Oral Ulcers and Erosion Definitions

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Questions and Answers

What is a likely underlying cause of persistent multiple ulcers in the mouth?

Exposure to sharp objects

Mechanical factors like dentures

An underlying systemic disease (correct)

Inadequate oral hygiene

Which of the following is least likely to cause recurrent mouth ulcers?

Iatrogenic factors

Anaemia

Non-accidental injury (correct)

Thermal injury from hot food

Which dermatological condition is associated with recurring mouth ulcers?

Rosacea

Lichen planus (correct)

Eczema

Psoriasis

Which gastrointestinal condition is known to cause recurrent oral ulcers?

Inflammatory bowel disease Signup and view all the answers

What type of drug is associated with recurrent mouth ulcers as a side effect?

Methotrexate Signup and view all the answers

What characterizes an ulcer as defined in the content?

Area of total loss of epithelium Signup and view all the answers

Which of the following is classified as a persistent ulcer?

Chronic Infections like TB Signup and view all the answers

What is a potential cause of multiple recurrent ulcers?

Drugs Signup and view all the answers

What type of ulcer can mimic neoplastic ulcers?

Deep fungal ulcers Signup and view all the answers

Which aspect is NOT a principle of diagnosis for oral ulceration?

Surgical intervention Signup and view all the answers

How can social history contribute to the diagnosis of oral ulcers?

Dietary habits and smoking status Signup and view all the answers

What is an example of a drug that is linked to the development of deep ulcers?

Nicorandil Signup and view all the answers

Which condition is not classified under single ulcers?

Chronic Infections Signup and view all the answers

What is the most common cause of a persistent single ulcer?

Trauma Signup and view all the answers

Which factor significantly increases the risk of oral malignancy?

Age Signup and view all the answers

Which of these conditions is least likely to cause a recurrent single ulcer?

Oral malignancy Signup and view all the answers

What metric is NOT relevant to understanding a patient's ulcer history?

Favorite color Signup and view all the answers

Which of the following best describes a common presentation of fungal infections that cause oral ulcers?

Multiple self-limiting ulcers with systemic features Signup and view all the answers

What kind of lifestyle factors can influence ulcer development related to menstruation?

Smoking and alcohol consumption Signup and view all the answers

Which of these is a characteristic feature of malignant ulcers?

Very deep ulcers with an injurated edge Signup and view all the answers

What can indicate a history of trauma in a patient's ulcer profile?

Irregular ulcer shape that grew over time Signup and view all the answers

Which oral condition is most likely to present with systemic features such as fever and malaise?

Multiple self-limiting ulcers Signup and view all the answers

Which behavior greatly increases the risk factor for developing oral malignancies?

Smoking and excessive alcohol use Signup and view all the answers

What is the estimated prevalence of lichen planus?

0.5-2% Signup and view all the answers

Which condition is most commonly associated with oral ulceration?

Lichen planus Signup and view all the answers

Which demographic is more likely to develop lichen planus?

Females aged 30-60 years Signup and view all the answers

What is a characteristic feature of lichen planus?

White patches Signup and view all the answers

Cyclical neutropenia leads to which oral condition?

Persistent oral ulcers Signup and view all the answers

Which gastrointestinal disease is known for causing oral ulceration?

Crohn's disease Signup and view all the answers

Which condition does NOT typically present with oral ulcers?

Tension headache Signup and view all the answers

What is a sign of Vitamin C deficiency in the oral cavity?

Red and swollen gingivae Signup and view all the answers

What medication or material can be associated with oral lichenoid lesions?

Amalgams Signup and view all the answers

Which of these conditions is classified as a haematological disease associated with oral lesions?

Chronic myeloid leukaemia Signup and view all the answers

Which vitamin deficiency is associated with spontaneous bleeding of the gingivae?

Vitamin C Signup and view all the answers

What is a common clinical feature of acute lupus affecting the oral cavity?

