Oral Ulcers Flashcards
What is Erosion?
- An area of partial loss of epithelium
What is an Ulcer?
- An area of total loss of epithelium (surface + basement membrane)
What is Atrophy?
Loss of epithelial thickness w/ no breakage
What is a plaque?
Raised uniform thickening of a portion of skin/mucosa with a well defined border
What is a blister?
epithelium filled with liquid
What is a vesicle?
- small fluid filled blister (<5mm)
What is a bullous?
Big fluid filled blister >5mm
What should you keep an eye out for in a pt’s MH when establishing ulcer diagnosis?
Any conditions involving:
- GU system
- GI system
-Cutaneous
What are the risk factors for carcinoma? (6)
Age
Other malignant disease
Smoking (pack years = no of packs/day x no.of years smoked) Increases risk by x10
Alcohol (14+units/ week) Increases risk by x 4
Smoking + alcohol combined= 40xrisk
Areca/betal nut
What are the features of an ulcer hx? (12) 🔑
SSS DANA FFE WUAC
-What does pt mean by ulcer? (i.e. is it really an ulcer)
-Age of onset
- Duration (+length of time needed to heal)
- No of.ulcers?
-Ulcer- free periods?
- Site, size, shape?
- Any prodromal symptoms, including pain + vesicles?
- Any rx to menstruation or smoking?
- Changes in degree of ulceration over time?
-
- Family hx?
- Frequency?
- E/R factors
What sites should you specifically pay attention to when examining IO mucosa for ulcers?
- retro-molar fossa
- posterior lingual aspects of tongue (i.e. back fo the tongue)
- Sulci
- FOM
What is the general classification for oral ulcerative disease?
- Local ulcers (affecting mouth only)
a) Traumatic
b) Recurrent aphthous stomatitis (RAS) - only affects the mouth + is NOT rx to any systemic disease - Systemic (ulcers affecting the mouth because of these diseases)
-Bacterial- TB, Syphilis, ANUG
-Viral- HIV
-Fungal- candidiasis
-Cutaneous disease- all mucocutaneous + vesicibullous conditions
-Blood disorders- anaemia
-GI disorders - Crohn’s, Coeliac, UC, Peutz Jegher’s Syndrome, GORD
-GU disorders: STIs- syphilis, HSV1+2, HIV/AIDS Oral + genital ulcers- Behcet’s disease, Lichen Planus, Reactive Arthritis
-CT diseases (lupus)
-Malignant ulcers (SCC, lymphoma)
3.Assoc w/ drugs
Cytotoxic drugs
Nicorandil (used to reduce chest pain in angina- vasodilator)
Radiotherapy
What is the clinical classification for ulcers?
- Recurrent ulceration e.g. RAS, Erythema multiforme (crop of ulcers that heal completely before another episode)
- Recurrent/ persistent - ulcer takes a long time to heal, by the time it heals another ulcer erupts - this is secondary to systemic disease e.g. Behcet’s disease (ulcers last for weeks/months)
- Single episode ulcer - went away + never came back e.g. infective, traumatic or drug interaction
- Single persistent ulcer that is not healing = neoplastic, not healing despite tx + getting worse
What is Recurrent Aphthous Stomatitis?
= Oral condition of recurrent ulcers that is not rx to any secondary disease
3 types:
1. Major RAS
2. Minor RAS
3. Herpetiform
(smoking rx RAS is when smokers stop smoking, due to change in heat shock protein, heals w/ time)
What surfaces of the mouth are covered by non-keratinized squamous epithelium?
- soft palate
- inner lips
- inner cheeks
- floor of mouth
- ventral surface of the tongue (bottom side of tongue)
What surfaces of the OC are keratinised?
Dorsum of tongue
Ginigiva
Hard palate
Key features of MINOR RAS?
N-A$$$ DC 🍑 🇺🇸
Age= 2nd decade
Size=2-7mm diameter
Shape = oval
No.in crop= 1-5
Colour= grey base, erythematous border
Site= non-kerat mucosa (buccal mucosa)
Duration= 2-12 weeks
most common
Key features of MAJOR RAS?
N-A$$$ DC
Age= 1st decade
Size= >10mm diameter
Shape = Irregular/oval
No.in crop= 1-10
Colour= grey base +/- indurated edge
Site= any surface (mostly back of mouth)
Duration= 2-12 weeks (scar on healing)
2nd most common
Key features of HERPETIFORM RAS?
SSS CAND
Age= 3rd decade
Size= 0.5-3mm diameter
Shape = Round, may coalesce
No.in crop= 1-20
Colour= yellow base, erythematous border (no scarring)
Site= Most non-kerat sites (esp ventral of tongue, FoM)
Duration= 1-2weeks
What are the investigations for RAS?
Blood tests - FBC + haematinics B12,folate,ferritin/iron + LFT
Biopsy (rare, but if potential malignancy)
Scans - rare
What is the tx for RAS? (5)
REOR PM
- Rule out systemic conditions/ review (inc. nutritional def)
- Eliminate local aggravating factors to resolve trauma e.g. smoking, any sharp cusps
- OHI + px CHX M/W to decrease bacterial load
- Relieve pain (topical - difflam, systemic- analgesics; paracetamol)
- Promote healing (topical/systemic steroids - betamethasone m/w or prednisolone OR azothioprine (non-steriodal immunosuppresant)
- Maintenance/ prevent ulcer recurrence (assess response to therapy, no response: review diagnosis)
Which pt’s should avoid steroidal drugs?
TTHOD
- those with liver disease (damages your liver) + kidney disease
- osteoporosis (causes bone destruction)
- diabetes (reduces bodies sensivity to insulin, therefore more insulin needed)
- heart/blood pressure problems
- those w. active infection/conditions (w no hx of prior steroids)
What to do if RAS tx fails?
(i x 5) + S
Is pt taking drug?
Is drug being absorbed?
Is dose adequate?
Is drug (eg mouthwash) being used correctly?
Is the diagnosis correct?
Super infection stopping healing of ulcer? i.e. candida
Key information about ulcers rx to Behçet’s disease?
MORGS
= chronic autoimmune disorder of recurrent oral & genital ulceration, eye & skin lesions, triad of:
1) aphthous-
like oral ulcers!! 👄
2) genital lesions 🍆
3) eye inflammation 👁️
Common in Mediterranean, middle east, east & south east countries
Begins in 3-4th decade
Affects small blood vessels
Fatal if not managed
