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 stomatitisHerpes labialisHerpes zoster and chickenpoxHand-foot-and-mouth disease

Infective

Cytomegalovirus-associated ulcerationSome acute specific feversTuberculosisSyphilis

Non-infective

Pemphigus vulgarisMucous membrane pemphigoidLinear IgA diseaseDermatitis herpetiformisBullous erythema multiforme

Non-infective

TraumaticAphthous stomatitisBehçet’s diseaseHIV-associated mucosal ulcersLichen planusLupus erythematosusChronic ulcerative stomatitisEosinophilic ulcerationWegener’s granulomatosisSome mucosal drug reactionsCarcinoma

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 1

trauma by the teeth and prosthesis or foods; (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

streptococci or L-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 2

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

secondary to malabsorption. An association with celiac disease (sometimes

asymptomatic) has been found in approximately 5% of patients with aphthae,

but a secondary haematinic 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 worsen in 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.

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8- Stress: Some patients relate exacerbations of ulceration 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 recognized feature 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, almost exclusively, 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 or effect. However, in a minority of patients there is a clear association

with hematological deficiencies. The latter in turn may be secondary to small-

intestine disease or other 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 featuresThe 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 affected than 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.

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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 managementThe 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

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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.

Topical salicylate 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

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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 effects and is strongly teratogenic, and like other drugs

mentioned, can only be given under specialist supervision.

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