Ulcerative Lesions Flashcards
Oral Mucosal Ulcerative Lesions Evaluation
Onset History
◦ Gradual vs. Acute
Preceded by vesicle
Mucosal Lesion Distribution/Site
◦ Symmetrical vs. Asymmetrical
◦ Keratinized or Non-kernatinized Tissue
Associated Cutaneous Skin or Ocular Lesions
Outcome History
◦ Self-limiting and how long vs. Chronic
Current medication, change
Recurrent Aphthous Ulcer Considerations
History and diagnosis
Identify and eliminate any local factors
Investigate any
◦ Vitamin deficiencies
◦ Hormonal changes/imbalances
◦ Dietary factors
◦ Allergies
◦ Gastrointestinal problems
◦ Psychological factors
Treatment and management
Isolated - Acute
Traumatic Ulcer
Recurrent Aphthous Ulcer
Recurrent HSV Labialis
Recurrent HSV (Intraoral Crop)
Necrotizing Sialometaplasia
Anesthetic Necrosis
Syphilis (Primary)
Traumatic Ulcer
Irritation of the mucosa that results in erosion of surface layer
Red macule with irregular margins and typically tender to the
touch
Lesion does NOT blanch with pressure
Can occur most any place and is typically associated with
trauma or irritant exposure
TX: Palliative treatment, will typically resolve in a week
◦ If not, will require follow-up to ensure not systemic involvement or constantly retraumatizing site
◦ Must r/o child abuse
Recurrent Aphthous Stomatitis (RAS)
More commonly referred to as “Canker Sore”
MOST common ulcerative disease of the oral mucosa
Typically healthy individual
Does NOT typically occur on heavily keratinized mucosa of the palate or gingiva
Can be associated with multiple medical conditions
◦ Cyclic neutropenia
◦ Crohn’s
◦ Lupus
◦ Dietary deficiency
◦ Allergens
◦ PFAPA Periodic fever, aphthous stomatitis, pharyngitis, and adenitis
Recurrent Aphthous Stomatitis (RAS) Etiology
Cause can be stress related, sodium lauryl sulfate in toothpaste, lysine deficiency, dietary factors, immunologic
deficiency
Local Factors:
◦ Trauma, Changes in salivary pH
Microbial Factors
◦ Streptococcus sanguis → Cause antigen stimulation
Medical Condition Related
◦ Behcet’s Disease
◦ MAGIC Syndrome: Mouth And Genital ulcers with Inflamed Cartilage Syndrome
◦ Crohn’s disease → Very painful usually
◦ GI PPT for more info
◦ Cyclic neutropenia
◦ Blood Disorder PPT for more info
◦ PFAPA: Peridoic Fever, Apthous, Pharyngitis, Adenitis (Cervical)
Recurrent Aphthous Stomatitis (RAS) Etiology
Hereditary and Genetic
◦ Familial occurrence and hereditary causes is BEST explanation to date of etiology
◦ Children have 90% of having RAS if the parent had same issue as teenager
◦ HLA-A2, HLA-B5, HLA-B12
Allergic Factors
◦ Certain food/dietary triggers
◦ Sodium lauryl sulfate → Foaming agent in toothpaste
Immunologic Factors
◦ Abnormal CD4 to CD8 ratio or local increase in CD8 T Cells → hyperactive immune response
◦ Elevated IL-2 or IFN alpha
Nutritional Factors
◦ Lower levels of iron (Fe), folate, zinc and vitamin B’s (Especially B12)
Medication (NSAIDs)
◦ NSAIDs can disrupt inflammatory pathway and lead to ulcers
Recurrent Aphthous Stomatitis (RAS)
Presentation
Major Type
◦ Larger than 1 cm in diameter
◦ Long lasting, weeks to months
◦ Healing WITH scar
Minor Type
◦ Less than 1 cm in diameter
◦ Healing WITHOUT scar
Herpetiform
Recurrent Aphthous Stomatitis (RAS)
Pre- symptoms?
Appearance?
Duration?
% population?
peak incidence (age)?
Short prodromal burning sensation from 2-48 hours prior to ulcer appearance
Circular, well defined with erythematous margin and shallow ulcerated center with white-yellow
pseudomembrane
NON-Keratinized mucosa
7-10 day duration
20% of population will have recurrent aphthous ulcer episodes
◦ Possible genetic/familial connection to occurrence (Parents-Children)
Peak incidence occur in the 10-19 year old patient population, then becomes less frequent with
age
recurrent apthous stomatitis
Treatment
Treatment will vary and is based on size, timing, number of ulcerative sites and frequency
Infrequent or occasional minor aphthous ulcers can be treated with topical OTC
Carbon dioxide laser can treat these lesions as well, but more practical when already in the
office presenting for another treatment or as unknown source of emergent pain
More frequent occurrence may warrant topical steroid
◦ Clobetasol (0.05%)
◦ Triamcinolone in Orabase
◦ Dexamethasone elixir 0.5mg / 5mL
Systemic steroids can also be used, but have more profound side effects vs. local treatments
Vitamin B12 can help treat ulcers once other sources have been removed
Magic Mouthwash for RAS
Parent made at home Magic Mouthwash:
◦ 1 Part Benadryl (NO Alcohol)
◦ 2 Part Mylanta (Pick a Flavor – Cherry is usually readily available)
◦ 3 Part Sterile Water
Mix and shake well
Either place on lesions with Q-Tip or if more diffuse, rinse for 30 seconds and expectorate
Do this PRIOR to eating, and should help allow patient to tolerate food better
AVOID acidic foods → Keep diet bland and basic
AVOID POPCORN…..Extremely irritating to the tissue
Behcet’s Disease (BD)
Chronic idiopathic condition that involves multiple systems and occurs in relapsing episodes
Recurrent oral, genital, ocular and skin lesions
◦ 3 episodes of oral ulcers with a 12 month period
◦ PLUS any 2 of the following, recurrent genital ulcers, eye lesions, skin lesions or positive pathergy test
Higher occurrence in and around the Mediterranean sea region
More common in females > males in North America
Diagnosis based on clinical features due to NO pathognomonic laboratory tests
Management with anti-TNF-alpha, steroids, immunosuppressants
Recurrent HSV Labialis
Commonly referred to a Cold Sore, they are caused by HSV-1
Virus occurs with close personal contact to someone else with HSV-1
Multiple triggers can cause virus to go from dormant to active
◦ Sun, stress, hormone changes, weakened immune response, recent dental work, fever
Virus will lay dormant in the trigeminal ganglion
Prodromal phase will occur with tingling and then vesicular lesion start to appear
MUST be treated in prodromal phase with either laser or antivirals to short the duration and
decrease the pain and discomfort
Typically occur on lower lip , but can appear on upper lip, and ala of nose
Intraoral crops can occur
Anesthetic Necrosis
Typically a result of injections that are administered
too quickly or at larger volumes than the tissue and
area are able to hold
Palatal anesthesia and delivery is common to
experience this due to limited space for the
anesthetic to diffuse into
Very high doses of epi (1:50,000 can increase
chance of necrosis)
Will self resolve, but may lead to tissue sloughing
and discomfort, that needs to be manged