Erythemato-purpuric macules Signup and view all the answers

Which of the following best describes herpetiform ulcers?

Multiple small ulcers occurring together Signup and view all the answers

What is a notable clinical feature of recurrent aphthous stomatitis (RAS)?

Includes minor, major, and herpetiform types Signup and view all the answers

Which condition commonly causes oral and genital ulcers and is often confused with others?

Behçet's disease Signup and view all the answers

What is the relation between single persistent ulcers and oral cancer?

They are unlikely to be malignant. Signup and view all the answers

What role does the general dental practitioner (GDP) have in identifying ulcers?

To decide whether to treat, not treat, or refer Signup and view all the answers

What distinguishes discoid lupus lesions from lichen planus lesions in the oral cavity?

They often occur on uncommon sites like the palate. Signup and view all the answers

Study Notes

Definitions

Erosion - Skin or mucous membrane loss not reaching the basement membrane
Excoriation - Scratch mark with intact base of the mucous membrane/epidermis
Ulcer - Complete loss of epithelium, reaching underlying connective tissue

Classification of Oral Ulcers

Single ulcers:
- Recurrent - trauma, aphthous stomatitis, herpes
- Persistent - neoplasms, trauma, TUGSE, infections, drugs
Multiple ulcers:
- Recurrent - aphthous stomatitis, erythema multiforme, recurrent herpes
- Persistent - dermatological conditions (lichen planus and vesiculobullous conditions), drugs
Ulcers mimicing neoplastic ones: Deep fungal ulcers, syphilitic ulcers, drug-related ulcers (e.g. nicorandil)

Key Points for Diagnosis

History
- Presentation: appearance and patient's interpretation
- History of presentation: recurrence, cause
- Medical History: new medications
- Social history: diet, smoking
- Review of systems: underlying disease e.g. Lupus

Features of Ulcer History

Age of onset
Duration - time to heal
Frequency of attacks - duration of healing and ulcer-free periods
Site - common and unaffected areas
Size - growth
Shape
- Oval or irregular
- Coalescence: do multiple smaller ulcers combine to form one larger ulcer?
Prodrome - does the patient feel the ulcer developing?
Relation to menstruation or smoking
Change in degree of ulceration over time
Synchronous/Asynchronous: do ulcers heal one at a time, or overlap?

Risk Factors for Oral Malignancy

Age (older = higher risk)
Other malignant diseases
Smoking (risk x10)
Alcohol (risk x4; threshold 14 units/week)
Smoking + Alcohol (risk x40)
Areca nut/Betel nut chewing
UV radiation (lip cancer)
Potentially malignant oral epithelial lesions

Examination

Establish a routine, systematic approach
Extra Oral
- Lymphadenopathy
- Skin and ocular changes
- General appearance (well or unwell)
Intra Oral
- Soft tissues: all mucosal surfaces, typically before teeth
- Two mirrors to reflect buccal mucosae and lips
- Pay special attention to the retro-molar fossa and posterior lingual aspects of the tongue

Persistent Single Ulcer

Trauma

Most common cause of a single ulcer

Mechanical: sharp tooth, appliances, non-accidental injury, self-inflicted, iatrogenic
Thermal: hot/cold
Chemical: e.g., aspirin sucking
Radiation
Electric current

Infection

Mostly multiple and self-limiting, with systemic features (fever, malaise)
Bacterial
- Tuberculosis (Mycobacterium Tuberculosis)
- Syphilis (Treponema pallidum)
Fungal (deep mycosis) usually requires further investigation and history of travel

Drug Reaction

Often multiple ulcers/erosions (but can be single, more likely to be associated with chemical burn)
Patients may recall a timeline
Most common example: Aspirin
Other medicines causing ulcers:
- Methotrexate: multiple ulcers
- Nicorandil: single, large, deep ulcers

