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Oral Disease - Soft tissue > Oral Ulceration > Flashcards

Oral Ulceration Flashcards

1
Q

Define: erosion

A

Area of partial loss of skin or mucous membrane

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2
Q

Define: Ulceration

A

Area of total loss of epithelium and lamina propria

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3
Q

Define: atrophy

A

Loss of thickness

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4
Q

Define: plaque

A

Raised, uniform thickening of a portion of the skin/mucosa with a well defined edge

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5
Q

Define: excoriation

A

Scratch mark which has scored the epidermis

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6
Q

Define: Lichenification

A

Thickening of the prickle cell and horny layer of the epidermis with underlying inflammation

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7
Q

List the local causes of oral ulceration

A

Trauma - dentures, sharp teeth or restorations, self-inflicted or iatrogenic
Burns - chemical, thermal, electric or radiation (radiotherapy ulcers)

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8
Q

List the systemic causes of oral ulceration

A
  • haematological - anaemia, leukemia, neutropenia
  • Gastrointestinal - coeliac, crohns, ulcerative colitis
  • Dermatological - bechets, EB, EM, lichen planus, PV
  • Infections
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9
Q

List the drugs which play a role in the aetiology of oral ulceration

A
  • Cytotoxic drugs
  • Nicorandil
  • NSAIDs
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10
Q

List the differential causes of oral ulceration

A
  • Local
  • Systemic including infections
  • Drug therapy
  • Malignancy
  • Recurrent aphthous ulceration
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11
Q

List the infectious causes of oral ulceration

A

Bacterial - ANUG, TB, syphillis
Viral - HIV, VZV, HSV, coxsackie
Fungal - deep mycoses

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12
Q

Presentation of oral ulceration due to local trauma

A
  • Usually a single episode of ulceration (unless causative factor is not removed)
  • Associated with trauma prone site e.g. lip, BM, denture flange
  • Tenderness
  • Yellow-grey floor of fibrin slough with red margins
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13
Q

What is the appearance of ulcers due to chronic local trauma

A
  • Chronic trauma may lead to induration due to scarring, or keratotic margins
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14
Q

What are some presenting signs of ulcers due to anaemia

A

Pale mucosa

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15
Q

What are presenting signs for ulcers due to cyclical neutropenia

A

Pale yellow ulcers without erythema (due to reduced inflammatory response)

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16
Q

What are presenting signs of ulcers due to leukemia

A
  • Gingival swelling and bleeding associated with ulceration

- Other signs of malignancy

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17
Q

What are the characteristic lesions associated with ulcerative colitis?

A
  • Pyoderma gangernosum

- Pyostomatitis vegetans

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18
Q

What does pyostomatitis vegetans look like?

A

Lots of small yellow pustules that coalesce

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19
Q

What is the presentation of ulcers due to drugs?

A
  • Aspirin causes chemical trauma when placed on the mucosa
  • RAS-like lesions with nicorandil and methotrexate
  • Mucositis with cytotoxic agents
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20
Q

Warning signs an ulceration is malignant

A
  • > 3 weeks persistent without any other expalanation
  • Thick and indurated
  • Asymptomatic
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21
Q

Special IX for oral ulcerations

A
  • Blood tests

- Biopsies

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22
Q

Topical analgesics used for oral ulceration

A

Difflam (benzydamine hydrochloride)

Lidocaine gel or ointment

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23
Q

Topical steroids used for management of oral ucleration

A

Betamethasone
Fluticasone
Moometasone

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24
Q

Topical anti-inflammatory agents used for the management of oral ulceration

A

Doxycycline 100mg as mouthwash

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25
Q

Systemic agents used for the management of oral ulceration

A
  • Corticosteroids (prednisolone)
  • Dapsone
  • Colchicine
  • Tacrolims
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26
Q

Management of ulceration due to underlying disease

A
  • Referral to GMP to investigate

- Resolving condition will resolve ulceration

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27
Q

Why are blood tests used as a special ix for oral ulceration?

A
  • 25% of ulcers are associated with a haematological abnormality
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28
Q

Questions to ask during ulcer history taking

A
  • What does the pt mean by an ‘ulcer’
  • Age of onset
  • Noticed any changes
  • Duration (how long before they heal)
  • How long before ulcers recur
  • Frequency of ulcer attacks - Any associations e.g. smoking
  • Number, shape, size, site, symptoms, any ulcerations elsewhere e.g. skin or genitals
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29
Q

Medical history aspects relevant to ulcer history

A
  • Age
  • History of malignancy
  • Drug history
  • Smoking history
  • Alcohol history
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30
Q

Prevalence of recurrent aphthous stomatitis

A

10-25%

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31
Q

What is recurrent aphthous stomatitis?

A

Common condition characterised by round or ovoid painful ulcers recur on the oral mucosa

32
Q

What are the hypothesised aetiological factors of RAS

A
  • Genetic predisposition
  • Infections
  • Immunological abnormalities
  • GI and haematological disorders
  • Hormonal disturbances
  • Stress
  • Non-smokers
33
Q

Epidemiology of RAS

A
  • Often childhood onset with a peak in adolescence or early adult life
  • Sometimes positive family history
34
Q

When do we biopsy an ulcer?

A

Only if it mimics a carcinoma

35
Q

What are the categories of RAS ulcers

A

Minor
Major
Herpetiform

36
Q

Describe minor RAS ulcers

A

Oval shaped lesion <10mm diameter, often found on non-keratinised mucosa (BM) with a grey base and erythematous border
- Usually around 1-5 ulcers are present

37
Q

Describe major RAS ulcers

A

Irregularly shaped lesion >10mm, may occur anywhere (tends to be posterior or masticatory mucosa), grey base which may have indurated borders, may have 2-10+ ulcers

38
Q

How long do minor RAS ulcers last?

