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Oral Mucosal Ulceration - a Clinician’S Guide to Diagnosis and Treatment

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Oral Mucosal Ulceration - a Clinician’S Guide to Diagnosis and Treatment 500 > COMMUNICATION Oral mucosal ulceration - a clinician’s guide to diagnosis and treatment SADJ November 2016, Vol 71 no 10 p500 - p508 J Fourie,1 SC Boy2 ABSTRACT Oral mucosal ulceration is a common clinical complaint. ACRONYMS Ulceration is often debilitating and affects patients from a ACE: angtiotensin-converting enzyme inhibitors wide age group. The clinician confronted with such a pa- EM: Erythema Multiforme tient often feels overwhelmed by the different diagnostic HS: Herpes Simplex Virus possibilities. Given the wide spectrum of conditions en- SLE/DLE: Lupus Erythematosus countered, it is striking that the common use of antibiotics MMP: Mucous Membrane Pemphigoid and antifungals to treat oral ulceration, is largely inappro- NUG: Necrotising Ulcerative Gingivitis priate. This overview provides general dental practitioners NSAIDs: Nonsteroidal Anti-Inflammatory Drugs (GDP’s) and other general healthcare workers with a broad NUG: Necrotising Ulcerative Gingivitis classification of commonly encountered mucosal ulcera- OLP: Oral Lichen Planus tive lesions, a practical approach to reach a diagnosis and OLCL: Oral Lichenoid Contact Lesion basic treatment strategies for each condition. OLDR: Oral Lichenoid Drug Reaction OSCC: Oral squamous cell carcinoma Keywords: Oral, ulceration, vesicle, immune mediated, PV: Pemphigus Vulgaris treatment TB: Tuberculosis RAS: Recurrent Apthous Stomatitis Oral mucosal ulceration is a common clinical complaint HHV-3: Varicella Zoster Virus encountered by medical and oral health care providers. Ulceration involves a breach in the epithelial covering (Fig- ure 1) of mucosa exposing the underlying lamina propria The oral mucosa is biologically subdivided into keratinised while erosions represent an incomplete breach of the epi- (gingiva and palate), non-keratinised (lips, cheeks and ven- thelial covering and appears as erythematous patches. tral tongue) and specialised due to the function of taste (dor- Lesions are often debilitating, hampering nutrition and af- sum of the tongue). As a result of its relation to the underly- fecting quality of life. The clinician confronted with such ing alveolar bone it may also be divided into masticatory a patient often feels overwhelmed, resulting in a kind of (bone-bound) and non-masticatory. Certain ulcerative con- shotgun treatment approach that favours the inappropri- ditions affect the keratinised mucosa preferentially whilst ate use of antibiotics. The aim of this review is to provide others are found almost exclusively on non-keratinised the general dentist with a workable classification of more mucosa. The exact location of ulcers is therefore crucial commonly encountered mucosal ulcerative lesions with information to assist with the correct diagnosis. basic treatment strategies for each. Classification of oral mucosal ulceration may be accord- ing to the (i) clinical features, (ii) microscopic features or (iii) 1. J Fourie: BChD, DipOdont (Perio), DipOdont (Rest), MScOdont pathogenesis (traumatic, metabolic, dermatological, aller- (Rest), MChD (Oral Medicine and Periodontics). Department of Periodontics and Oral Medicine. Sefako Makgatho Health Sciences gic, immunological, infectious, and neoplastic) but classifi- University. cation according to (iv) the clinical presence or absence of 2. Sonya C Boy: BChD, MChD (Oral Path), PhD, FCPath(SA) (Oral preceding fluid-filled vesicles/ bullae will form the basis for Path), Department of Oral Pathology, Sefako Makgatho Health the discussion in this review (Figure 2). Secondary infor- Sciences University. mation such as systemic signs and symptoms, location, Corresponding author duration and number (single or multiple) of ulcerations are J Fourie: supplied for each condition to guide the clinician to a more Department of Periodontics and Oral Medicine. Sefako Makgatho focused differential diagnosis. Vesicles (depending on the Health Sciences University. Po Box 230, Irene 0062. Cell: 082 460 8368. E-mail: [email protected] size are also termed bleb, bulla or blister) are the clinical manifestation of separation of either epithelial cell layers www.sada.co.za / SADJ Vol 71 No. 10 COMMUNICATION < 501 The potency of the topical steroid, frequency and vehicle of application should be tailored to each individual case and response to treatment. Generally, widely distributed ulceration may be more effectively treated with a corticosteroid rinse, single lesions with the local application of an ointment, and oropharyngeal lesions with a steroid inhaler. Ointments are not adhesive to the oral mucosa but may be combined with either orabase1 or denture adhesives.2 Topical corticosteroids are considered in