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K-oral.-Oral ulceration
- 1. 1 ORAL MEDICINE Dr. Ali Al-Ibrahemy ORAL ULCERATION The oral or mucosal ulcerations are a break in epithelial continuity which frequently a feature of stomatitis. Important causes of oral ulcerations are summarized in the table illustrated below, however the oral ulceration is not a feature of all mucosal diseases in the oral cavity. Vesiculo-bullous diseases Ulcerations without preceding vesiculation Infective Primary herpetic stomatitis Herpes labialis Herpes zoster and chickenpox Hand-foot-and-mouth disease Infective Cytomegalovirus-associated ulceration Some acute specific fevers Tuberculosis Syphilis Non-infective Pemphigus vulgaris Mucous membrane pemphigoid Linear IgA disease Dermatitis herpetiformis Bullous erythema multiforme Non-infective Traumatic Aphthous stomatitis Behçet’s disease HIV-associated mucosal ulcers Lichen planus Lupus erythematosus Chronic ulcerative stomatitis Eosinophilic ulceration Wegener’s granulomatosis Some mucosal drug reactions Carcinoma Traumatic Ulcers Traumatic ulcers are usually caused by a denture and often seen in the buccal or lingual sulcus. They are tender, have a yellowish floor, and red margins; there is no induration. If caused by the sharp edge of broken-down tooth, they are usually on the tongue or buccal mucosa. Occasionally, a large ulcer by biting the cheek after a dental local anaesthesia. The traumatic ulcers classified according to the cause into :- (1) physical trauma, which includes thermal factors such as the hot food and drink, like pizza burn; sharp edges
- 2. 2 trauma by the teeth and prosthesis orfoods; (2) factitious ulceration or so called self-inflicted oral lesions that caused by disturbed mental state (‘a call for attention’); (3) chemical trauma, which represented by caustic dental materials, and locally application of aspirin for attempted to relieving of dental pain. Traumatic ulcers heal a few days after elimination of the cause. If they persists after 10 days without cause, a biopsy should be carried out. Recurrent Aphthous Stomatitis (Recurrent Aphthae) Recurrent aphthae constitute the most common oral mucosal disease and affect 10-25 % of the population, but many cases are mild and accepted with little complaint. Possible etiological factors for recurrent aphthae:- 1- Genetic Factors: There is some evidence for a genetic predisposition. the family history is sometime positive and the disease appears to affect identical twins more frequently than non-identical, however, this theory probably applies to a minority. In the possibly related Behçet’s disease, the evidence for a genetic predisposition is much stronger. 2- Exaggerated response to trauma: Some patients think that the ulcers result from trauma because the early symptoms create pricking of the mucosa by a toothbrush bristle. Trauma may dictate the site of ulcers in patients who already have the lesion. 3- Infections: There is no evidence that aphthae are directly due to any microbes, and there is scanty evidence that cross-reacting antigens from streptococciorL-forms play a significant role. The hypothesis that there may be defective immune-regulation caused by herpes or other viruses is unproven. 4- Immunological abnormalities: Since the etiology recurrent aphthae is unknown, there has been a superficial tendency to label them as ‘autoimmune’. A great variety of immunological abnormalities have been reported but there have been almost as many contrary findings and no convincing theory of
- 3. 3 immuno-pathogenesis takes into account the clinical features. It is also possible that the immunological abnormalities are as much a consequences of the ulcers as the cause. Evidence of an association with atopic (IgE-mediated) disease is unconfirmed. Circulating antibodies to crude extracts of fetal oral mucosa have been reported, but their titer is unrelated to the severity of disease and in many patients there are no significant changes in Ig levels. Depressed circulating helper/suppressor T lymphocyte ratios have been reported, but others have found no difference between active and remittent phases of the disease. Recurrent aphthae also lack virtually all features of typical autoimmune diseases, and they also fail to respond reliably to immunosuppressive drugs and become more severe in the immune deficiency state induced by HIV infection. 5- Gastrointestinal disease: Aphthae were previously known as ‘dyspeptic ulcers’ but are only rarely associated with gastrointestinal disease. Any association is usually because of a deficiency, particularly of vitamin B12 or folate secondaryto malabsorption. An associationwith celiac disease(sometimes asymptomatic) has been found in approximately 5% of patients with aphthae, but a secondaryhaematinic deficiency, particularly folate deficiency is probably the cause. 6- Haematological deficiencies: Deficiencies of vitamin B12 , folate, or iron have been reported in up to 20% of patients with aphthae. Such deficiencies are probably more frequent in patients whose aphthae start or worsenin middle age or later. In many patients, the deficiency is latent, the hemoglobin is within normal limits, and the main sign is micro- or macrocytosis of the red cells. In patients who thus prove to be vitamin B12 or folate deficient, treatment the deficiency may bring rapid resolution of the ulcers. 7- Hormonal factors: In a few women, aphthae are associated with the stressful phase of the menstrual cycle, but there is no strong evidence that hormonal treatment is reliable effective.
