Oral Medicine: 1. Ulcers: Aphthous and Other Common Ulcers
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OralMedicine-UpdatefortheDentalTeam This series provides an overview of current thinking in the more relevant areas of Oral Medicine, for primary care practitioners. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders. Approaching the subject mainly by the symptomatic approach, as it largely relates to the presenting complaint, was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made, along with guidance on management David H Felix Jane Luker Crispian Scully and when to refer, in addition to relevant websites which offer further detail. Oral Medicine: 1. Ulcers: Aphthous and other Common Ulcers and complain of soreness in relation to oral Specialist referral may be indicated if the ulceration. It is always important to exclude Practitioner feels: serious disorders such as oral cancer (Article The diagnosis is unclear; 3) or other serious disease, but not all patients A serious diagnosis is possible; who complain of soreness have discernible Systemic disease may be present; organic disease. Even in those with detectable Unclear as to investigations indicated; lesions, the level of complaint can vary Complex investigations unavailable in enormously – some patients with large ulcers primary care are indicated; complain little; others with minimal ulceration Unclear as to treatment indicated; complain bitterly of discomfort. Sometimes Treatment is complex; there is a psychogenic or cultural influence. Figure 1. A small erosion. Treatment requires agents not readily available; Unclear as to the prognosis; Terminology The patient wishes this. Epithelial thinning or breaches may be seen in: Mucosal atrophy or desquamation – terms often used for thinning of the epithelium 1. Ulceration which assumes a red appearance since the underlying lamina propria containing blood Ulceration is a breach in the oral vessels shows through. Most commonly epithelium, which typically exposes nerve seen in desquamative gingivitis (usually endings in the underlying lamina propria, Figure 2. Minor aphthous ulcer, labial mucosa. related to lichen planus, or less commonly resulting in pain or soreness, especially on to pemphigoid) and in geographic tongue eating spicy foods or citrus fruits. Patients vary (erythema migrans, benign migratory enormously in the degree to which they suffer glossitis), a similar process may also be seen in systemic disorders such as deficiency states (of propria. An inflammatory halo, if present, also iron, folic acid or B vitamins). highlights the ulcer with a red halo, around the Mucosal inflammation (mucositis, stomatitis) yellow or grey ulcer (Figure 2). Most ulcers are David H Felix, BDS, MB ChB, FDS can cause soreness. Viral stomatitis, candidosis, due to local causes such as trauma or burns RCS(Eng), FDS RCPS(Glasg), FDS RCS(Ed), radiation mucositis, chemotherapy-related but recurrent aphthous stomatitis must always FRCP(Edin), Postgraduate Dental Dean, mucositis and graft-versus-host-disease are be considered. NHS Education for Scotland, Jane Luker, examples. BDS, PhD, FDS RCS , DDR RCR, Consultant Erosion is the term used for superficial Causes of oral ulceration and Senior Lecturer, University Hospitals breaches of the epithelium. These often Ulcers and erosions can also be Bristol NHS Foundation Trust, Bristol, initially have a red appearance, since there the final common manifestation of a spectrum Professor Crispian Scully, CBE, MD, PhD, is little damage to the underlying lamina of conditions, ranging from epithelial damage MDS, MRCS, BSc, FDS RCS, FDS RCPS, propria, but it typically becomes covered by resulting from trauma, to an immunological FFD RCSI, FDS RCSE, FRCPath, FMedSci, a fibrinous exudate and then has a yellowish attack as in lichen planus, pemphigoid or FHEA, FUCL, DSc, DChD, DMed(HC), Dr appearance (Figure 1). Erosions are common in pemphigus, to damage because of an immune HC, Emeritus Professor, University College vesiculobullous disorders such as pemphigoid. defect, as in HIV disease and leukaemia, London, Hon Consultant UCLH and HCA, Ulcer is the term used usually where there infections as in herpesviruses, tuberculosis London, UK. is damage both to epithelium and lamina and syphilis, or nutritional defects such as in September 2012 DentalUpdate 513 OralMedicine-UpdatefortheDentalTeam Causes Mnemonic Systemic diseases So Malignant disease Many Local causes Laws Aphthae And Drugs Directives Table 1. Main causes of oral ulceration. Systemic disease Malignant neoplasms Blood (Haematological) disorders Oral Anaemia