Podcast
Questions and Answers
What is a likely underlying cause of persistent multiple ulcers in the mouth?
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?
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?
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?
Which gastrointestinal condition is known to cause recurrent oral ulcers?
What type of drug is associated with recurrent mouth ulcers as a side effect?
What type of drug is associated with recurrent mouth ulcers as a side effect?
What characterizes an ulcer as defined in the content?
What characterizes an ulcer as defined in the content?
Which of the following is classified as a persistent ulcer?
Which of the following is classified as a persistent ulcer?
What is a potential cause of multiple recurrent ulcers?
What is a potential cause of multiple recurrent ulcers?
What type of ulcer can mimic neoplastic ulcers?
What type of ulcer can mimic neoplastic ulcers?
Which aspect is NOT a principle of diagnosis for oral ulceration?
Which aspect is NOT a principle of diagnosis for oral ulceration?
How can social history contribute to the diagnosis of oral ulcers?
How can social history contribute to the diagnosis of oral ulcers?
What is an example of a drug that is linked to the development of deep ulcers?
What is an example of a drug that is linked to the development of deep ulcers?
Which condition is not classified under single ulcers?
Which condition is not classified under single ulcers?
What is the most common cause of a persistent single ulcer?
What is the most common cause of a persistent single ulcer?
Which factor significantly increases the risk of oral malignancy?
Which factor significantly increases the risk of oral malignancy?
Which of these conditions is least likely to cause a recurrent single ulcer?
Which of these conditions is least likely to cause a recurrent single ulcer?
What metric is NOT relevant to understanding a patient's ulcer history?
What metric is NOT relevant to understanding a patient's ulcer history?
Which of the following best describes a common presentation of fungal infections that cause oral ulcers?
Which of the following best describes a common presentation of fungal infections that cause oral ulcers?
What kind of lifestyle factors can influence ulcer development related to menstruation?
What kind of lifestyle factors can influence ulcer development related to menstruation?
Which of these is a characteristic feature of malignant ulcers?
Which of these is a characteristic feature of malignant ulcers?
What can indicate a history of trauma in a patient's ulcer profile?
What can indicate a history of trauma in a patient's ulcer profile?
Which oral condition is most likely to present with systemic features such as fever and malaise?
Which oral condition is most likely to present with systemic features such as fever and malaise?
Which behavior greatly increases the risk factor for developing oral malignancies?
Which behavior greatly increases the risk factor for developing oral malignancies?
What is the estimated prevalence of lichen planus?
What is the estimated prevalence of lichen planus?
Which condition is most commonly associated with oral ulceration?
Which condition is most commonly associated with oral ulceration?
Which demographic is more likely to develop lichen planus?
Which demographic is more likely to develop lichen planus?
What is a characteristic feature of lichen planus?
What is a characteristic feature of lichen planus?
Cyclical neutropenia leads to which oral condition?
Cyclical neutropenia leads to which oral condition?
Which gastrointestinal disease is known for causing oral ulceration?
Which gastrointestinal disease is known for causing oral ulceration?
Which condition does NOT typically present with oral ulcers?
Which condition does NOT typically present with oral ulcers?
What is a sign of Vitamin C deficiency in the oral cavity?
What is a sign of Vitamin C deficiency in the oral cavity?
What medication or material can be associated with oral lichenoid lesions?
What medication or material can be associated with oral lichenoid lesions?
Which of these conditions is classified as a haematological disease associated with oral lesions?
Which of these conditions is classified as a haematological disease associated with oral lesions?
Which vitamin deficiency is associated with spontaneous bleeding of the gingivae?
Which vitamin deficiency is associated with spontaneous bleeding of the gingivae?
What is a common clinical feature of acute lupus affecting the oral cavity?
What is a common clinical feature of acute lupus affecting the oral cavity?
Which of the following best describes herpetiform ulcers?
Which of the following best describes herpetiform ulcers?
What is a notable clinical feature of recurrent aphthous stomatitis (RAS)?
What is a notable clinical feature of recurrent aphthous stomatitis (RAS)?
Which condition commonly causes oral and genital ulcers and is often confused with others?
Which condition commonly causes oral and genital ulcers and is often confused with others?
What is the relation between single persistent ulcers and oral cancer?
What is the relation between single persistent ulcers and oral cancer?
What role does the general dental practitioner (GDP) have in identifying ulcers?
What role does the general dental practitioner (GDP) have in identifying ulcers?
What distinguishes discoid lupus lesions from lichen planus lesions in the oral cavity?
What distinguishes discoid lupus lesions from lichen planus lesions in the oral cavity?
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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
- Recurrent Aphthous Stomatitis (RAS)
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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