Oral ulceration

Question 1

Generally what 6 things might cause ulceration in the oral mucosa?

Answer 1

• Trauma
• Immunological
• Infections
• Gastrointestinal disease’s - Crohn’s , ulcerative colitis

Question 2

What might have caused this ulceration?

Answer 2

Trauma from orthodontic appliances

Question 3

What viral infections can cause ulceration in the oral mucosa?

Answer 3

• Herpes simplex virus
• Varicella zoster virus

Question 4

What two types of oral ulceration is associated with Crohn’s disease?

Answer 4

• Apthous type ulcers
• Crohn’s specific ulcers

Question 5

What is associated with apthous type ulcers in crohn’s disease?

Answer 5

• Haematinic deficiency

Question 6

Describe 3 characteristics Crohn’s specific oral ulceration?

Answer 6

• Linear at the depth of the sulcus
• Associated with granulomas
• Persist for months - intalesional steroids help

Question 7

What 3 types of ulcer margins?

Answer 7

• Flat
• Raised
• Rolled

Question 8

What is a common type of ulceration?

Answer 8

Traumatic ulceration , usually single episode if cause is removed

Question 9

When do traumatic ulcers usually heal?

Answer 9

Within 2 weeks

Question 10

3 Characteristics of recurrent herpetic ulceration?

Answer 10

• limited to one nerve branch
• Often affects the hard palate
• Recurs in the same place

Question 11

What would you use to treat a herpetic ulcers?

Answer 11

Aciclovir

Question 12

A patient present with this type of ulceration with pain, what would be the cause ?

Answer 12

Reactivation of varicella zoster virus

Question 13

What are the 4 forms of recurrent apthous ulceration?

Answer 13

• Major
• Minor
• Herpetiform
• oro-genital ulcer syndromes - Behcet’s syndrome

Question 14

What is a general rule for diagnosing recurrent apthous ulcers?

Answer 14

• Recurrent self healing ulcers that only affects the non-keratinised mucosa

Question 15

What are Aphthous ulcers ?

Answer 15

A type of oral ulceration that is immunologically generated that is recurrent can be associated with genetics and environmental factors

Question 16

How does a standart minor ulcer appear intraorally?

Answer 16

• Yellow or grey base with red margins

Question 17

Describe the diameter, healing, area affected of minor apthous ulcers?

Answer 17

• Less than 10mm diameter
• Last for up to 2 weeks
• Heal without scarring
• Affect non keratinised mucosa

Question 18

Describe the diameter, healing, area affected of major apthous ulcers?

Answer 18

• larger than 10mm
• can last for months
• may scar when healing
• affect any part of the mucosa

Question 19

Explain how major and minor ulcers are treated with steroid?

Answer 19

Minor respond well to topical steroids while major are poorly responsive to topical steroid and may need intralesional steroid

Question 20

What is the rarest form of apthous ulcers?

Answer 20

Herpetiform apthae

Question 21

What is herpetiform apthous ulcers?

Answer 21

• multiple small ulcers on non keratinised mucosa
• heal within 2 weeks
• these are not related to herpes viruses

Question 22

Why are herpetiform apthous ulcers named this way?

Answer 22

Because in the early stages they look like primary herpetic gingivostomatitis

Question 23

What are the 2 criteria that should be met for the diagnosis of oral and genital ulceration?

Answer 23

• three episodes of mouth ulcers in a year
• at least two of the following : genital source, eye inflammation, skin ulcers, pathergy

Question 24

Give two other conditions other than behcet’s that may cause oro-genital ulceration?

Answer 24

• Vesiculobullous diseases
• Lichen planus

Question 25

5 signs of behcet’s disease?

Answer 25

• Bowel ulceration
• Brain damage
• Joint pain
• Inflammation of blood vessels
• Eye disease
• Genital ulceration

Question 26

3 steps to manage Behcet’s disease?

Answer 26

• Treat oral disease with steroids
• Systemic immunomodulation
• Liaise with rheumatologist

Question 27

What systemic immunomodulator is used first off label for behcet’s disease?

Answer 27

• Colchicine

Question 28

Name other 2 immunomodulators used for behcet’s?

Answer 28

• Azathioprine
• Mycophenolate

Question 29

Give 1 drug used for biological management of behcet’s?

Answer 29

infliximab

Question 30

4 predisposing factors of RAS other than genetics and viral infections?

Answer 30

• Horomonal changes
• Stress
• Trauma
• systemic diseases - Crohn’s

Question 31

Immunologically , explain how apthous ulcers develop?

Answer 31

Immune cells cause attack basal cells resulting in lack of epithelial cells at the surface of the epithelium which results in ulceration

Question 32

When is the treatment of apthous ulceration is most effective??

Answer 32

Ulcer prodome period

Question 33

What 4 investigations would you take for apthous ulcers other than haematinics?

Answer 33

• Blood test for coeliac disease
• Allergy tests to benzoates, sorbate , cinammoon and chocolate

Question 34

What test is carried out for coeliac screening?

Answer 34

TTG test ( tissue transgutaminase)

Question 35

What food additives may cause allergic reaction leading to apthous ulceration?

Answer 35

E210 - E219

Question 36

How to manage apthous ulceration after investigation?

Answer 36

• Correct blood deficiencies
• Refer for investigation if coeliac positive
• Avoid dietary triggers and SLS toothpaste

Question 37

What would you give an apthous ulcer patient for symptomatic relief?

Answer 37

betamethasone mouthwash

Question 38

What group of patients would you consider referral when presenting with apthous ulcers?

Answer 38

Children under 12