Ulcers, kerr Flashcards
What is this clinical finding?
Aphthous ulcer (“The canker sore”)
What would it be like to have a canker sore on your uvula?
o Painful to swallow
‐ The location of the canker sore will predict the symptoms
What is this clinical finding?
‐ Aphthous Ulcer of the tongue
‐ Aphthous ulcers can occur on specialized structures of the mouth
What are the Hallmarks of
Aphthous Ulcers
‐ Hallmarks:
o 1. Central ulceration
o 2. Ring of erythema (erythematous border)
▪ Accentuated in right image
What is this clinical finding?
Minor Recurrent
Aphthous Ulcers
(RAS)
- aka‐ “Canker Sores”
- ‐ High prevalence: 5‐25%
- ‐ Comprises the overwhelming majority of cases
- o 75‐85% of ALL RAS cases
- ‐ <10 mm in diameter
- ‐ Ulcer appearance:
- o Shallow
- o Round/Oval Shaped
- o Yellow pseudomembrane
- ▪ Slightly raised margin
- ▪ Erythematous Halo
-
‐ Typically resolves in 7‐10 days
- o *May take longer if in a “high‐traffic” site
- ‐ No scarring
- ‐ Recurrence rates vary
What is this clinical finding?
‐ Minor Recurrent
Aphthous Ulcers
(RAS)‐ Rare Case
o Keratinized
Mucosal
Site
‐ 11‐year‐old boy
‐ Canine is in process of erupting
‐ Canker sore present on his keratinized mucosa (RARE)
o 99% of canker sores occur on NON-KERATINIZED MUCOSA
What is this clinical finding?
Major Recurrent
Aphthous Ulcers
(RAS)
- ‐ 10 – 15% of all RAS cases
- ‐ >10 mm in diameter
- ‐ Ulcer Appearance:
- o Deeper
- o Irregular borders (usually)
- ‐ Typically resolves in WEEKS or MONTHS
- ‐ May be associated with fever or malaise
- o The associated cytokine release can induce a fever
- ‐ Predilection for the throat
- ‐ Often DOES leave scarring
- ‐ Recurrence rates vary
What is this clinical finding?
Herpetiform aphthous stomatitis
- Apppears like herpesvirus but unrelated to it
- account for 5% of cases (the least common)
Appearance:
- begin as multiple (up to 100) 1- to 3-mm crops of small, painful clusters of ulcers on an erythematous base.
- They coalesce to form larger ulcers that last 2 weeks.
- A bunch of smaller ulcers that coalesce
What is this clinical finding?
Transient Lingual
Papillitis
- ‐ Relatively rare
- ‐ Canker sore meets fungiform papilla of tongue
- Multiple papilla can become inflamed (above image)
- Very painful
- ‐ Ulcer Appearance:
- Tiny
- Transient
- On fungiform papilla of tongue
- ‐ Typically resolves in 7‐10 days
What are these clinical findings?
Inflammatory
Bowel Diseases
-
Specific lesions:
- o Diffuse labial and buccal swelling
- o Cobblestones
- o Other specific lesions
- ▪ Mucosal tags
- ▪ Deep linear ulcerations
- o Mucogingivitis
- o Granulomatous cheilitis
- Non‐specific lesions:
- o Aphthous ulcerations
- o Pyostomatitis vegetans
- o Dental caries
- o Gingivitis and periodontitis
- o Other non‐specific lesions
What is this clinical finding?
HIV‐Associated
Aphthous
- CD4 counts <100 cells/mm3 are predisposed to major RAS
- ‐ Other sites may be affected:
- o Esophagus
- o Genitals
- o Anus/rectum
- ‐ We see this less frequently since ART
- ‐ Diagnosis is important, particularly if no prior history
What is this clinical finding?
Hematinic
Deficiencies
‐ Superficial ulcers
o Not classic aphthous ulcers
‐ Equivocal associations with iron, Vit B1, B2, B6, B12, and folate.
‐ Blood tests are not recommended routinely in all patients with RAS.
‐ Indications for blood work (CBC):
o Older patient with recent RAS history
o Suspicious medical history/review of systems
o Strict vegetarian patients
What is this clinical finding?
Behcet’s Disease
‐ Recurrent inflammatory disorder of unknown cause:
o Bacterial?
