Oral Ulceration Lecture 3 PDF

Lecture 3) Oral Ulceration ========================== Definitions ----------- Mucosal terminology: **Erosion -** area of partial loss of skin/ mucous membrane, base of defect doesn't breach basement membrane **Excoriation -** scratch mark with scored epidermis, defect is a bit deeper but the bas...

Lecture 3) Oral Ulceration ========================== Definitions ----------- Mucosal terminology: **Erosion -** area of partial loss of skin/ mucous membrane, base of defect doesn't breach basement membrane **Excoriation -** scratch mark with scored epidermis, defect is a bit deeper but the base of the mucous membrane/epidermis is intact **Ulcer -** area of total loss of epithelium, breach from outside to underlying connective tissue Classification -------------- Not by colour/shape/size -------------------------------------------------------------------------------------------------------------------------------------- Single Ulcers Multiple Ulcers ------------ ------------------------------------------------- ----------------------------------------------------------------------- Recurrent Trauma Recurrent Aphthous Stomatitis\ Recurrent Oral Ulcers Erythema Multiforme Recurrent Herpes Persistent Neoplasms\ Dermatological conditions(Lichen planus& Vesiculobullous conditions)\ Trauma\ Drugs TUGSE\ Chronic Infections (Syphilis, TB, Fungal) Drugs -------------------------------------------------------------------------------------------------------------------------------------- Deep fungal ulcers and syphilitic and drug related (nicorandil- used for treating angina, gives rise to single, v deep ulcers) ulcers mimic neoplastic ones Principle of Diagnosis - History Examination Differential diagnosis Special investigations Diagnosis History - Presentation - What it looks like - What has the patient noticed/what do they think it looks like - History of Presentation - Have they noticed this before - Can the patient tell you how this ulcer occurred - Medical History - E.g. new medicines - Social History - Diet? - Smoking currently? Given up? - A lot of patients develop new ulcers once they stop smoking - Review of Systems - Underlying disease e.g. Lupus Features of Ulcer History ------------------------- What does the patient mean by an ulcer - Age of onset - Duration -length of time to heal - Frequency of attacks - Recurrent? How long does it take for the ulcer to heal and go back to normal - Length of ulcer free periods (Can impact what therapy you can provide) - Site - common & those never affected (V rare to get a palatal ulcer) - Size- Did it grow - Shape - Oval? Naturally irregular? - Did any trauma occur to make it irregular? - Coalesce Do lots of smaller ulcers come together to form one large ulcer - Prodrome - Patient can feel where the ulcer is coming - Can ask the patient to use a certain mouthwash prior to the ulcer actually becoming present - Relation to menstruation / smoking - Change in degree of ulceration over time - Synchronous / asynchronous - Does one ulcer start, heal, then another comes - Or do the ulcers overlap eachother Risk factors for oral malignancy --------------------------------  Age (older = higher risk)  Other malignant diseases  Smoking (risk x10)  Alcohol (risk x4) Thershold 14 units/week  Smoking + Alcohol (risk x40)  Areca nut/Betel nut chewing  UV radiation (lip cancer)  Potentially malignant oral epithelial lesions Examination - Intra-Oral Mucosa ------------------------------- - Establish a routine, systematic approach / pattern - Extra Oral - Lymphadenopathy - Skin & Ocular changes - Does the patient look ill/unwell - Intra Oral - Soft tissues include all mucosal surfaces, typically before examining teeth - Use two mirrors to reflect buccal mucosae and lips - Pay special attention to the retro-molar fossa and posterior lingual aspects of the tongue (frequent sites of oral cancer) Persistent Single Ulcer ----------------------- ### Trauma is the most common cause of a single ulcer - Mechanical (sharp tooth, appliances, non-accidental injury, self-inflicted, iatrogenic) - Thermal (hot/cold) - Chemical (e.g., pt sucking on aspirin) - Radiation - Electric current ### Infection - Majority of infective causes of ulceration present with multiple oral ulcers which are self-limiting Often associated with systemic features including fever & malaise - Bacterial - Tuberculosis (Mycobacterium tuberculosis) - Syphilis (Treponema pallidum) male presenting with single persistant ulcer on soft palate, otherwise fit an healthy, may want to query syphilis if history suggests it - Fungal Deep mycosis to diagnose would need more investigation and history about travel Top is a syphilitic ulcer, and bottom is a deep fungal mycosis ### Drug reaction - Often drugs results in multiple ulcers or erosions (but can also be single, more likely to be associated with chemical burn- aspirin sucking) - Patients can sometimes identify an associated timeline - The most common example is aspirin - Other medicines causing ulcers Methotrexate several ulcers present at one time Nicorandil single large, deep ulcers ### Malignant Ulceration - Range of neoplasms present with oral ulcers Very deep ulcers with an injurated edge - Vast majority are **oral squamous cell carcinomas** - Rare causes include - Haematological malignancies (mainly lymphoma) - Salivary gland neoplasms - Sarcoma (rare) - Metastatic disease (lymph nodes or bone, rarely gingival)  Recurrent Single Ulcer ---------------------- Similar to the causes of persistent single ulcers with the exception of the oral malignancy because trauma from a denture, you can have multiple ulcers occurring at the site, if the denture is taken out, the ulcer can heal and then the denture can be put back in again. Likewise in ortho, the ulcers can come and go and it would be unusual for there to be repeated episodes of non-accidental injury-caused ulcers in the mouth as its likely that non-accidental injury is going to happen in the same place on the face, causing an ulcer inside the mouth Mechanical - Sharp tooth or restoration - Appliances - Non accidental injury - Self inflicted eg: toothbrush (v common) - Iatrogenic (should