Ulcers Flashcards
What are the common causes of oral ulceration?
Idiopathic - RAS (minor, major, herpetiform)
Hypersensitivity - erythema multiforme
Hameatinic deficiency
Trauma (Intra oral appliance, cheek biting)
What should you ask the patient regarding ulcer history?
Site of ulcer
Size of ulcer
Shape of ulcer
Duration of each
Number of ulcers
Frequency
Preceded by vesicles?
Age off onset
FH
Exacerbating or relieving factors
What are the typical features of minor RAS?
3-8mm diameter
Lasting up to 2 weeks
On non-keratinised mucosa
Heals without scarring
Longer periods ulcer free
Usually single ulcers or crops of 2-5
What are the typical features of major RAS?
> 1cm diameter
Can last for months
Can affect any mucosa
May scar when healing
Poor response to topical steroids
One or two ulcers at a time
What are the features of herpetiform RAS?
0.2-3mm diameter
May last 7-10 days (heals within 2 weeks)
Multiple small ulcers (30-100) on non keratinised mucosa which may coalesce
Not to do with herpes virus - in HSV, keratinised epithelium is involved
What shape are RAS ulcers?
Oval/ round and sharply defined (may become irregular with healing)
What feature of an ulcer can indicate healing?
Slight irregular margin
After a diagnosis of RAS, What are your next steps?
Consider any underlying predisposing factors eg haemantinics, GI disease, Behcets, smoking, medications
Blood test- FBC (haemantinics and TTG test)
What is Behçet’s disease?
A rare auto inflammatory condition that can present with oral ulcers as the most significant problem.
Biopsy of the ulcer will show underlying vasculitis
What is an example of mediation which can cause oral ulceration?
Nicorandil (management of angina)
Methotrexate (RA management)
- these ulcers do not follow typical RAS pattern
What is the treatment options for RAS?
Lifestyle advice - avoid diet triggers, smoking cessation, SLS
Analgesic mouthwash - Benzydamine
Antiseptic mouthwash - chlorohexidine
Steroid mouthwash - betamethasone
Topical steroid - oralone
Systemic therapies - prednisolone etc
What are aphthous ulcers?
Immunologically generated recurring oral ulcers which follow a set pattern
Can be major, minor, herpetiform
When is treatment most effective for aphthous ulcers?
Most effective in prodrome period (as damage happens before the ulcer appears).
Therefore prophylactic treatment is effective eg daily steroid mouthwash
What guidance is followed for treatment of ulcers?
SDCEP
What is the characteristic of a recurrent aphthous ulcer?
Yellow fibrous base with surrounding erythematous halo
What are the features of primary viral infection ulcer?
What is the treatment?
Herpes virus - Pattern on oral mucosa is of the innervation of maxillary nerve (limited to one nerve) - unilateral on hard palate.
Will be on the same site each time it recurs.
Pain suggests herpes zoster rather than simplex virus.
Treat with aciclovir.
What is the differential diagnosis for recurrent ulceration?
Aphthous ulcer action (minor, major, herpetiform)
Lichen planus
Vesiculobullous lesions (PV, EM, MMP, Angina bulbosa haemorrhagica)
Recurrent viral lesions - HSV, VZV
Trauma
Systemic disease eg. Chrons
What causes primary and secondary traumatic ulcers?
Primary - sharp edge on restoration/ tooth/ appliance
Secondary - parafunction rubbing mucosa against teeth
