Oral Ulceration And Recurrent Apthous Ulcers Flashcards
What may cause ulceration?
Trauma
Infections
Immunological
- aphthous ulcers
- lichen planus
Carcinoma
GI
- crohns or ulcerative colitis
What are often the causes of single episode oral ulceration?
Most likely trauma
1st episode of recurrent oral ulceration
Primary viral infections
Oral squamous cell carcinoma
What questions should i ask about oral ulceration?
Where?
Size and shape? Has it changed shape?
Fluid filled blister or ulcer?
How long for?
- more than 2 weeks is red flag
Recurrent?
- same site or different site
Painful?
How long between ulcers?
What should be done for examining an ulcer?
Margins
- flat, raised or rolled
Base
- soft, firm, hard
Surrounding tissue
- inflamed or Normal
Any systemic illness?
What is an aphthous ulcer
Recurrent, self healing ulcers affecting exclusively non-keratinised tissues
They are immunologically generated and often preceded by tinging or burning
Many experience change as risk factors change over life
Typically small and ovoid with a covering of greyish / white / yellow pseudo membrane
Describe a minor aphthous ulcer
Which treatment do they respond well to?
How determine severity of condition?
<10mm diameter
Lasts up to 2 weeks
Only non keratinised mucosa
Heal without scarring
Often fibrin deposit giving yellow appearance
Usually good response to topical steroids
Ulcer free period is good guide to morbidity
Describe major aphthous ulcer
What tx it respond better to?
Can last for months
Affect any part of oral mucosa
May scar when healing
Poorly responds to topical steroids, respond better to intralesional
Usually larger than 10mm
Describe herpetiform aphthous ulcers
Any other symptoms?
Multiple small ulcers on only non keratinised tissue
Heal within 2 weeks
Can form into larger areas of ulceration
Often systemic effects and fever
Nothing to do with herpes viruses but look similar
Give some predisposing factors to recurrent aphthous stomatitis
Stress
Trauma
Dietary triggers
HIV
Coeliac
Haematinic deficiency
How does the immunological process work for apthous ulcers
Implications?
Occurs at basement membrane where basal stem cells are damaged and epithelium cannot be produced
Dense infiltration of lymphocytes into tissue, typically T cells and TNF-alpha inflammatory cytokine
Tx should occur during prodrome period when ulcer is forming, not formed
How should one investigate apthous ulcers
Check haematinics
Check to see if coeliac and test with tissue transglutaminase
Allergy tests to food additives
How manage recurrent aphthae?
Correct haematinic deficiencies
Symptomatic relief
- difflam spray
- lidocaine mouthwash
Topical corticosteroids
- betamethasone
- beclomethasone
- hydrocortisone mucoadhesive pellet
How might one treat inconvenient and disabling apthous ulcers with drugs?
Steroid topical therapy for disabling lesions during prodromal period
Systemic pulses of Prednisolone or intra-lesional steroid injection
When may aphthous ulcers begin to present in kids?
What tx?
in growth period
- new shoe sign as feet usually grow first
between 8-11 and 13-16 years old
Usually responds to iron supplements
If ulcers not related to growth then they are largely a genetic component
- consider allergy testing as well as blood testing for haematinics
- symptomatic treatment during ulcer periods
When should one refer aphthous ulcers to oral med specialist?
Try arrange simple investigations in primary care
- haematinics
- 3/12 replacement therapy if deficient
Topical steroidal or non steroidal treatments
Refer if these have been achieved and no good result
Refer if child under 12
