week 3

Question 1

Where are traumatic ulcers seen?

Answer 1

• Traumatic ulcers are usually caused by a denture and often seen in the buccal or lingual sulcus
• If caused by the sharp edge of a broken-down tooth, they are usually on the tongue or buccal mucosa.
• Occasionally, a large ulcer is caused by biting the cheek after a dental local anaesthetic.

Question 2

Describe traumatic ulcer

Answer 2

They are:

1. tender
2. have a yellowish floor
3. red margins
4. no induration.
5. single
6. acute onset
7. short duration

Question 3

How does traumatic ulcer heal?

Answer 3

Traumatic ulcers heal a few days after elimination of the cause.

Question 4

What is the action that should be taken If they persist for more than 7-10 days, or there is any other cause for suspicion?

Answer 4

biopsy should be carried out.

Question 5

How common is the aphthous stomatitis (Recurrent Aphthae)?

Answer 5

one of the most common oral mucosal diseases and affect 10-25% of the population

Question 6

Describe the severity of aphthous stomatitis.

Answer 6

many cases are mild with a little complaint

Question 7

What are the Possible etiological factors for recurrent aphthae?

Answer 7

1. Genetic predisposition
2. Exaggerated response to trauma
3. Infections
4. Immunological abnormalities
5. Gastrointestinal disorders
6. Hematological deficiencies
7. Hormonal disturbances
8. Stress (Mainly)

Question 8

What are the Clinical Features of Recurrent Aphthae ?

Answer 8

1. Onset frequently in childhood but peak in adolescence or early adult life
2. Attacks at variable but sometimes relatively regular intervals (recurrent)
3. Most patients are healthy
4. A few have haematological defects
5. Most are non-smokers
6. Usually self-limiting

Question 9

What are the types of aphthous ulcer?

Answer 9

1. Minor
2. Herpetiform
3. Major

Question 10

What is the clinical picture of minor aphthous ulcer?

Answer 10

1. The most common type 80%
2. Non-keratinized mucosa affected
3. Ulcers are shallow, rounded, 5-7 mm across with an erythematous margin and yellowish floor.
4. One or several ulcers may be present
5. Healing without scar.

Question 11

What is the percentage of occurance of major and minor aphthous ulcers?

Answer 11

80% Minor

20 % Major

Question 12

What is the clinical features of Major aphthae?

Answer 12

1. Uncommon 20%
2. Ulcers are several centimeters across and deep.
3. Sometimes mimic a malignant ulcer (indurated base with everted edges).
4. Ulcers may persist for several months
5. Keratinized and non-keratinized mucosa affected (tongue dorsum, soft palate, retromolar area)
6. Healing with scar.

Question 13

What is the clinical features of Herpetiform ulcer?

Answer 13

1. Uncommon
2. Non-keratinized mucosa affected
3. Ulcers are 1-2 mm across
4. Dozens or hundreds may be present
5. May coalesce to form irregular ulcers.
6. Widespread bright erythema around the ulcers.

Question 14

What is the clinical picture of aphthous ulcer (general)?

Answer 14

1. Lesions are confined to oral mucosa (no extraoral manifestations).
2. Prodrome: burning sensation (2-48 hours) with the appearance of localized erythema
3. Ulceration: single or multiple ulcers appear within few hours. Ulcers are surrounded by erythema and painful.
4. No tissue tags surround the ulcers (helps to differentiate it from ulcers due to vesiculo- bullous diseases).

Question 15

How does aphthous ulcer heal?

Answer 15

1. in minor form it takes 7-14 days
2. in major ulcers it may take several months.
3. No scar formation occurs except in major form.
4. Healing is characterized by disappearance of the surrounding erythema.

Question 16

How is aphthous ulcer diagnosed?

Answer 16

1. The most important diagnostic feature is the history of recurrences of self-healing ulcers at fairly regular intervals.
2. The only other condition with this history is Behcet’s disease.
3. Otherwise, most patients appear well, but hematological investigation is particularly important in older patients.
4. Routine blood indices are informative, and usually the most important finding is an abnormal mean corpuscular volume (MCV). `

Question 17

What is the history checklist?

Answer 17

o Recurrences
o Pattern? Minor, major or herpetiform o Onset as child or teenager o Family history
o Distribution only on non-keratinized mucosa
o Signs or symptoms of Behcet’s disease
(ocular, genital, skin, joint lesions)

Question 18

What is the examination checklist?

Answer 18

o Discrete well-defined ulcers o Scarring or soft palate involvement suggesting major aphthae
o Exclude other diseases with specific appearances. e.g. lichen planus or vesiculobullous disease

Question 19

What is the special investigations checklist?

