Oral Ulcers Week 7 Curtin PDF

Oral Ulcers Dr Amanda Phoon Nguyen Does your patient really understand what you are saying? 40% percent of patients asked in this study did not know what “impacted tooth” meant. Many answers confused it with blunt force trauma, toothache, infection of gum or tooth, infected socket, procedure to a...

Oral Ulcers Dr Amanda Phoon Nguyen Does your patient really understand what you are saying? 40% percent of patients asked in this study did not know what “impacted tooth” meant. Many answers confused it with blunt force trauma, toothache, infection of gum or tooth, infected socket, procedure to a tooth, overcrowding and pushing a tooth back into the gum. In this study, questionnaires were offered to all patients in a UK centre over a two-week period. Exclusion criteria were non-English speakers who required a translator. Eighteen terms were assessed, including: ulcer, local anaesthetic, impacted tooth, radiograph, sedation, biopsy, mucosa and benign. A total of 137 questionnaires were completed. ~ only 56% selected the correct definition of 'ulcer' ~40% did not know what “impacted tooth” meant ~53% did not know what “mucosa” meant ~ 36.5% were incorrect in selecting what “sedation” meant “Commonly used terminology in oral surgery and oral medicine: the patient's perspective” Hamilton, A., Lamey, P., Ulhaq, A. et al. Commonly used terminology in oral surgery and oral medicine: the patient's perspective. Br Dent J 230, 823– 830 (2021). https://doi.org/10.1038/s41415-021-3073-1 know the def Normal  Traumatic Immune mediated Text Traumatic Squamous cell carinoma Text know the types of ulcers  An Approach to Oral Ulceration FLOWCHART What is an oral ulcer and what is the process by which it forms? *Not exhaustive  1. Immunocompromised Patient? Text Medication Transplants Chemotherapy T2DM- well controlled? 2. Has the patient been unwell? Malaise Fever Why 2 weeks? dont need to know list just know what is acute, aphous and viral Most common Traumatic  Acute Traumatic Ulceration Trauma (source) Typically solitary Harder to determine cause in kids Mucosal turnover- should not persist beyond 2 week if trauma source removed Chronic Traumatic (TUG/TUGSE) Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE) TUGSE/SCC? Solitary, painful or painless, firm/indurated to palpate  Drug Related Salivary Gland Hypofunction Most cited in the literature are oxybutynin (21 papers), tolterodine (19), duloxetine (19), quetiapine (14), bupropion (12), olanzapine Text (11), solifenacin (11), clozapine (9), fluoxetine (9), and venlafaxine (8). these medication cause drymouth reconise these on left  Riga Fede this is same as tuggsy but in children only Photo shared with permission RAS Multiple (x3) Anterior tip of tongue (dorsal and ventral) Yellow-grey Round Erythematous border Well-defined 2-3mm in diameter Recurrent Apthous Stomatitis commen in children often run in families Multiple recurrent, round or ovoid ulcers with circumscribed margins erythematous haloes, and yellow or grey floors. Non-keratinized and mobile mucosa  Common! Typically start in childhood. Family history They tend to improve with age. There is a slight female predisposition to RAS. RAS occurs worldwide though it appears to be most common in the developed world. High SES If RAS is due to an underlying condition…. Does it look different clinically? Usually not! https://escholarship.org/content/qt81f3k4dj/inner/2.jpg Behçet disease PFAPA  Systemic Involvement? 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. HIV  know this *Severe- Continuous Lips, cheeks and tongue +Palate and pharynx + Gingiva and FOM  Management Other things that can cause RAS One to two outbreaks a year- OTC Sublingual Vit B12? Intralesional CS Colchicine- more effective in Behcet’s Scully 2013 Pentoxifylline, dapsone, azathioprine Curasept MW or gel Allergy! Viral Can we really tell the common viruses apart? Patient details History Evolution Systemic signs Herpes Simplex Virus know diff between HSV !?2 HSV1 HSV2 Oral and pharnygeal Genital infection Meningoencephalitis Anal Dermatitis (Above the waist) Both types! Common! 16.2% of Americans aged between 14 and 49 years had HSV antibodies. Women (20.9%) compared with men (11.5%). HSV-1: Peak between 2 and 3 years of age. Occasional cases reported in patients older than 60 years. HSV-2: Puberty. Balasubramaniam et al (2014) Can be difficult to distinguish from other upper respiratory viral infections Preceded or accompanied by systemic symptoms, which may include fever, headache, malaise, nausea, vomiting, and accompanying lymphadenopathy Vesicles and ulcers appear on the oral mucosa and generalized acute marginal gingivitis occurs 1 to 2 days after the prodromal symptoms appear Self limiting. Supportive therapy Secondary HSV-1 Paraesthesia, erythema, vesiculation, pustule formation, superficial ulceration, and eventual spontaneous healing. 5–7 days Recurrent HSV has been known to trigger episodes of erythema multiforme (EM). Balasubramaniam et al (2014) Herpes Zoster just know can mimic toothache 59y F. P2P. Medical history was significant for follicular lymphoma. Severe right facial pain. She developed pain involving her right maxillary dentition, and soon had severe tenderness along her right temple, cheek and under her eye. This evolved into paraesthesia, with unilateral vesicles appearing 3 to 5 days later, with erythema, pain and tearing of her eye. There was no facial palsy. She was eventually hospitalized and this was her 6 months later. Now on long time acyclovir. Diagnosis: Herpes zoster About 75% of cases affect people over 50 years. Oral manifestations include ulcerations and a unilateral, severe pain and/or paraesthesia which occurs before, during or sometimes after the rash. Misdiagnosis of a toothache is possible if the patient is seen before the rash occurs. Cytotoxic drugs, immunosuppression, internal malignancies, and aging are among the risk factors for viral reactivation. -Involvement of bilateral or multiple dermatomes is uncommon and should raise concerns about immunosuppression. Immune Mediated Drug Related Antihypertensives Antidiabetics NSAIDS Methotrexate Allopurinol Amphotericin B Suspected Methotrexate related oral ulceration Mucositis (Chemoradiation) Direct Damage This Photo by Unknown Author is licensed under CC BY-SA Symplepharon Red Flags  Indurated Persistent This Photo by Unknown Author is licensed under CC BY  Take Home Points Oral ulcers can be difficult! Might not always have an answer 2 week rule Subtle pathology is still pathology