not really happen on multiple occasions to be recurrent) Thermal Hot / cold (if they eat certain things on a recurrent basis) Chemical Aspirin (unlikely that they would have multiple sites of this) Radiation (if radiation therapy was carried out on multiple sites) Electric Infective - - Persistent multiple ulcers -------------------------- Unlikely to be malignant, more likely to be and are more likely to be related to an underlying systemic problem as they keep recurring - Typically secondary to underlying systemic disease - Secondary to Dermatological - Lichen planus - Can have periods where its ulcerated and non-ulcerated) - Immunobullous (Pemphigus & Pemphigoid ulcers don't really heal between these episodes) - Secondary to Gastrointestinal - Inflammatory bowel disease (Crohn's & Ulcerative Colitis) - Secondary to Haematological disorders - Anaemia - (Haematological) Malignancy - Secondary to Connective tissue disease - Lupus, especially if they are undergoing a lupus flare - Patients can often use their mouth to gain an understanding of whether their lupus is stable/quiescent or having a flare as their mouth becomes very sensitive during a flare and their ulcers break out and joints become painful - Secondary to Drugs - Methatrexate e.g.  --------------------- Oral ulceration secondary to dermatological condition ----------------------------------------------------- - Lichen planus (most common) - Mucous membrane pemphigoid / Bullous pemphigoid - Linear Ig A disease / Dermatitis herpetiformis - Pemphigus - Erythema multiforme - Epidermolysis Bullosa Top = lichen planus, Middle = MMP / BP, Bottom = Pemphigus ### ### Lichen planus - Lichen planus is a chronic mucocutaneous disease of unknown aetiology - Considered an autoimmune, cell-mediated immunological reaction within affected tissues with unknown trigger - Estimated prevalence of **0.5-2%** with f:m **2:1** and typically onset **30-60 years old** - Range of classic clinical appearance with a characteristic histopathology - Areas of white patches (key feature) - Ulcers (in this is deep in the buccal sulcus) Close-up of teeth Description automatically generated  ### Plaque-like & Ulcerative Picture on the RHS is an ulcerated lichen planus case Top Left = plaque-like lichen planus without ulceration ### Oral lichenoid lesions - Subtle clinical and histopathological differences between lichenoid lesions & lichen planus - Associated with numerous medications (see lichen planus lecture) as well as dental materials (amalgams) Close-up of a person\'s mouth Description automatically generated Often ulceration associated with a unilateral patch Secodary to Gastrointestinal enteropathy ---------------------------------------- **Inflammatory bowel disease** - Crohn's disease - Ulcerative Colitis **Warning signs/symptoms in history** - change in bowel habit - dyspepsia (indigestion) - rectal bleeds/occult blood when they open their bowels A close up of a face Description automatically generated Folded tissues with ulcers in the buccal sulcus, oedema in the submandibular papillae  Parse (?) dermatitis - more classic of UC is when patient's have very active gut disease Oral ulceration secondary to haematological disease --------------------------------------------------- **Haematinic deficiency** Cyclical Neutropenia their oral ulcers are very recurrent and troublesome as it is v difficult to manage their cyclical lowering of their neutrophils, which is what is contributing to their persistence of their ulcers Leukaemia Other deficiencies Close up of a person\'s tongue Description automatically generatedClose up of teeth Description automatically generated 1\) Low iron -- can't always see the change in tongue clinically 2\) Excellent oral hygiene but the gingivae were red and swollen & spontaneous bleeding -- chronic myeloid leukaemia (CML) 3\) Vitamin C deficient patient - has haemorrhagic gingivae, along with his very poor oral hygiene. The spontaneous bleeding of the gingivae is not just oral hygiene but because of this vitamin deficiency 4\) Hypertrophic gingivae and ulceration -- pt needs to be investigated 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 Does not have the acute flares and rumbles on indulently. Pt often have less pruritic skin lesions but in the mouth they have atrophic or ulcerated lesions, which look like lichen planus but often the centre is ulcerated. It is easier to differentiate from lichen planus clinically as the distribution is not typical to lichen planus and the site is often on the palate, which is uncommon for oral lichen planus THUS a combination of the medical history and the clinical appearance gives you the suggestion that it might not be simple lichen planus but could be associated with discoid lupus Recurrent multiple ulcers ------------------------- Recurrent oral ulcers (ROU) - **Recurrent aphthous stomatitis** (RAS) - Minor - Major - Herpetiform A close up of a person\'s mouth Description automatically generated Minor Major Herpetiform is when there are multiple types of ulcers - Ulcers related to smoking cessation - Behçet's disease (beshet's disease) - Oral & genital ulcers - PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) - Most common in the Mediterranean - More common in young adolescents - They have episodes where they feel very unwell, have a sore throat, multiple mouth ulcers, a fever and its episodic - Recurrent erythema multiforme (bottom pic) - Very irregular, shallow ulcers - It is recurrent - The red patches are of a variety of shaped - Idiopathic - Don't know what causes them Major Roles for the GDP ----------------------- - Identify those ulcers which require treating and those that require referring - Screen for Malignant and Potentially Malignant Disease - Oral Squamous Cell Carcinoma - **Early detection**: Improves survival rates & reduces the need for radical surgery - Establish provisional diagnosis - Decision to treat, not treat or refer (all potential malignancies reffered viva 2 week wait pathway) - Prescription of correct drugs/therapies Note: Oral cancers come into the category of single persistent ulcers if the ulcer comes and goes its not likely to be an oral cancer