Recurrent oral ulceration Flashcards
What is an ulcer? (7)
A FULL-THICKNESS loss of epithelium Exposes underlying connective tissue Ulcer covered by slough Underlying granulation tissue Mixed Inflammatory infiltrate Usually painful Erosion = partial loss
Ulcer - histology (2)
Fibrino-purulent slough
Granulation tissue
What is a primary ulcer? (1)
Begin as ulcers
What is a secondary ulcer? (1)
Begins as a blister/ vesicle
Single episode ulcer examples (10)
Single ulcer e.g. SCC Multiple ulcers - Herpes simplex - Herpes zoster - Erythema multiforme - Hand, foot and mouth - Herpangina - Oral lichen planus - Vesiculo -Bullous disorders - Iatrogenic e.g. drugs
Recurrent episodes of ulcers examples (2)
- Single ulcer e.g. mucocutanous disorders
- Multiple ulcers e.g. RAS, mucocutaneous disorders
Causes of single episode ulcers (2)
Trauma: physical, chemical, thermal, factitious
Malignancy: SCC, salivary neoplasm, lymphoma
Infective: TB, syphyllis, HSV
Drugs: Methotrexate
Treatment for single episode traumatic ulcers (4)
Reassurance
Remove the cause
Consider Difflam and Corsodyl
Should show signs of improvement
Oral ulceration - oral cancer (3)
Any ulcer that is >3 weeks duration of unexplained cause
Should be regarded as malignant until proven otherwise – BIOPSY
Don’t be afraid of being wrong!
Drug induced oral ulcers - which drugs? (8)
Allopurinol Cytotoxics Gold Indomethacin Methotrexate Methyldopa Nicorandil Penicillamine
Causes of iatrogenic oral ulcers (2)
Drug induced
Irradiation - head and neck radiotherapy
Types of RAS (3)
Minor recurrent aphthous stomatitis (RAS)
Major RAS
Herpetiform RAS
Other causes of recurrent, multiple ulcers other than RAS (4)
Behçet’s disease
Recurrent erythema multiforme
Muco-cutaneous disorders
Other systemic disorders
RAS epidemiology (1)
Common, affects 20% of population at some time
Features of RAS (4)
Painful
May affect eating, drinking & speech
Occasionally very disabling
May be a familial component
Minor aphthous ulcers epidemiology (2)
80% of RAS ulcers
Peak age range 10-30
Minor aphthous ulcers features (7)
Usually 1-5 ulcers ~ 3-8 mm diameter Minor RAS: must be <10mm Last 7-10 days Variable ulcer free period Usually non-keratinised mucosa Usually front of mouth Heal without scarring
Major aphthous ulcers features (8)
10% of ulcers Ulcers may be larger (up to 1.5-2cm) Major RAS: Must be >10mm Last longer: 3wks - 3 months Single or multiple Often affect back of mouth Often non-keratinised mucosa, but can affect masticatory mucosa May heal with scarring
Herpetiform oral ulceration features (5)
<5% of ulcers
Dozens of small (1-2mm) ulcers
May coalesce to form larger irregular ulcers
Mainly floor of mouth, margins and ventral surface of tongue
Last 7-10 days
Contributory factors to aphthous ulcers (4)
Stress
Trauma
Hormones
Smoking –ve relationship
Predisposing/ underying factors for aphthous ulcers (6)
Haematological deficiencies (Fe, B12, Folate)
Neutropaenia
Immune deficiency (e.g. HIV+)
GI tract disease (Coeliac, Crohn’s, UC)
Vitamin deficiency (B1, B2, B6)
Food intolerance (e.g. chocolate, benzoates, cinnamon)
Investigations for aphthous ulcers (not always needed)
FBC, Ferritin, B12 & Folate
Coeliac screen
Other tests according to history
-e.g. for food allergens
Treatment for aphthous ulcers (3)
Preventative
Symptomatic
Suppressive
Preventative treatment for aphthous ulcers (4)
Correct haematological deficiencies
Treat underlying systemic disease
Remove Trauma
Dietary elimination
Symptomatic treatment (local) for aphthous ulcers (3)
Corsodyl (Chlorhexidine) mouthwash
Difflam (Benzidamine) mouthwash
Covering agents e.g. Gengigel, Orobase paste
Suppressive treatment (local) for aphthous ulcers (3)
Topical Steroids
- Hydrocortisone pellets (Corlan)
- Beclometasone spray (Clenil Modulite inhaler)
- Betamethasone mouthwash (Betnesol)
Suppressive treatment (systemic) for apththous ulcers (3)
Prednisolone (Steroid)
Thalidomide
Azathioprine
Treatment for herpetiform oral ulceration (2)
Symptomatic
Doxycycline mouthwash
Behçet’s disease can lead to (5)
Serious systemic disease: Blindness Neurological damage Severe oro-genital ulceration Vasculitis Death
Behçet’s disease epidemiology (3)
Mainly young adult males ~30yrs
Male:Female ratio = 2.3:1
Increased Incidence in Japan and Turkey
Behçet’s disease features (3)
Recurrent oral aphthous ulceration
Plus two of the following:
-recurrent genital ulcers
-uveitis, cells in the vitreous, orretinal vasculitis
-skin lesions: erythema nodosum, acne like papulopustular lesions
-positive pathergy test
Other Common Features:
-arthritis, GI lesions, CNS involvement, Vascular lesions etc.
Management of Behçet’s disease (4)
Multi-disciplinary approach oral medicine dermatology rheumatology ophthalmology
A biopsy of an ulcer (3)
If a biopsy of an ulcer is undertaken, it is usually because the clinician wants to exclude malignancy
Many non-malignant ulcers look identical under the microscope
Clinical history and findings therefore crucial