Answer 19

Used to exclude underlying conditions especially in patients with onset in later life. Check for:
o Anemia, iron, red cell folate and vitamin B12 status.
o History of diarrhea, constipation or blood in stools suggesting gastrointestinal disease, e.g. celiac disease or malabsorption.

Question 20

What is the treatment of aphthous ulcer?

Answer 20

If macro-or microcytosis is present, further investigation is necessary to find and remedy the cause.

Treatment of vitamin B12 deficiency or folate deficiency is sometimes sufficient to control or abolish aphthae.

Apart from the minority with underlying systemic disease, treatment is empirical and palliative only.

Patients should be made to understand that the trouble may not be curable but can usually be alleviated and usually resolves eventually of its own accord.

Question 21

What is the treatment of minor aphthous ulcer?

Answer 21

• For minor aphthae: treatment is related to the severity.

1. In mild cases: Protective topical treatment as orabase can be used and to relief pain topical anesthetic or non-steroidal antiinflammatory can be used.
2. Benzydamine hydrochloride mouth wash can also be used.
3. In more severe cases: Potent topical steroid can be used.

Question 22

What does corticosteroids do to aphthous ulcers? and when are they used?

Answer 22

Corticosteroids are unlikely to fasten healing of existing ulcers, but probably reduce the painful inflammation.

Also, early application before ulcer development can abort the lesion (patients with highly frequent ulcers can recognize the burning sensation preceding the ulcer)

Triamcinolone dental paste is a corticosteroid in a vehicle which sticks to the moist mucosa. Then it is slowly released and has an anti-inflammatory action.

Question 23

What is the treatment of herpetiform aphthous ulcer?

Answer 23

1. For herpetiform aphthae: Tetracycline mouth rinses the contents of a tetracycline capsule (250 mg) can be stirred in a little water and held in the mouth for 2-3 minutes three times daily.
2. Some patients like to use this mouth rinse regularly for 3 days each week if they have frequent ulcers.
3. An antifungal drug may be given to patients who are susceptible to superinfection by Candida albicans.
4. Chlorhexidine. A 0.2% solution has also been used as a mouth rinse three times daily after meals and held in the mouth for at least 1 minute.

Question 24

What is the treatment of major aphthous ulcer?

Answer 24

1. For major aphthae. Major aphthae may some times be so painful, persistent, and resistant to conventional treatment.
2. Effective treatments include systemic or intralesional steroids, azathioprine, cyclosporine colchicines and dapsone.

Question 25

What is behcet’s syndrome?

Answer 25

1. Behcet’s syndrome was originally defined as a triad of oral aphthae, genital ulceration and uveitis.
2. However, it is a multisystem disorder with varied manifestations.

Question 26

What age range does behcet’s syndrome affect?

Answer 26

20-40 years

Question 27

What are the patterns of behce’s syndrome?

Answer 27

1. Mucocutaneous (oral and genital ulceration)
2. Arthritic (joint involvement with or without mucocutaneous involvement)
3. Neurological (with or without other features) or
4. Ocular (with or without other features).

Question 28

Why is becet’s syndrome considered a differencial diagnosis to aphtous ulcer?

Answer 28

The oral aphthae of Behcet’s disease are not distinguishable from common aphthae.

They are the most consistently found feature and frequently the first manifestation.

Question 29

What is the test that’s done to diagnose behcet’s disease?

Answer 29

Pathergy Test: The test is positive if there is an exaggerated response to a sterile needle puncture of the skin, where such puncture is followed by pustule formation.

Question 30

What is the diagnostic criteria for Behcet’s disease?

Answer 30

Major Criteria:

1. Recurrent oral aphthae
2. Genital ulceration
3. Eye lesions (uveitis, retinal vasculitis )
4. Skin lesions
   (Erythema nodosum, subcutaneous thrombophlebitis, hyperirritability of the skin +ve pathergy test)

Minor Criteria
1. Arthralgia or arthritis

2. Gastrointestinal lesions
3. Vascular lesions (mainly thrombotic)
4. Central nervous system involvement

Question 31

What is the treatment of becet’s syndrome?

Answer 31

No specific treatment, but oral lesions can be controlled by:

1. Topical or intralesional corticosteroids
2. Topical anesthesia to alleviate pain
3. Systemic corticosteroids in resistant cases (40-60 mg prednisone/day).
4. Combination of steroid and immune suppressive drugs (e.g.
   azathioprine) .

Question 32

What is reiter’s syndrome?

Answer 32

A triad of urethritis, arthritis and conjunctivitis.

Question 33

What are the oral manifestations of reiter’s syndrome?

Answer 33

1. Painless circinate white lesions that may ulcerate giving aphthous-like ulcers.
2. Geographic tongue like lesions
3. Purpuric rash in palate

Question 34

What is the treatment of reiter’s syndrome?

Answer 34

Oral lesions are self limiting