Oral Ulceration Flashcards
Define: erosion
Area of partial loss of skin or mucous membrane
Define: Ulceration
Area of total loss of epithelium and lamina propria
Define: atrophy
Loss of thickness
Define: plaque
Raised, uniform thickening of a portion of the skin/mucosa with a well defined edge
Define: excoriation
Scratch mark which has scored the epidermis
Define: Lichenification
Thickening of the prickle cell and horny layer of the epidermis with underlying inflammation
List the local causes of oral ulceration
Trauma - dentures, sharp teeth or restorations, self-inflicted or iatrogenic
Burns - chemical, thermal, electric or radiation (radiotherapy ulcers)
List the systemic causes of oral ulceration
- haematological - anaemia, leukemia, neutropenia
- Gastrointestinal - coeliac, crohns, ulcerative colitis
- Dermatological - bechets, EB, EM, lichen planus, PV
- Infections
List the drugs which play a role in the aetiology of oral ulceration
- Cytotoxic drugs
- Nicorandil
- NSAIDs
List the differential causes of oral ulceration
- Local
- Systemic including infections
- Drug therapy
- Malignancy
- Recurrent aphthous ulceration
List the infectious causes of oral ulceration
Bacterial - ANUG, TB, syphillis
Viral - HIV, VZV, HSV, coxsackie
Fungal - deep mycoses
Presentation of oral ulceration due to local trauma
- 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
What is the appearance of ulcers due to chronic local trauma
- Chronic trauma may lead to induration due to scarring, or keratotic margins
What are some presenting signs of ulcers due to anaemia
Pale mucosa
What are presenting signs for ulcers due to cyclical neutropenia
Pale yellow ulcers without erythema (due to reduced inflammatory response)
What are presenting signs of ulcers due to leukemia
- Gingival swelling and bleeding associated with ulceration
- Other signs of malignancy
What are the characteristic lesions associated with ulcerative colitis?
- Pyoderma gangernosum
- Pyostomatitis vegetans
What does pyostomatitis vegetans look like?
Lots of small yellow pustules that coalesce
What is the presentation of ulcers due to drugs?
- Aspirin causes chemical trauma when placed on the mucosa
- RAS-like lesions with nicorandil and methotrexate
- Mucositis with cytotoxic agents
Warning signs an ulceration is malignant
- > 3 weeks persistent without any other expalanation
- Thick and indurated
- Asymptomatic
Special IX for oral ulcerations
- Blood tests
- Biopsies
Topical analgesics used for oral ulceration
Difflam (benzydamine hydrochloride)
Lidocaine gel or ointment
Topical steroids used for management of oral ucleration
Betamethasone
Fluticasone
Moometasone
Topical anti-inflammatory agents used for the management of oral ulceration
Doxycycline 100mg as mouthwash
Systemic agents used for the management of oral ulceration
- Corticosteroids (prednisolone)
- Dapsone
- Colchicine
- Tacrolims
Management of ulceration due to underlying disease
- Referral to GMP to investigate
- Resolving condition will resolve ulceration
Why are blood tests used as a special ix for oral ulceration?
- 25% of ulcers are associated with a haematological abnormality
Questions to ask during ulcer history taking
- 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
Medical history aspects relevant to ulcer history
- Age
- History of malignancy
- Drug history
- Smoking history
- Alcohol history
Prevalence of recurrent aphthous stomatitis
10-25%
What is recurrent aphthous stomatitis?
Common condition characterised by round or ovoid painful ulcers recur on the oral mucosa
What are the hypothesised aetiological factors of RAS
- Genetic predisposition
- Infections
- Immunological abnormalities
- GI and haematological disorders
- Hormonal disturbances
- Stress
- Non-smokers
Epidemiology of RAS
- Often childhood onset with a peak in adolescence or early adult life
- Sometimes positive family history
When do we biopsy an ulcer?
Only if it mimics a carcinoma
What are the categories of RAS ulcers
Minor
Major
Herpetiform
Describe minor RAS ulcers
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
Describe major RAS ulcers
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
How long do minor RAS ulcers last?
1-2 weeks and heal without scarring
How long do major RAS ulcers last
2-12 weeks and heal with scarring
Describe herpetiform ulcers
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
What are the peak ages of the RAS ulcers
Minor - 2nd
Major - 1st decade
Herpetiform - 3rd decade
What are herpetiform ulcers?
