oral.-Oral ulceration

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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

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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

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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.

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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.

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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 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

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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.
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

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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 effectsand is strongly teratogenic,and like other drugs
mentioned, can only be given under specialist supervision.