BDS10038 Oral Ulceration - Traumatic Causes PDF

BDS10038 Oral ulceration: traumatic causes Oral ulceration – traumatic causes Aims: •The aim of this lecture is to detail the clinical, diagnostic and therapeutic aspects of oral mucosal ulceration due to trauma Objectives: On completion of this lecture, the student should be able to: •Understand...

BDS10038 Oral ulceration: traumatic causes Oral ulceration – traumatic causes Aims: •The aim of this lecture is to detail the clinical, diagnostic and therapeutic aspects of oral mucosal ulceration due to trauma Objectives: On completion of this lecture, the student should be able to: •Understand the spectrum of causes of traumatic oral mucosal ulceration •Understand the management of physical traumatic ulceration of the mouth •Have an awareness of the management of traumatic oral ulceration of non-physical cause Classification of Oral Ulceration 1) Trauma Typically physical; Radiotherapy and chemotherapy-associated disease more common than before; chemical is uncommon. 2) Infection Typically viral (HSV, VZV; T. pallidum; short term, well defined features) 3) Immunologically-mediated Typically autoimmune; also autoinflammatory (e.g. Behcet’s; FPAPA) Can be a feature of vasculitic or granulomatous disease 4) Haematological/gastroenterological reflects an anaemia or neutropenia 5) Malignancy Typically OSCC (but many others can occur) 6) Iatrogenic Mechanisms of above 7) Recurrent aphthous stomatitis Probably the most common of all causes of mouth ulcers 8) Others Connective tissue disease (e.g. epidermolysis bullosa; Ehler Danlos syndrome etc) Trends relevant to oral ulceration 1. Changing patterns of infectious disease. 2. Lifestyle influences oral disease (e.g. trauma can be a reflection of psychological upset, recreational drug use etc) 3. Lifespan is increasing. 4. Oral malignancy remains a significant problem. 5. Widening spectrum of iatrogenic disease. 6. Effective treatment remains challenging. 7. Easy access patient information is lacking. Traumatic oral ulceration Pathogenic mechanisms (Causes): 1.Physical: sharp objects in the mouth, habits. 2.Chemical: accidental, deliberate self harm. 3.Thermal. 4.Radiotherapy-associated (becoming less common). 5.Chemotherapy-associated (direct loss of epithelial turn over). 6.Electrical – very rare. 1) Oral ulceration due to physical trauma A) Typically due to: 1. Fractured restorations or teeth. 2. Orthodontic appliances. 3. Ill-fitting dentures especially when recently placed or when there is a loss of retention. 4. Physical injuries (e.g. sports and/or violence). 5. Children falling while having a toy/pencil in the mouth (can cause palatal stripping). • The ulceration: 1. Is solitary and/or adjacent to a likely cause. 2. A cause that becomes evident when the patient is asked whether they are chewing an area. 3. Does not have the features of malignancy. Fractured teeth Physical injuries Orthodontic braces Sharp teeth B) Less commonly due to: • Parafunctional habits e.g.: 1. Cheek biting 2. Lip-dragging 3. Tongue chewing • These may arise in patients with other orofacial symptoms such as Temporomandibular Disorder • The ulceration is: 1. Often affecting a wide area of one part of the mouth 2. May be accompanied by some hyperkeratosis. 3. Does not have the features of malignancy (i.e. destruction or speckling) C) Very uncommonly (Rare causes ) 1. Repeated trauma to the oral mucosa by nail picking: • This may arise in children or adults. • Presents as solitary areas of ulceration without obvious cause. • Patients may deny any habit although partners/parents/guardians may report that they have observed repeated picking at the mouth. • Overzealous tooth brushing can cause superficial ulceration of the gingivae that can take on the appearance of “clean” ANUG. 2. Exfoliative chielitis: • Presents as areas of dry, thickened, exfoliating epithelium of the labial mucosae and/or skin. • Can affect one or both lips. • Patients usually complain of the appearance rather than any pain. • There is often a denial of any lip-picking habit. 3. Unintentional self-mutilation due to systemic disease: • Congenital disease Lesch-Nyhan syndrome, familial dysautonomia. • Tardive dyskinesia (e.g. side effect with some anti-psychotic drugs). Exfoliative chielitis Clean ANUG Unintentional self-mutilation Tardive dyskinesia 2) Oral ulceration due to chemical trauma • This is uncommon • Reported causes: 1. Aspirin being placed at the site of oral pain. 2. Cocaine placed on the gingivae. 3. Inadvertent drinking of acids/alkalis 4. Deliberate drinking of acids/alkalis (deliberate self-harm) • The ulceration: 1. Is usually superficial but painful. 2. A cause becomes evident when the patient is asked questions like “Have you placed anything on this site?” 3. Does not have the features of malignancy 3) Oral ulceration due to thermal trauma • This is uncommon • Reported causes: 1. Very hot foods placed in the mouth inadvertently. 