Encroaching from antrum Gammopathies Haematinic deficiencies Local causes Leukaemia and myelodysplastic Trauma Figure 3. Thermal burn, palate. syndrome Appliances Neutropenia and other white cell Iatrogenic dyscrasias Non-accidental injury Infections Self-inflicted Acute necrotizing gingivitis Sharp teeth or Chickenpox restorations Deep mycoses Burns Hand, foot and mouth disease Chemical Herpangina Cold Herpes simplex virus Electric HIV Heat Infectious mononucleosis Radiation Syphilis Aphthae Tuberculosis Drugs Gastrointestinal disease Cytotoxic drugs Coeliac disease Nicorandil Figure 4. Chemical burn, right maxillary tuberosity. Crohn disease NSAIDs Ulcerative colitis Miscellaneous uncommon diseases Skin (Mucocutaneous) disease Eosinophilic ulcer Behcet syndrome Giant cell arteritis Chronic ulcerative stomatitis Hypereosinophilic syndrome Epidermolysis bullosa Lupus erythematosus Erythema multiforme Necrotizing sialometaplasia Lichen planus Periarteritis nodosa Pemphigus vulgaris Reiter syndrome Sub-epithelial immune blistering Sweet syndrome diseases (pemphigoid and Wegener granulomatosis variants, dermatitis herpetiformis Figure 5. Traumatic ulceration, lateral tongue. linear IgA disease), Table 2. Main causes of mouth ulcers dental local anaesthesia. Ulceration of the upper labial fraenum, especially in a child with bruised and swollen lips, or subluxed teeth or fractured jaw can represent non- vitamin deficiencies and some gastrointestinal or ionizing radiation or factitious ulceration, accidental injury. At any age, trauma, hard disease (Tables 1 and 2). especially of the maxillary gingivae (Figures 3 foods, or appliances may also cause ulceration. Ulcers of local causes and 4). The lingual fraenum may be traumatized At any age, there may be burns Children may develop ulceration by repeated rubbing over the lower incisor from chemicals of various kinds, heat, cold, of the lower lip by accidental biting following teeth in cunnilingus or in recurrent coughing 514 DentalUpdate September 2012 OralMedicine-UpdatefortheDentalTeam as in whooping cough or in self-mutilating conditions. Most ulcers of local cause have an obvious aetiology, are acute, usually single ulcers, last less than 3 weeks and heal spontaneously. Chronic trauma may produce an ulcer with a keratotic margin (Figure 5). Recurrent aphthous stomatitis (RAS; aphthae; canker sores) Figure 6. Minor aphthous ulceration. Figure 7. Minor aphthous ulceration. RAS is a very common condition which typically starts in childhood or adolescence and presents with multiple recurrent small, round or ovoid ulcers with some oral healthcare products, may produce they may represent three different diseases. circumscribed margins, erythematous haloes, oral ulceration; and yellow or grey base (Figures 6 and 7). Cessation of smoking: may precipitate or 1. Minor aphthous ulcers (MiAU; Mikulicz Ulcer) RAS affects at least 20% of the aggravate RAS; Occur mainly in the 10–40 year age group; population, with the highest prevalence in Gastrointestinal disorders particularly coeliac Often cause minimal symptoms; higher socio-economic classes. Virtually all disease (gluten-sensitive enteropathy) and Are small round or ovoid ulcers 2–4 dentists will see patients with aphthae. Crohn’s disease in about 3% of patients; mm in diameter in most situations but Endocrine factors in some women whose often more linear when in the buccal sulcus, RAS is clearly related to the fall in progestogen Aetiopathogenesis a common site. The ulcer base is initially level in the luteal phase of their menstrual Immune mechanisms appear at yellowish but assumes a greyish hue as cycle; play in a person with a genetic predisposition healing and epithelialization proceeds. They Immune deficiency; ulcers of a similar to oral ulceration. A genetic predisposition are surrounded by an erythematous halo and appearance to RAS may be seen in HIV and is present, and there is a positive family some oedema; other immune defects, although clearly the history in about one third of patients with Are found mainly on the non-keratinized aetiopathogenesis is different; RAS. Immunological factors are also involved, mobile mucosa of the lips, cheeks, floor of the Food allergies: in some studies with T helper cells predominating in the RAS mouth, sulci or ventrum of the tongue. hypersensitivity to various food additives has lesions early on, along with some natural killer They are only uncommonly seen on the been shown to be important, although this is (NK) cells. Cytotoxic cells then appear in the keratinized mucosa of the palate or dorsum of not a universal finding. lesions