Week 3 - A - Oral disease - Ulcers (Apthous, Lichen, Lupus, Bullous), Angular stomatitis, Leuko/erythroplakia, Candidasis, Cancer

Question 1

Multiple local and systemic disorders can give rise to oral ulceration They can present as solitary or multiple ulcers What are different causes of solitary ulcers in the mouth?

Answer 1

Trauma - physical or chemical Malignancy - eg oral squamous cell carcinoma Infective

Question 2

What is stomatitis?

Answer 2

Stomatitis is inflammation of the mouth and lips. It refers to any inflammatory process affecting the mucous membranes of the mouth and lips, with or without oral ulceration

Question 3

Multiple ulcers also have different causes Aphthous stomatitis is one of the most common diseases of the oral mucosa, and is thought to affect about 20% of the general population to some degree. What is apthous stomatitis also known as? How does it present?

Answer 3

Apthous stomatitis aka recurrent apthous ulcers aka canker sores They present as recurrent ulces that are shallow and painful on the tongue or oral mucosa that heal without scarring

Question 4

Although recurrent apthous ulcers are thought to affect roughly 20% of the general population, what diseases can cause them - usually causes severe apthous ulcers?

Answer 4

Apthous ulcers are sometimes associated with other conditions Crohn’s disease and coeliac disease Rarely - Haematinic deficiencies (nutrients required for haematopoeisis) - vitamin B12, folic acid, iron

Question 5

In treating recurrent apthous ulcer, what should you try to avoid? How is it usually treated?

Answer 5

Try to avoid oral trauma such as hard foods or hard toothbrushes and acidic foods/drinks More severe cases may require steroids eg oral prednisolone

Question 6

What is an important infective cause of multiple ulcers not to miss? mainly seen in children What is it caused by?

Answer 6

Gingivostomatitis is a combination of gingivitis and stomatitis, or an inflammation of the oral mucosa and gingiva Primary herperitform gingivo-stomatitis is caused by herpes simplex virus 1 (can be HSV2)

Question 7

What is used to treat primary herpetic gingivostomatitis?

Answer 7

The aim of treatment is mostly supportive such as pain control, duration of symptoms, viral shedding and in some cases, preventing outbreak. Aciclovir is often prescribed (usually reserved for severe cases of HSV1 or shingles)

Question 8

Different mucocutaneous disorders are also linked to the formation of multiple ulcers * Lichen planus * Lupus erythematous * Bullous disorders What causes lichen planus? How does it appear on the skin?

Answer 8

Lichen planus is caused by T cell mediated inflammation targeting an unknown protein in the skin and mucosal keratinocytes Appears as a pruritic, planar, poly-angular, purple papular rash Typically affects volar aspects of wrists , forarms, shins and ankles

Question 9

How does mucosal lichen planus appear?

Answer 9

Usually appears as asymptomatic bilateral white-reticular patches - often adjacent to reddish ulcerated lesions Whitish reticular networks are known as Wickham’s striae - due to thickening of the granular layer (hypergranulosis)

Question 10

What is the treatment of lichen planus?

Answer 10

Potent/very potent topical steroids Betnovate - bethametasone valerate or Dermovate - clobetasol proprionate If extensive, can give systemic oral steroids eg prednisolone

Question 11

Both systemic lupus erythematous and discoid lupus can cause cutaneous and oral lesions What is discoid lupus erythematous confined to?

Answer 11

Discoid LE is the most common form of chronic cutaneous Discoid LE is confined to the skin above the neck in most patients but can spread below the neck to affect upper back, V of neck, forearms and backs of hands.

Question 12

How do lesions in patients with discoid lupus present? - both oral and cutaneous lesion

Answer 12

Typically presents with * Scarring alopecia * Photosensitivity causing red, scaly rash on sun-exposed sites * Butterfly rash across cheeks and noes * Ulceration and or red/white patches in mouth Slow healing leads to post inflammatory pigmentation

Question 13

What is the treatment for discoid lupus?

Answer 13

Typically sun avoidance and sunscreen are very important Potent/very potent topical steroids If this does not help, often hydroxychloroquine is tried

Question 14

Which bullous disorder commonly affects the mucosa?

Answer 14

Painful mucosal lesions affecting the oral mucosa are often the first sign seen in pemphigus vulgaris (also affects other mucoal areas eg eyes and genitals) Mucosal lesions are rarer in bullous pemphigoid

Question 15

How do the lesions in pemphigus vulgaris present?

Answer 15

Painful extensive oral ulceration Begins as blisters that rupture easily Nikolsky sign positive

Question 16

What is angular stomatitis? What is it also known as?

Answer 16

Angular stomatitis (cheilitis or cheilosis) is inflammation and fissuring of the corners of the mouth often bilaterally

Question 17

What are different causes of angular stomatitis?