A

1-2 weeks and heal without scarring

39
Q

How long do major RAS ulcers last

A

2-12 weeks and heal with scarring

40
Q

Describe herpetiform ulcers

A

Round (or irregular with coalescence) lesion around 0.5-3mm, found on the non-keratinised mucosa (ventral tongue common) with a yellow base and widespread, bright erythematous border

41
Q

What are the peak ages of the RAS ulcers

A

Minor - 2nd
Major - 1st decade
Herpetiform - 3rd decade

42
Q

What are herpetiform ulcers?

A

Appear like HSV ulcers, but contain no viral component

43
Q

What is the most common management option for RAS?

A
  • Symptomatic relief
  • Eliminate local factors
  • Promote healing of ulcers
44
Q

Topical drugs for the management of RAS

A
  • Corticosteroids - Betamethasone or triamcinolone paste
  • Tetracycline, CHX or difflam mouthwash
  • Salicylate preparations
45
Q

When may systemic drug therapy be indicated in RAS?

A

Major apthae that are painful

Persistent and resistant to conventional treatment

46
Q

What is the ulcer severity score?

A

Index used to classify ulcers based on their severity - it accounts for number of ulcers, size, duration, site, pain, length of ulcer free period and evidence of scarring

47
Q

What conditions are characterised by oral and genital ulceration?

A
  • Reactive arthritis
  • Mouth and genital ulcers with inflamed cartilage
  • Bechets disease
48
Q

What is reactive arthritis?

A

Autoimmune condition developing 2-4 weeks after GI or genitourinary infections, which presents with non-infectious urethritis, arthritis and conjunctivitis.

49
Q

What are the oral findings in reactive arthritis

A

Erythematous macules and plaques with diffuse erythema, erosions and bleeding of the mucosa
- Circinate lesions on the tongue

50
Q

Management of reactive arthritis

A
  • Most is self limiting

- If symptomatic then NSAIDs, corticosteroids, antibiotics if the cause is chlamydia or DMARDs if NSAIDS are ineffective

51
Q

What is mouth and genital ulcers with inflamed cartilage (MAGIC)?

A

Rare syndrome with probable autoimmune aetiology characterised by relapsing polychronditis and bechets and orogenital ulcers

52
Q

Management for MAGIC

A

Pentoxifylline
Corticosteroids
Dapsone
Infliximab

53
Q

What is Bechets disease?

A

Chronic, relapsing, inflammatory mulisystem disease of unknown aetiology

54
Q

Epidemiology of Bechets

A
  • Young adult males - 20-40

- Common in Turkey and Japan (silk road distribution)

55
Q

Aetiology of Bechets

A
  • Unknown but probable inflammatory reaction due to HSV or streptococci OR autoantigen in genetically predisposed individuals
56
Q

What genetic component is associated with bechets?

A

HLA-B51

57
Q

What inflammatory aspects are associated with Bechets

A
  • T helper17 and interleukin 17 pathways are active
  • There are circulating immune complexes
  • Neutrophil activity is increased and infiltrates affected organs alongside lymphocytes
58
Q

What are the types of Bechets disease divisions?

A

Mucocutaneous (orogenital ulceration
Arthritic (+/- mucocutaneous)
Neurological
Ocular

59
Q

How is a bechets diagnosis made?

A

Bechets is highly variable - diagnosis is made when there is aphthous ulcers alongisde 2 major criteria

60
Q

What are the oral S/S for bechets

A

Minor RAS is common, major is also associated but herpetifom is rare

61
Q

What are the genital S/S for bechets

A

Ulcers commonly associated with the scotum or labia

May occur less commonly on the vagina, or perineum

62
Q

What are the ocular S/S for bechets

A

Anterior uveitis
Cells in vitreous
Retinal vasculitis

63
Q

What are the skin S/S for bechets

A

Erythema nodosum
Pseudofolliculitis or papulopustular lesions
Acneiform lesions

64
Q

What are the minor criteria for bechets

A
  • Arthritis
  • DVT, PE or aortic aneurysm
  • CNS involvement
  • GI lesions
65
Q

What are the major criteria for bechets

A
  • Oral ulcers
  • Genital ulcers
  • Eye lesions
  • Skin lesions
66
Q

Management of Bechets disease

A
  • Initial - colchicine, topical steroids or non-steroidal mouthwash and antibiotics
  • Maintenance = oral steroids (azathioprine), then to infliximab or riuximab upon flare ups
67
Q

What is steven johnsons syndrome?

A

Rare condition resulting from hypersensitivity to drugs or infections, or idiopathic in nature.

68
Q

What drugs are associated with SJS?

A
  • Barbiturates
  • Sulphonamides
  • NSAIDS
  • Carbemazepine
69
Q

What infections are associated with sjs?

A

Herpes simplex (60%)
Mycoplasma
EBV
HIV

70
Q

Pathology of SJS?

A

immune complex formation and deposition in the microvasculature (cutaneous or mucosal)

71
Q

S/S of SJS

A
  • Oral ulceration or erosions in the anterior mouth
  • Crustation of lips (looks haemorhagic)
  • Skin lesions - look like targets, macules, papules, vesicles or bulla
72
Q

Management of SJS

A

Supportive oral care

ICU or burns unit

73
Q

Morality rate of SJS

A

10%

74
Q

What is toxic epidermal necrolysis?

A

Severe form of SJS where >30% of the body surface is affected

75
Q

Mortality rate of TENS

A

30%

76
Q

What is PFAPA?

A

Periodic fever, aphthae, pharyngitis and cervical adenitis

Oral Disease - Soft tissue (12 decks)

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