Ulcers

Oral Ulceration

History

¨ Age of patient

¨ Relevant medical history

¨ Duration of ulcer - persistent?

¨ Multiple or single?

¨ Site and distribution

¨ Recurrence and do ulcers resolve completely?

¨ Tingling or itching before ulceration?

¨ Pain and blistering

¨ Other sites of ulceration—skin, eyes, genital regions

¨ Smoking and alcohol intake. Tobacco chewing?

Examination of an ulcer

Again, requires a systematic approach. Carefully document what you find in the patients notes.

¨ Site

¨ Number (single or multiple?)

¨ Size

¨ Shape

¨ Characteristics—colour, presence of slough, scab, fungating, granulating, bleeding

¨ Base - indurated (firmness to palpation), fixed to deep structures

¨ Edge—raised, rolled, everted, undermined/ overhanging, punched out, rolled, pearly

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)

¨ Genetic predisposition

¨ Trauma (appliances, self-inflicted, sharp teeth/restorations) and Burns (chemical. heat, radiation)

¨ Infections

¨ Immunological abnormalities

¨ Gastrointestinal disorders – 3% (Coeliac, Crohn’s, U.Colitis)

¨ Haematinic deficiencies – 20% of cases (Fe, B12, Folate)

¨ Stress

¨ Hormonal disturbances (menstrually associated -fall in progesterone)

¨ Nutritional (certain foodstuffs - allergy)

¨ Smoking (aphthae start once smoking is ceased)

¨ Drugs (cytotoxic, NSAID’s)

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:-

¨ Benzydamine hydrochloride (0.15%, mouth rinse with 15ml, up to 7 times a day) gives symptomatic relief

¨ Corlan (Hydrocortisone hemisuccinate) 2.5mg pellets, dissolved in mouth, tds

¨ Adcortyl in Orabase (Triamcinolone acetonide in carboxymethyl cellulose paste) adheres best to dry mucosa, qds

¨ Stronger topical corticosteroids (Betamethasone sodium) 0.5mg tablet dissolved in 15ml water to make a mouth rinse, qds

¨ Tetracycline mouth rinses—250mg tetracycline capsule dissolved in 10ml water, tds

¨ Becotide 100 (Beclomethasone diproprionate spray) 1 puff (100mcg) to lesion (*high potency)

If failure to respond to the above measures - SYSTEMIC IMMUNOMODULATORS may be required. Only to be used with specialist supervision.

¨ Levamisole

¨ Colchicine (inhibits polymorph chemotaxis, need regular blood tests)

¨ Systemic corticosteroids (prednisolone)

¨ Thalidomide (inhibits tumour necrosis factor)

¨ Azathioprine

¨ Cyclosporin

¨ Dapsone

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:-

Nutritional deficiencies – Iron, Folic acid, Vitamin B12

Leukaemia – Lymphocytic, Myeloid (other oral features = purpura, gingival bleeding, candidosis, recurrent herpes labialis) SEE picture on right

Plasma cell tumours

Marrow aplasia - Pancytopenia, Neutropenia