Oral Ulcer Overview and RAS

Oral Ulceration Overview

• Oral ulcers can be solitary or multiple.
• Oral ulcers can be painful or painless.
• Oral ulcers can be firm to palpate.

Drug Related Salivary Gland Hypofunction

• Dry mouth can be caused by medications.
• Medications commonly associated with dry mouth include: oxybutynin, tolterodine, duloxetine, quetiapine, bupropion, olanzapine, solifenacin, clozapine, fluoxetine, and venlafaxine.

Riga-Fede

• Similar to Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE) but occurs in children.

Recurrent Aphthous Stomatitis (RAS)

• RAS lesions are round or ovoid.
• RAS lesions have circumscribed margins.
• RAS lesions have erythematous haloes.
• RAS lesions present a yellow or grey base.
• RAS lesions are found on non-keratinized and mobile mucosa.

RAS Epidemiology

• RAS is common, frequently starting in childhood.
• RAS often has a family history.
• RAS tends to improve with age.
• RAS presents a slightly higher prevalence in females.
• RAS is prevalent worldwide, occurring most often in developed countries with higher socioeconomic status.

Differentiating RAS in Underlying Conditions

• RAS usually appears clinically identical, regardless of an underlying condition.
• Behçet disease and PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Adenitis) can mimic RAS.

Systemic Involvement in RAS

• RAS may be associated with systemic conditions.
• Systemic conditions can be autoimmune, hematological, gastrointestinal, infectious, or neoplastic.
• Systemic conditions associated with RAS include:
  • Behçet syndrome
  • Subepithelial immune blistering diseases
  • Pemphigoid and variants
  • Dermatitis herpetiformis
  • Linear IgA disease
  • Epidermolysis bullosa
  • Erythema multiforme
  • Lichen planus
  • Pemphigus vulgaris
  • Hematological disorders
  • Anemia
  • Gammopathies
  • Hematinic Deficiencies
  • Micronutrient Deficiencies
  • Leukemia and myelodysplastic syndrome
  • Neutropenia
  • Cyclic neutropenia
  • Other white cell dyscrasias
  • Gastrointestinal disease
  • Celiac disease
  • Crohn’s disease
  • Ulcerative colitis
  • Giant cell arteritis
  • Hypereosinophilic syndrome
  • Lupus erythematosus
  • Periarteritis nodosa
  • Reiter’s syndrome
  • Sweet’s syndrome
  • PFAPA
  • Sarcoidosis
  • MAGIC
  • Wegener’s granulomatosis
  • Infectious mononucleosis
  • Syphilis
  • Tuberculosis
  • Neoplasms of the salivary glands
  • Metastatic neoplasms
  • Kaposi sarcoma
  • Oral Ulcers

Patient Understanding of Terminology

• Many patients may not understand the terminology used in oral surgery and medicine.
• Studies show that a significant number of patients misunderstand common terms.
• Common terms that are often misunderstood include:
  • Ulcer
  • Impacted tooth
  • Radiograph
  • Sedation
  • Biopsy
  • Mucosa
  • Benign

Oral Ulcer Types

• Oral ulcers can be classified as either traumatic or immune-mediated.
• Traumatic ulcers may also lead to squamous cell carcinoma.

An Approach to Oral Ulceration Flowchart

• A flowchart is used to guide diagnosis and treatment of oral ulcers.
• Factors to consider in the flowchart include:
  • Immunocompromised Patient?
    • Transplants
    • Chemotherapy
    • T2DM - well controlled?
  • Has the patient been unwell?
    • Malaise
    • Fever

Oral Ulcer Duration Considerations

• Oral ulcers usually resolve within 2 weeks.
• Oral ulcers that persist beyond two weeks may have an underlying cause.
• An ulcer lasting more than two weeks is considered chronic.

Acute Traumatic Ulceration

• Acute traumatic ulcers are usually solitary.
• Causes may be difficult to determine in children.
• Ulcers should resolve within two weeks if the trauma source is removed.

Chronic Traumatic Ulceration (TUG/TUGSE)

• Chronic traumatic ulceration is known as Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE).

TUGSE and Squamous Cell Carcinoma (SCC)

• TUGSE can be misdiagnosed as an SCC.
• Herpes zoster can present with oral ulcers.
• Herpes zoster symptoms can mimic toothache before the rash appears.
• Oral ulcers should not be attributed to toothache before a complete assessment.

Drug Related Ulceration

• Oral ulcers can be caused by medications.
• Common drug classes that can lead to oral ulcers include:
  • Antihypertensives
  • Antidiabetics
  • NSAIDs
  • Methotrexate
  • Allopurinol
  • Amphotericin B

Methotrexate-Related Oral Ulceration

• Oral ulcers can be a possible side effect of methotrexate therapy.

Mucositis (Chemoradiation)

• Oral mucositis, a side effect of chemotherapy and radiation, damages the lining of the mouth.

Oral Ulceration - Direct Damage

• Oral ulcers can result from direct damage to the oral mucosa.

Symblepharon

• Symblepharon is a condition where the eyelid adheres to conjunctiva.

Red Flags in Oral Ulceration

• Indurated oral ulcers are a concerning finding.
• Persistent oral ulcers should be investigated.

Oral Ulceration Take Away Points

• Diagnosing oral ulceration can be challenging.
• The two-week rule is helpful for evaluating oral ulcers.
• Even subtle oral ulcer pathology should be evaluated.

This quiz covers essential information about oral ulceration, including types, causes, and specific conditions such as recurrent aphthous stomatitis (RAS). Explore the characteristics, epidemiology, and medication-related issues regarding salivary gland hypofunction. Test your knowledge to enhance your understanding of these important oral health topics.