Appear like HSV ulcers, but contain no viral component
What is the most common management option for RAS?
- Symptomatic relief
- Eliminate local factors
- Promote healing of ulcers
Topical drugs for the management of RAS
- Corticosteroids - Betamethasone or triamcinolone paste
- Tetracycline, CHX or difflam mouthwash
- Salicylate preparations
When may systemic drug therapy be indicated in RAS?
Major apthae that are painful
Persistent and resistant to conventional treatment
What is the ulcer severity score?
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
What conditions are characterised by oral and genital ulceration?
- Reactive arthritis
- Mouth and genital ulcers with inflamed cartilage
- Bechets disease
What is reactive arthritis?
Autoimmune condition developing 2-4 weeks after GI or genitourinary infections, which presents with non-infectious urethritis, arthritis and conjunctivitis.
What are the oral findings in reactive arthritis
Erythematous macules and plaques with diffuse erythema, erosions and bleeding of the mucosa
- Circinate lesions on the tongue
Management of reactive arthritis
- Most is self limiting
- If symptomatic then NSAIDs, corticosteroids, antibiotics if the cause is chlamydia or DMARDs if NSAIDS are ineffective
What is mouth and genital ulcers with inflamed cartilage (MAGIC)?
Rare syndrome with probable autoimmune aetiology characterised by relapsing polychronditis and bechets and orogenital ulcers
Management for MAGIC
Pentoxifylline
Corticosteroids
Dapsone
Infliximab
What is Bechets disease?
Chronic, relapsing, inflammatory mulisystem disease of unknown aetiology
Epidemiology of Bechets
- Young adult males - 20-40
- Common in Turkey and Japan (silk road distribution)
Aetiology of Bechets
- Unknown but probable inflammatory reaction due to HSV or streptococci OR autoantigen in genetically predisposed individuals
What genetic component is associated with bechets?
HLA-B51
What inflammatory aspects are associated with Bechets
- T helper17 and interleukin 17 pathways are active
- There are circulating immune complexes
- Neutrophil activity is increased and infiltrates affected organs alongside lymphocytes
What are the types of Bechets disease divisions?
Mucocutaneous (orogenital ulceration
Arthritic (+/- mucocutaneous)
Neurological
Ocular
How is a bechets diagnosis made?
Bechets is highly variable - diagnosis is made when there is aphthous ulcers alongisde 2 major criteria
What are the oral S/S for bechets
Minor RAS is common, major is also associated but herpetifom is rare
What are the genital S/S for bechets
Ulcers commonly associated with the scotum or labia
May occur less commonly on the vagina, or perineum
What are the ocular S/S for bechets
Anterior uveitis
Cells in vitreous
Retinal vasculitis
What are the skin S/S for bechets
Erythema nodosum
Pseudofolliculitis or papulopustular lesions
Acneiform lesions
What are the minor criteria for bechets
- Arthritis
- DVT, PE or aortic aneurysm
- CNS involvement
- GI lesions
What are the major criteria for bechets
- Oral ulcers
- Genital ulcers
- Eye lesions
- Skin lesions
Management of Bechets disease
- Initial - colchicine, topical steroids or non-steroidal mouthwash and antibiotics
- Maintenance = oral steroids (azathioprine), then to infliximab or riuximab upon flare ups
What is steven johnsons syndrome?
Rare condition resulting from hypersensitivity to drugs or infections, or idiopathic in nature.
What drugs are associated with SJS?
- Barbiturates
- Sulphonamides
- NSAIDS
- Carbemazepine
What infections are associated with sjs?
Herpes simplex (60%)
Mycoplasma
EBV
HIV
Pathology of SJS?
immune complex formation and deposition in the microvasculature (cutaneous or mucosal)
S/S of SJS
- Oral ulceration or erosions in the anterior mouth
- Crustation of lips (looks haemorhagic)
- Skin lesions - look like targets, macules, papules, vesicles or bulla
Management of SJS
Supportive oral care
ICU or burns unit
Morality rate of SJS
10%
What is toxic epidermal necrolysis?
Severe form of SJS where >30% of the body surface is affected
Mortality rate of TENS
30%
What is PFAPA?
Periodic fever, aphthae, pharyngitis and cervical adenitis
