BDS What is an ulcer Full thickness loss of the epithelium where underlying connective tissue can be observed and fibrin may be deposited on surfaces Symptoms painsoreness discomfort when eating spicyacidic foods ID: 912422
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Slide1
Oral ulceration
Amy
Sterritt
BDS
Slide2What is an ulcer?
Full
thickness loss of the epithelium where underlying connective tissue can be observed and fibrin may be deposited on surfaces
Symptoms- pain/soreness, discomfort when eating spicy/acidic foods
Causes of ulcers?
Iatrogenic: Trauma Heal within 2 weeks when traumatic agent is removed Immunological Recurrent aphthous stomatitis, lichen planus, lupus, vesiculo-bullous disorders and erythema multiforme NeoplasmsCarcinoma: squamous cell carcinoma Infections Viral (HSV, Coxsackie, Varicella-Zoster, HIV) , bacterial (e.g. syphilis) or fungal Gastrointestinal Coeliac disease, Crohn’s disease, ulcerative colitis Drugs related Nicorandil – angina pectoris vasodilator medication, cytotoxic drugs
Slide3Ulceration history
Where is the ulceration?
What is the size and shape?
Is it a blister or ulcer?
How long has the ulcer been present for? Is it at the same site? Recurrent?
Is it painful? Are the margins – flat, raised or rolled? Is the base soft, firm or hard?
Slide4Classification –
Recurrent Oral Ulceration (ROU)
Non-aphthous
Traumatic ulceration
Lichen planus
Vesiculo-bullous PemphigoidPemphigus Angina bullosa haemorrhagica Viral infection Drug related e.g. NicorandilRecurrent aphthous stomatitis (RAS)Categories MinorMajorHerpetiform Behcet’s syndrome
Slide5Recurrent aphthous stomatitis aetiology
Host factors
genetic – HLA types A2 and B12 (positive family history in 1/3 of patients with RAS)
Nutritional deficiency – 20% have iron, folate or B12 deficiency
Systemic disease – menorrhagia, chronic GI blood loss (carcinoma, gastric bleeding), dietary malabsorption conditions (Crohn’s disease, pernicious anaemia), Coeliac disease, OFG, Ulcerative Colitis
Endocrine – F>M; related to menstrual cycle luteal phase: remission in pregnancy Immunity CD4:CD8 ration: pre ulcer 2:1; ulcer 1:10; healing 10:1 Environmental factors TraumaAllergies: e.g. benzoates (E210-219), SLS in toothpaste.Other factors: smoking (often related to stopping smoking), infections and stress
Slide6Minor Aphthae diagnosis
Size: <10mm (usually 3-8mm)
Shape: round or oval with red halo and yellow base
Number: 1-20 per crop (usually 2-5)
Histology: chiefly non keratinising mucosa affected
Lining mucosa: cheeks, FOM, labial mucosa Duration: heals within 1-2 weeks Outcome: heals without scarring Affects:10-40 years80% of RAS is MINOR
Slide7Major aphthae diagnosis
Size: >10mm
Shape: oval or irregular
Number: <5 at a time, can occur singly
Histology: keratinising or non keratinising mucosa e.g. dorsum of tongueDuration: heals within 6-12 weeks
Outcome: often heal with scarring
Slide8Herpetiform aphthae diagnosis
Size: <5mm (0.5-3mm)
Shape: round or oval often coalesce into large areas of ulceration
Number: 1-200 per crop
Extremely painfulHistology: non keratinising mucosa affected
Duration: heals within 1-2 weeks Outcome: heals without scarring Commoner in older groups and females
Slide9Management/treatment
Reassurance
Correct underlying cause:
replace nutrient deficiency, treat systemic disease, remove trauma/allergens
Medication (see SDCEP guidance/prescribing app)
Topical immune modulation Benzydamine numbing spray 0.15%Betamethasone M/W (500microgram tablet dissolved in 10ml water used as a mouthwash 4 times daily)Betamethasone inhaler 50 micrograms/puff 1-2 puffs twice daily (Clenil Modulite)CHX M/WHydrocortisone pellets 2.5mg 4 times dailyDoxycycline M/W (100mg tablet, dissolved)- rinse for 2 minutes 4 times daily for 3 daysSystemic immune modulation (Secondary care)Systemic steroids – prednisolone Immunosuppressive – azathioprine DMDs – adalimumab
Immunomodulator – thalidomide
Slide10Reiter’s syndrome
(Reactive Arthritis)
It is a condition characterised by inflammatory arthritis that develops in response to an infection elsewhere in the body which then triggers this reaction
Most cases, clear up within few months and cause no long term problems
Common between ages 20-40
Triad of symptoms - Inflammatory arthritis of large jointsConjunctivitis or uveitis Urethritis or cervicitis Oral symptoms Mucocutaenous lesions: Oral ulcers that come and go Recurrent aphthous stomatitis Geographic tongue Migratory stomatitis (reddish area surrounded by white borders located anywhere in oral cavity)
Treatment
Antibiotics to clear any infections that may have triggered reactive arthritis
Painkillers – NSAIDS for joints
DMARDS in severe ongoing cases
Slide11Behcet’s syndrome
It is a chronic autoinflammatory condition associated with variety of health problems due to inflammation of the the blood vessels (vasculitis)
Most commonly small blood vessels: mouth, genital, skin and eyes
Diagnosis
Blood tests; urine testing
X-rays/CT/MRIsSkin biopsy Pathergy test: pricking skin with needle to observe if red spot appears – common to have sensitive skin with Behcet’s. Mouth ulcer observation At least 3 episodes of ulcers in past 12 months and have 2 of the following symptoms: genital ulcers, eye inflammation, skin lesions or pathergy is a a positive diagnosis of Behcet’s. Oral manifestations Painful mouth ulcers called aphthous ulcers on the lips, tongue, inside of cheek, palate, throat and tonsils Ulcers heal within 1-2 weeks and may have associated genital ulcers
Clinical presentation
Ulcers of the mouth
Painful bumps and sores on skin – pus filled resembling acne
Uveitis causing blurry vision and light sensitivity
Joint involvement – painful and swollen
Treatment
Referral to Behcet’s syndrome centres of excellence
Steroids
Immunosuppressants
Biological therapies
Slide12References
Behcetsuk.org. 2020. [Online] Available at: <https://behcetsuk.org/> [Accessed 27th August 2020].
Chavan, M., Jain, H., Diwan, N., Khedkar, S., Shete, A. and Durkar, S., 2012. Recurrent aphthous stomatitis: a review.
Journal of Oral Pathology & Medicine
, 41(8), pp.577-583.
nhs.uk. 2020. Reactive Arthritis. [Online] Available at: <https://www.nhs.uk/conditions/reactive-arthritis/> [Accessed 27 August 2020].Odell, E., 2000. Clinical problem solving in dentistry. 2nd Ed. Edinburgh: Churchill Livingstone, pp.75-77University of Glasgow.2020. Oral Medicine – Oral Ulceration