How can we identify herpetic lesions?
Lesion is usually limited to one nerve group/branch and are often seen on the HARD PALATE
Ulceration reappears in same area each time - often before ulcer appears pt feels discomfort
Why can recurrent herpetic lesions caused by herpes simplex be painful?
Not usually due to virus - often due to vesicle which bursts resulting in exposed connective tissue
What tx can we provide for recurrent herpetic lesions?
Systemic acyclovir - for viral replication suppression - important when lesion is associated with inc nerve damage and possibility of persisting nerve pain after lesion settles
What in to history makes us suspicious lesion is herpetic lesion?
Oral ulceration that has history of recurring in same place
What is the general rule aphthous ulcers?
They tend to be self healing ulcers that affect NON KERATINISED MUCOSA
What ulcers tend to be self healing affecting non k mucosa only?
Apthous
What is the general rule for viral caused ulcers?
They tend to affect keratinised mucosa and recur
What is often the cause of recurring ulceration on k mucosa?
Viral cause
If ulcer doesn’t heal in 2 weeks what can we do?
Urgent cancer pathway
Discuss with hospital specialist and then biopsy