- 4. 4 8- Stress:Some patients relate exacerbations ofulceration to times of stress, and some studies have reported a correlation. However, stress is infamously difficult to quantify, and some studies have found no correlation. 9- HIV infection: Aphthae stomatitis is a recognizedfeature of HIV infection. Its frequency and severity are related to the degree of immune deficiency. 10- Non-smokers: It has long been established that recurrent aphthae are a disease, almostexclusively, of non-smokers, and this is one of the few consistent findings. Recurrent aphthae may also start when smoking is discarded. The reasons are unclear but it is believed that smoking has a systemic protective action against this disease. In brief, therefore, the etiology of recurrent aphthae is unclear. There is no evidence that they are a form of auto-immune disease in any accepted sense, and it is uncertain whether many of the reported immunological abnormalities are cause oreffect. However, in a minority of patients there is a clearassociation with hematological deficiencies. The latter in turn may be secondary to small- intestine disease orother cause of malabsorption. The theory about the cause of recurrent aphthae has continued for at least half a century, the variety of current theories and the contradictory findings, indicate how little is known. Clinical features The typical features of recurrent aphthae are the onset frequently in childhood but peak ulcers appear in adolescence or early adult life, the attacks at variable but sometimes relatively regular intervals, most patients are otherwise healthy, a few have hematological defects, most of patients are non- smokers, and usually the ulcer self-limiting eventually. Females are not significantly more frequently affectedthan males. The usual history is of painful ulcers recurring at intervals of approximately 3 to 4 weeks. Individual minor aphthae persist for 7 to 10 days then heal.
- 5. 5 Types of recurrent aphthae ulcers (clinically) Minor aphthae ulcers are most common type affects the non-keratinised mucosa such as labial and buccal mucosa, floor of the mouth, and lingual mucosa. Ulcers are shallow, rounded, 5-7 mm in diameter, with an erythematous margin and yellowish floor. One or several ulcers may be present at sometimes and heal with 7 to 10 days then heal without scarring. Major aphthae ulcer is uncommon type, frequently several centimeter in diameter, and mimic a malignant ulcer. Masticatory mucosa such as the dorsum of the tongue or occasionally the gingiva may be involved. The ulcer may persists for several months then heal with scarring. Herpetiform aphthae ulcers are uncommon type, affect the non- keratinised mucosa. The ulcers are 1-2 mm in diameter, dozens handerds may be present and may coalesce to form irregular widespread bright erythema round ulcers. Diagnosis and management The most important diagnostic feature is the history of recurrences of self- healing ulcers at fairly regular intervals that not preceded by vesiculation. Biopsy is of no value in the diagnosis except to exclude carcinoma in the case of major aphthous ulcer. The smear readily distinguish herpetiform aphthae ulcers from herpetic ulceration that caused by viral infection. Usually, increasing frequency of ulcers brings the patients to seek treatment, otherwise most patients appear well. The recurrent aphthae may related to be Behçet’s disease that consider the most important feature of this disease. Hematological investigation is particularly important in older patients. Routine blood indices are informative, and usually the most important finding is an abnormal mean corpuscular volume (MCV). If macro- or microcytosis is present, further investigation is necessary to find and remedy the cause. Treatment of vitamin
- 6. 6 B12 or folate deficiency is sometimes sufficient to control aphthae. Apart from the minority with underlying systemic disease, treatment is empirical and palliative only. Despite numerous clinical trials, no medication gives completely reliable relief. Patients should therefore be made to understand that the trouble may not be curable but can usually be alleviated and usually resolved eventually of its own accord. Corticosteroid give relief to some patients by use of Corlan pellets (hydrocortisone hemisuccinate 2.5 mg) allowed to dissolve in the mouth three times a day, and by use of corticosteroid mouth washes for several days one or two or three times a day as the opinion of oral physician. Corticosteroids are unlikely to hasten healing of existing ulcers, but probably reduce the painful inflammation. Triamcinolone dental paste (kenalog in orobase) is a corticosteroid in a vehicle which sticks to the moist mucosa. This adhesive gel form a protective layer over the ulcer to help make it comfortable. The corticosteroid is slowly released and has an anti-inflammatory action. Another alternative is the use of a corticosteroid asthma spray to deposit a potent corticosteroid over the ulcer. Topical corticosteroid used as described have no systemic effect. A 0.2% solution of Chlorhexidine has also been used as a mouth rinse for aphthae. Used three times daily after meals and held in the mouth for at least 1 minute, it has been claimed to reduce the duration and discomfort of aphthous stomatitis. Zinc sulphate or Zinc chloride solutions may also have a slight beneficial effect. Topicalsalicylate preparations have an anti-inflammatory action and also have local effects. Preparations of choline salicylate in a gel can be applied to aphthae. Other salicylate preparations like Pyralvex or Rotavex as oral lotions with brush to facilitate the application. These preparations which are available over the counter, sometimes appear to be helpful. Anginovag oral spray that
- 7. 7 contain of antiseptic, antibiotic, analgesic, and other components that helps to heal and/or relief the symptoms of ulcers. Treatment of major aphthous ulcer Major aphthae, whether or not there is underlying disease such as HIV infection, may sometimes be so painful, persistent, and resistant to conventional treatment. The effective treatments include azathioprine, cyclosporine, colchicine, and dapsone, but thalidomide is probably most reliable effective. Their use may be justified for major aphthae even in otherwise healthy persons if they are disabled by the pain and difficulty of eating. However, thalidomide can cause severe adverse effectsand is strongly teratogenic,and like other drugs mentioned, can only be given under specialist supervision.