2. Most likely with hot adherent foods (e.g. cheese in a pizza “Pizza Burn”). 3. Uncommon with drinks. • The ulceration: 1. Is usually superficial but painful. 2. A cause becomes evident as the patient will usually state that they ate something very hot and sticky! 3. Does not have the features of malignancy. 4) Oral ulceration due to local radiotherapy (radiation mucositis) • This is becoming less common as there is an increasing use of Intensity Modulated Radiotherapy (IMRT). • Arises within days of commencement of radiotherapy that passes across any part of the oral mucosa. • The ulceration: 1. There is initial erythema, followed by sloughing and eventual diffuse superficial ulceration. 2. The affected area exactly accords with the site of radiotherapy. 3. Does not have the features of malignancy. 5) Oral ulceration due to chemotherapy •This only arises with certain chemotherapeutic agents (e.g. cyclophosphamide, methotrexate) •Arises within a few days of commencement of the chemotherapy •The ulceration: 1. There is initial erythema, followed by sloughing and eventual diffuse superficial ulceration. 2. Ulceration is widespread affecting all surfaces. 3. With repeated dosages there may be petechiae due to a drug-induced thrombocytopenia. 4. Does not have the features of malignancy. 6) Oral ulceration due to electrical causes • This is probably historical. • Supposedly reflects an electrical potential being created by adjacent restorations of different metals. • The ulceration: 1. There may be superficial ulceration of any adjacent mucosa or gingivae. 2. Does not have the features of malignancy. Management of traumatic oral ulceration 1) Physical: 1. Resolve the local cause. 2. Local covering with carboxymethyl cellulose paste. 3. Symptomatic relief with benzydamine HCl spray/mouthwash or lignocaine gel 4. For habits that may reflect “distress” referral to an appropriate specialist should be considered – it is advisable not to engage in any detailed discussion of possible causes of distress. 2) Chemical: 1. Remove any local cause. 2. Symptomatic relief with benzydamine HCl spray/mouthwash or lignocaine gel. 3. Referral to an appropriate service for support regarding any recreational drug use issue or deliberate self-harm behaviour. 3) Thermal 1. Symptomatic relief with benzydamine HCl spray/mouthwash or lignocaine gel 2. Remind the patient to be careful of the temperature of foods. 4) Radiotherapy: • Remains challenging. • Local covering with carboxymethyl cellulose paste is of little value. • Symptomatic relief with benzydamine HCl spray/mouthwash or lignocaine gel – but this rarely controls the severe pain • There may be a need for opioid analgesia. • Ice cubes being held in the mouth has been found to be of some benefit 5) Chemical: • As radiotherapy. • Keratinocyte Growth Factor (KGF) given subcutaneously is a known, but expensive therapy. Diagnostic clues to traumatic ulceration I. History: 1-History of CC: The patient may report a likely cause/event e.g. fractured tooth/restoration 2-Social history: There may an aspect of the social history that is relevant – e.g. “worry”, recreational drug use, deliberate self-harm 3-Medical history: The patient may have undergone a dental or medical procedure or have commenced new drug therapy. II. Clinical features: • Extra-oral - lymphadenopathy or facial swelling is unlikely • Intra-oral – physical causes tend to give rise to solitary ulcers; drug-induced ulceration may be more widespread. Traumatic oral ulceration– key points • Physical trauma to the mouth commonly causes ulceration. • It is usually short-term and has an identifiable cause. • Physical trauma to the oral mucosa may rarely have a complex underlying cause that warrants investigation by other specialities. • Chemical and thermal ulceration of the oral mucosa is rare and usually heals without long-lasting sequelae such as scarring. • Radiotherapy and chemotherapy-induced oral ulceration remain challenging to prevent and manage. Reading material Students are advised to review any relevant teaching provided in the first year. In addition they are advised to read relevant sections of the following texts: 1. 2. 3. Scully C. Oral and Maxillofacial Medicine Churchill Livingstone 2008 pp 131-133 Felix D, Luker J, Scully C. Oral Medicine Dental Update Books 2015 pp 1-3 Odell EW Cawson’s Essentials of Oral Pathology and Oral Medicine 9th edition Elsevier 2017 pp 255-256 Oral ulceration – traumatic causes Aims: •The aim of this lecture is to detail the clinical, diagnostic and therapeutic aspects of oral mucosal ulceration due to trauma Objectives: On completion of this lecture, the student should be able to: •Understand the spectrum of causes of traumatic oral mucosal ulceration •Understand the management of physical traumatic ulceration of the mouth •Have an awareness of the management of traumatic oral ulceration of non-physical cause