Malignant Ulceration

Range of neoplasms present with oral ulcers, very deep with injured edge
Most are oral squamous cell carcinomas
Rare causes:
- Haematological malignancies (mainly lymphoma)
- Salivary gland neoplasms
- Sarcoma (rare)
- Metastatic disease (lymph nodes or bone, rarely gingiva)

Recurrent Single Ulcer

Similar to persistent single ulcers, but excluding oral malignancy

Mechanical
- Sharp tooth or restoration
- Appliances
- Non-accidental injury
- Self-inflicted (e.g., toothbrush)
- Iatrogenic (unlikely to be recurrent)
Thermal: hot/cold (if recurring with specific foods)
Chemical: Aspirin (unlikely to be multiple sites)
Radiation (if multiple sites of radiation therapy)
Electric
Infective

Persistent Multiple Ulcers

Typically secondary to underlying systemic disease
Secondary to Dermatological:
- Lichen Planus
- Immunobullous conditions (Pemphigus & Pemphigoid)
Secondary to Gastrointestinal:
- Inflammatory Bowel Disease: Crohn's & Ulcerative Colitis
Secondary to Haematological disorders:
- Anemia
- (Haematological) Malignancy
Secondary to Connective tissue disease:
- Lupus (especially during flare)
Secondary to Drugs:
- Methotrexate

Oral Ulceration Secondary to Dermatological Conditions

Lichen planus (most common)
Mucous Membrane Pemphigoid / Bullous Pemphigoid
Linear IgA Disease / Dermatitis Herpetiformis
Pemphigus
Erythema Multiforme
Epidermolysis Bullosa

Lichen Planus

Key features:

Chronic mucocutaneous disease of unknown etiology
Autoimmune, cell-mediated immunological reaction
Prevalence: 0.5-2%
Female: Male ratio 2:1
Onset: 30-60 years old
Range of clinical appearances with characteristic histology
- White patches
- Ulcers (usually in buccal sulcus)

Oral Lichenoid Lesions

Subtle clinical and histopathological differences from lichen planus
Associated with numerous medications and dental materials (amalgams)

Secondary to Gastrointestinal Enteropathy

Inflammatory Bowel Disease
- Crohn's disease
- Ulcerative Colitis
Warning signs/symptoms:
- Change in bowel habit
- Dyspepsia (indigestion)
- Rectal bleeds/occult blood

Oral Ulceration Secondary to Haematological Disease

Haematinic deficiency (iron, vitamin B12, etc.)
Cyclical Neutropenia
Leukaemia

Oral Ulceration Secondary to Connective Tissue Disease

Acute lupus
- Erythemato-purpuric macules
- Palatal erythema
- Petechiae
- Ulceration
Chronic (discoid lesions)
- Atrophic or ulcerated round lesions with peripheral keratotic striae
- Linear ulcers with keratotic striae
- Palatal discoid lesions

Recurrent Multiple Ulcers

Recurrent Oral Ulcers (ROU)
- Recurrent Aphthous Stomatitis (RAS)
  - Minor
  - Major
  - Herpetiform
- Ulcers related to smoking cessation
- Behcet's disease
- PFAPA syndrome (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis)
- Recurrent Erythema Multiforme
- Idiopathic

Major Roles for the General Dental Practitioner (GDP)

Identify ulcers requiring treatment and referral
Screen for Malignant and Potentially Malignant Disease
- Oral Squamous Cell Carcinoma - Early detection improves survival rates and reduces need for radical surgery
Establish provisional diagnosis
Decide to treat, not treat, or refer (all potential malignancies referred via 2-week wait pathway)
Prescribe correct drugs/therapies

Note:

Oral cancers fall under the category of single persistent ulcers. If the ulcer comes and goes, it is unlikely to be an oral cancer.

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Description

Test your knowledge on the definitions and classifications of oral ulcers. This quiz covers various types of ulcers, their characteristics, and key points for diagnosis, including patient history and potential causes. Improve your understanding of oral health issues and diagnostic criteria.