‐ Affects:
o Middle Eastern Males
o Asian Females
‐ Onset 3rd – 4th decade
‐ HLA‐B51 association
Recurrent aphthous ulcers generally precede other signs:
o Genital/skin/eye lesions & others (arthritis, Gl lesions, CNS symptoms, vascular lesions)
‐ Diagnosis based upon criteria (point system): no laboratory tests
What is this clinical finding?
Behcet’s Disease
‐ Recalcitrant oral ulcers associated with Behcet’s Disease
‐ Later developed genital ulcers and other complications
‐ Image:
o Sores in the labial mucosa have classic aphthae appearance
o Other ulcers are major aphthae:
▪ Larger
▪ Irregular borders
▪ Intense proliferative erythema
How do we treat this?
‐ Repair sharp teeth/restorations
‐ Remove plaque
‐ Optimize lubrication
Ulcer
Steps in Managing RAS patient
‐ History of RAS
‐ Medical History
o Medications
o Review of Systems
‐ Social History
‐ Dental History
‐ Diet/Nutritional History
‐ Physical Examination
‐ LaboratoryTests
Infrequent Simple
Minor RAS
Treatment
‐ Treatment to reduce pain
Also Consider
- using Sodium Lauryl Sulfate‐Free Toothpastes
- Remove Obvious Possible Causes
- ‐ Repair sharp teeth/restorations
- ‐ Remove plaque
- ‐ Optimize lubrication
Frequent Minor
RAS or Major RAS
Treatment
‐ Treatment to reduce pain
‐ vs.
‐ Abortive treatment to reduce healing time
‐ vs.
‐ Suppressive treatment to suppress recurrences
‐ Combination of all
Also Consider
- Using Sodium Lauryl Sulfate‐Free Toothpastes
- Remove Obvious Possible Causes
What are the Topical Therapy
Categories to treat ulcers?
Topical anesthetic agents
o To numb the pain
‐ Surface protective agents/bioadhesives
o Cover the ulcer if small enough
‐ Anti‐inflammatory/immunomodulatory agents
o Applied to ulcer surface (corticosteroids)
‐ Anti‐microbials
o Some evidence that topical tetracycline may help
‐ Chemical/physical cautery Lasers
‐ Over‐the‐counter (OTC) versus prescription (Rx
All essentially do the same thing:
o Numbing agent
o Mucosal covering agent
‐ Bottomline:
o ALL canker sores will heal on their on with time
Rx Topical
Treatments:
Cautery
‐ Debacterol (sulfonated phenolics; sulfuric acid solution)
o Chemical cautery
o Label: one time application for 5‐10 seconds
‐ NOT recommended to patients with frequent outbreaks
Rx Topical
Treatments:
Corticosteroids
for
Ulcers
‐ Triamcinolone acetonide in Orabase 0.1% (intermediate)
o Disp: 5g tube Dental Past
o Label: apply a thin film over ulcer after meals and bedtime APOTHECON
o Do not use for more than 2 weeks
‐ Fluocinonide gel or ointment 0.05% (Potent)
o Disp: 15g tube
o Label: apply a thin film over
o Do not use for more than 2 weeks
‐ Clobetasol ointment 0.05% (Ultra potent)
o Disp: 15gtube Label: apply a thin film over ulcer bid
Rx Topical
Treatments:
Corticosteroid
Rinse‐
‐ Dexamethasone elixir 0.5mg/5ml (ETOH base) or solution (H20 base)
‐ Indicated for difficult to reach lesions to obtain access to all of them
o Disp:600ml
o Label: swish with 5‐10 ml for 5 minutes up to 0.5mg/5mL 4x/day and
expectorate 00s preservalve.) May be used as suppressive therapy in
selected patients with close surveillance
o Prevent recurrences
‐ May buy an EXTRA DAY of healing time
dr. Kerr prefers the elixir
Problem with topical tx
Topical Treatments
‐ Drug is easily washed away or rubbed off
‐ Topical anesthetics have a short‐lived effect
‐ Often difficult to apply due to location
‐ Cost may be a disincentive to buy OTC
‐ Once ulcers are established, these treatments are not as effective, therefore
abortive treatment early on is preferred
What about
systemic
treatments – taking
pills to treat ulcers?
‐ Prednisone or systemic steroids were the one systemic treatment that Dr. Kerr
has has success with in practice
o 0.5 mg/kg of Prednisone would be prescribed for about 1 week
o Very successful in patients with frequent outbreaks of multiple canker
sores
‐ In some limited cases Dr. Kerr has seen some success with:
o Colchicine
o Pentoxifylline
