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Oral Ulceration |
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Oral ulceration is the most commonly seen oral mucosal disease. Definition of ulceration: An ulcer is a pathological condition in which there is breach in the epithelium exposing the underlying connective tissue.
History
Examination of an ulcer Again, requires a systematic approach. Carefully document what you find in the patients notes.
Causes of Oral Ulceration: 1 Aphthae Recurrent aphthae (recurrent aphthous stomatitis-RAS) constitute the most common oral mucosal disease and affects up to 25% of the population. There are 3 subgroups, any of which may occur in conjunction with genital or conjunctival lesions as part of Behcet’s syndrome. Minor aphthae * The most common type (85% of aphthae) * Only present on non-keratinized mobile mucosa (lips, cheeks, FOM, ventrum of tongue, sulci) * Ulcers are shallow, 5-7mm diameter, with an erythematous margin and yellowish base * Last between 3 – 14 days, heal without scarring * May be single, or in crops of two or three. Occasionally multiple * May have swollen and tender cervical lymph nodes
Major aphthae * Large, recurrent painful ulcers— > 1 cms diameter * Ulcers persist for several months (10-40 days), and can resemble a malignant ulcer (irregular outline) * Masticatory mucosa, such as dorsum of tongue or gingivae may be involved * Scarring often follows healing * Usually single, can be multiple (1-6) * Seen in patients with HIV infection * More painful - can interfere with eating
Herpetiform aphthae * Multiple, extremely painful, recurrent mouth ulcers * Any oral site, including keratinized mucosa—tongue, floor of mouth, buccal mucosa * As many as 100 at the same time, may coalesce and become confluent * Small 1—2mm diameter, last for 3 – 14 days, heal without scarring * Widespread bright erythema around ulcer * Distinguished from primary herpetic gingivostomatitis
Behcet’s Syndrome Rare. Male. Mediterranean, Middle-Eastern, Japanese predilection. HLA associations. Triad of recurrent oral (RAS in 90-100%) and painful genital ulceration, with ocular lesions (uveitis, retinal vascular changes)
Aetiology of Aphthae (RAS)
Diagnosis Based on history and clinical features Biopsy rarely indicated (useful if different diagnosis suspected) Haematological investigation— FBC, serum ferritin, vitamin B12 and red cell folate levels, +/- autoimmune profile
Management Treat any haematinic deficiencies Dietary avoidance if obvious relationship to certain foods Maintain good OH; Chlorhexidine 0.2% mouthrinse, TDS, after meals Try TOPICAL preparations first:-
If failure to respond to the above measures - SYSTEMIC IMMUNOMODULATORS may be required. Only to be used with specialist supervision.
2 Carcinoma One of the most important differential diagnoses. If persisting >3 weeks without healing, must be biopsied. 90% of oral carcinomas occur on lateral border of tongue, or floor of mouth. Ulcers persisting in this region should be regarded with suspicion. (SEE picture above)
3 Gastrointestinal Disease The following are associated with or exacerbate RAS:- Pernicious anaemia
Coeliac disease (if malabsorption = haematinic deficiency = also angular stomatitis or glossitis) Crohn’s disease (SEE picture on right) Ulcerative colitis
4 Haematological Disease Haematological causes include:-
5 Infections A very significant cause of oral ulceration. Causes include:-
6 Mucocutaneous Disorders Also an important cause of oral ulceration. Main causes include:-
7 Radiotherapy An increasingly important cause of oral ulceration, associated with radiation mucositis. If mucositis is severe, sloughing with resultant ulceration can continue for several weeks. Ulcers are non-specific and often become superinfected. Treat with analgesia and Chlorhexidine mouthwash
8 Trauma Usually an obvious cause, sharp tooth or ill-fitting denture. Can occur while anaesthetised during dental treatment. Removal of the cause usually leads to uneventful healing. |