the following clinical settings: (i) as short course to speed up recovery e.g. recurrent aphtous stomatitis (RAS), erythema multiforme and drug induced ulceration; (ii) sporadic use in conditions with chronic, often cyclical clinical course i.e. oral lichen planus (OLP), severe RAS and mucous membrane pemphigoid (MMP); (iii) maintenance therapy following a short course of systemic corticosteroids i.e. severe OLP; (iv) concurrently with systemic immunosuppressive therapy Figure 1: Ulceration of the ventro-lateral border of the tongue situated in the to reduce the dosages thereof i.e. pemphigus vulgaris.3 unkeratinised mucosa, with breach of the entire thickness of the epithelium to expose the underlying connective tissue. ULCERS PRECEDED BY VESICLES from each other or from the underlying lamina propria that (VESICULO-ULCERATIVE LESIONS) subsequently become filled with fluid. The final diagnosis of oral mucosal ulcerations is usually dependent on perform- Patients may present with or without intact vesicles preceding ing a biopsy and submitting the tissue to a pathologist for the ulcers. Vesicles are often lost due to functional oral activity, histological diagnosis. Special investigations in the form of remaining only in protected areas of the mouth or in diseases stains and immunofluorescence are often necessary and the with thick-roofed sub-epithelial vesicles i.e. MMP. Irrespective, pathologist will employ these as necessary. Table 1: Examples of corticosteroids that may be used topically. Topical corticosteroids in the management Potency Corticosteroid Application Example of oral ulcerative conditions Weak Hydrocortisone Locally Dilucort ointment 0.5% The anti-inflammatory and immunosuppressive Prelone syrup Moderate Prednisolone Rinse properties of corticosteroids render them ideal for 15mg/5ml the management of especially immune mediated Potent Fluocinolone Locally Synalar gel 0.025% oral ulcerative conditions. Side effects of systemic acetonide corticosteroids make them less favourable as pri- Betanoid solution Betamethasone Rinse mary treatment options and topical steroids are 0.6mg/5ml often good alternatives. Kenalog in Orabase® (tri- amcinolone acetonide 0.1%) was often the agent Beclometasone Inhaler Beclate aerosol 50 mcg Clobetasol of choice but since its discontinuation alternatives Very potent Locally Dovate ointment have to be considered (Table 1). 0.05% ointment Oral mucosal ulceration Preceded by vesicles No vesicles Infections Immunological Infections Immunological Trauma Neoplasia Bacterial Primary and Viral (Human Pemphigus (Syphillis, TB RAS metastatic Herpes Viruses) vulgaris and NUG) malignancies Mucous Fungal membrane (Aspergillus and OLP Mucositis pemphigoid Mucor) Erythema Allergic reactions multiforme Lupus erythematosus Figure 2: Algorithm depicting the basic distinction of ulceration based on the presence or absence of preceding vesicles 502 > COMMUNICATION patients frequently provide a history of “blisters” preceding divided into 5 doses for adults for 5 days instituted within the ulcerations or previous episodes of ulcerations and that, 24 hours of onset of the rash may reduce duration of the together with the specific mucosal region affected provide lesions.11 Herpes zoster (shingles) signifies recurrent HHV- mandatory information to formulate a correct diagnosis. 3 infection, mostly affecting old and debilitated patients, Generally, lesions in this category that presents with an and follows the dermatome of the ganglion in which the acute onset are likely of viral origin, while lesions with a virus established latency. Severe burning or stinging pain chronic or relapsing course more likely immune mediated. to the affected dermatome is followed by fluid filled vesicles that rupture to leave painful shallow ulcerations that may I Infections: Vesiculo-ulcerative lesions of viral origin coalesce to form large denuded areas. Oral manifestations Preceding systemic signs and symptoms are typically signify involvement of the mandibular or maxillary divisions present. of the trigeminal nerve with pathognomonic abrupt termination of lesions along the midline. Osteonecrosis with Herpes Simplex Virus (HSV) tooth exfoliation has been reported, especially in immune The most common to affect the oral mucosa, primary deficient individuals.12,13 Post-herpetic neuralgia is defined as HSV-1 infection mostly affects children presenting either persistence or recurrence of pain more than a month after as asymptomatic infection or with mucosal vesicles fol- onset of shingles and is seen with increased frequency in lowed by painful ulceration affecting both keratinised and old patients with facial infection. Administration of antiviral non-keratinised mucosa. Adults with primary infection suf- drugs within 72 hours of onset of the rash14 is recommended fer symptomatic herpetic pharyngotonsillitis
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