Answer 17

Different causes include * ill fitting dentures, * candidiasis Associated with angular stomatitis and glossitis * Iron deficiency * B12 deficiency * B2 deficiency (riboflavin)

Question 18

White patches in the mouth can be divided into those that wipe off and those that do not wipe off Which is pseudomembranous candidiasis? (Thrush) - what is formed here and where in the mouth? Which is leukoplakia?

Answer 18

Pseudomembranous candidiasis forms soft white patches on the mucosa which can be wiped off, leaving a red, raw or bleeding and painful surface - buccal mucosa, palate and tongue are common locations Leukoplakia forms an oral mucosal white patch that cannot be wiped off

Question 19

What are different risk factors for oral candidiasis?

Answer 19

Risk factors - * extremes of age, * diabetes mellitus, * antibitoics, * immunocompromised, * immunosupression - corticosteroids (incl inhalers), malignancy, HIV

Question 20

What is the treatment of oral thrush? What should be given if the patient is taking warfarin?

Answer 20

Miconazole or fluconazole gel are usually indicated for oropharyngeal thrush If contraindicated eg patient is taking warfarin (azoles enhance the anticoagulant effect of warfarin) * Then give nystatin suspension

Question 21

What is leukoplakia? Where in the mouth is affected? Why is it a lesion of worry?

Answer 21

Leukoplakia is a white patch in the mouth that cannot be rubbed away and is usually painless Leukoplakia most often appears on the tongue but can appear on the cheeks It is a lesion of worry as it is often a pre-malignant lesion to squamous cell carcinoma and therefore needs treatment

Question 22

What is the most common risk factors for leukoplakia? How is the condition treated?

Answer 22

Leukoplaia risk factors * Biggest one is smoking * Excessive alcohol intake is also a risk factor Most patches do not require treatment but it is important that you stop smoking / drinking * Usually a biopsy is taken, which may indicate the need for surgery

Question 23

What is erythroplakia? What is it highly suggestive of?

Answer 23

Erythroplakia (red plaque) represents vascularised leukoplakia and is highly suggestive of squamous cell dysplasia Biopsy warranted

Question 24

What is the form of leukoplakia seen in HIV patients that is caused by epsteinn barr virus? Is this pre-malignant?

Answer 24

The form of leukoplakia seen in HIV patients is oral hairy leukoplakia - shaggy white patch is seen on the side of the tongue It is not pre-malignant or malignant

Question 25

What is dry mouth known as? What is thought to be the main causes?

Answer 25

Xerostomia Dehydration Drugs After radiotherapy Sjorgen’s syndrome - dry eyes, dry mouth , parotid swelling

Question 26

Oral cancers are often preventable if people know and avoid the risk factors What are some risk factors for oral cancers?

Answer 26

SMOKING ALCOHOL HPV - 16 and 18 - strongly implicated in those who do not drink or smoke and are young Candida Chewing tobacco Diet and nutrition - low in Vit A, C and iron also increase risk

Question 27

What do smoking and alcohol both increase that is a major carcinogen?

Answer 27

Smoking (tobacco) and alcohol can both cause an increase in acetaldehyde - this is a major carcinogen

Question 28

What are the high risk sites of the mouth for oral cancer?

Answer 28

Soft non-keratinizing sites * The vental tongue/floor of mouth * Lateral tongue * Soft palate * Tonsillar pillars Rarer sites include - keratinised sites Dorsal tongue and hard palate

Question 29

What are the warning signs for oral cancer?

Answer 29

* Lump in the lip or oral cavity * Oral cavity red or red and white patch consistent with erythroplakia or erythroleukoplakia * Persistent neck lump * Ulceration in the oral cavity (unexplained and lasting for more than 3 weeks) Abnormal bleeding may occur also urgent referral for these within 2 weeks are generally recommended

Question 30

What are the key relevant questions to ask a patient when considering oral cancer?

Answer 30

* How long has the lesion been present? * Is the lesion painful? - pain is uusally a late manifestation - but would be expected of a benign ulcer * Does the patient smoke or drink and how much? * What colour is the lesion?

Question 31

What type of cancers are the majority of oral cancers?

Answer 31

90% of oral cancers are squamous cell carcinomas Other types such as adenocarcinomas (usually fro salivary glands), melanomas, sarcomas may occur

Question 32

How is an oral cancer diagnosed?

Answer 32

Biopsy of the lesion is usually the first step in diagnosis If the biopsy confirms that you have mouth cancer, you’ll need further tests to check what stage it’s reached before any treatment is planned - * Fine needle aspiration of neck lymph nodes * Often Ct / PET scan head and neck

Question 33

What are the main treatment options for oral cancer?

Answer 33

If found early, surgery +/- adjuvant radiotherapy can be given If found late, chemoradiotherapy is often advised