Oral Ulceration

 Localized defect of the surface of oral mucosa, in which the covering epithelium is
destroyed, leaving an inflamed area of exposed connective tissue.
 Ulceration is the most common lesion of the oral mucosa and is a manifestation of many
local and general disorders.

Principal causes of oral ulceration:

1. lnfective
 Bacterial
 Viral
 Fungal
2. Traumatic
 Mechanical
 Chemical
 Thermal
 Factitious injury
 Radiation
 Eosinophilic ulcer (traumatic granuloma)
3. Idiopathic
 Recurrent aphthous stomatitis
o minor aphthous ulcers
o major aphthous ulcers
 Herpetiform ulcers
4. Associated with systemic disease
 Hematological diseases
 Gastrointestinal trace diseases
 Behcet's disease (syndrome)
 HIV infection
 Other diseases
5. Associated with dermatological diseases
 Lichen planus
 Chronic discoid lupus erythematosus
 Vesiculobullous diseases
6. Neoplastic
 Squamous cell carcinoma
 Other malignant neoplasms
 Traumatic Ulceration
Aetiology
 Traumatic ulcers can be due to physical (mechanical, thermal, electrical) or chemical
trauma. Common causes of mechanical trauma are sharp, broken down teeth, orthodontic
and prosthetic appliances, and numb lips or tongue being bitten after a local anaesthetic
injection.
 Aspirin placed directly on the oral mucosa, as a remedy for toothache, can cause a
chemical burn.

Clinical features
 Sore, painful to touch, and tend to have an irregular border with erythematous margins
and a yellow base.
 During the healing phase they frequently develop a keratotic halo.

Management
 Elimination of the suspected cause.
 Use of an antiseptic mouthwash (for example, 0.2 per cent chlorhexidine) or a simple
covering agent such as Orabase during the healing phase of ulceration.
 If they persist (for more than 10-14 days) then a biopsy should be carried out to exclude
squamous cell carcinoma.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease affecting
humans.
Recurrent bouts of one or several, shallow, ovoid, painful ulcers, occurring at intervals of a few
days or up to a few months.
Three clinical presentations of RAS are recognized:

1. Minor recurrent aphthous stomatitis (MiRAS)

Most common form of RAS
Clinical Features
 56 per cent of the patients are females and that the peak age of onset of the ulcers is in the
second decade.
 Small ulcers (one to five) appearing on the buccal mucosa, the labial mucosa, the floor of
the mouth, or the tongue.
 Pharynx and tonsillar fauces are rarely implicated in this form of ulceration.
 Prodromal stage: sensation described as burning or pricking for a short period before the
ulcers appear.
 Size is approximately 4 or 5 mm in diameter.
 Possible to have large minor ulcers and small major ones.
 Base is grey-yellow, often with a red and slightly raised margin.
 Painful, particularly if the tongue is involved, and may make eating or speaking difficult.
 If the lips are implicated, there may be a minor degree of oedema in the surrounding area.
 Lymph node enlargement is seen only as a response to secondary infection in severely
affected patients.
  Course of these ulcers varies from a few days to a little over 2 weeks, but usually their
duration is of the order of 10 days.
 Variable ulcer-free interval 3 to 4 weeks is most common after healing.

2. Major recurrent aphthous stomatitis (MjRAS)

Clinical Features
 Ulcers are generally larger than those of MiRAS and they are of greater duration, up to a
period of months in some cases.
 Ulcers are painful, and eating may become extremely difficult and the general health of
the patient may suffer as a consequence.
 On eventual healing, the ulcers may leave a substantial scar.
 May produce lesions throughout the entire oral cavity, including the soft palate and
tonsillar areas, and ulceration often extends to the oropharynx. This is a diagnostic
criterion.
 The number of ulcers present at one time varies from one to 10 in MjRAS.
 Single ulcer will persist for a long period, while other (usually smaller) ulcers fade.
 Long periods of remission may be followed by intervals of intense ulcer activity, without
any obvious precipitating factor.

3. Herpetiform ulceration (HU)

Clinical Features
 In HU the ulcers are small (1-2 mm) in diameter.
 Multiple (as many as 100 ulcers) may be present at the same time).
 Characteristically the affected sites are the lateral margins and ventral surface of the
tongue and the floor of the mouth.
 Individual ulcers are grey and without a delineating erythematous border.
 Very painful and may make eating and speaking difficult.
 Ulcers may last for approximately 7-14 days.
 Ulcers may coalesce to form larger confluent areas of ulcer, usually with marked
erythema.
 Female to male ratio is 2.6:1.
 Relatively short-lived, most patients experiencing spontaneous remission within 5 years
of onset.
 Healing with scar formation.

Recurrent aphthous stomatitis (RAS) in children

 Appearance of major ulceration in this group was at the age of 7 years.

 Well-established patterns of RAS were seen.
 Within this group there was only one patient with an abnormal jejeunal mucosa typical of
coeliac disease.
Aetiology
 Hereditary predisposition
 Trauma
 Emotional stress and other psychological factors
 Bacterial and viral infection
 Allergic disorders
 Haematological and deficiency disorders
 Gastrointestinal diseases
 Hormonal disturbance

Histopathology of RAS

Preulcerative stage:
 Infiltration of the lamina propria by a mononuclear, predominantly lymphocytic infiltrate.
 Small numbers of lymphocytes also infiltrate the epithelium.
Ulcerative Stage:
 Ulcerative phase begins the population of T lymphocytes capable of inducing
cytotoxic effects in epithelial cells increases dramatically.
 CD4+/CD8+ratio about 1:10.
 Increased infiltration of the tissues, especially of the epithelium, by lymphocytes.
 Oedema and damage to epithelial cells, leading eventually to their death and the
formation of an ulcer.
 Fluctuation in lymphocytic infiltration throughout the ulcerative cycle suggests that
immune mechanisms are involved in the pathogenesis of RAS.
Healing Stage:
 The healing phase is characterized by a striking reversal of this ratio and CD4+ T
cells predominate (CD4+/CD8+ratio about 10:1).

Investigations:
 Haemoglobin and full blood count
 ESR/CRP
 Serum B12
 Serum/red cell folate
 Anti-gliadin and anti-endomysial autoantibodie
Treatment

Type Therapy
Topical antiseptic Chlorhexidine gluconate (mouthwash)
Topical analgesic Benzydamine hydrochloride (mouthwash)
Lignocaine rinse
Topical corticosteroids Hydrocortisone hemisuccinate (pellets)
Triamcinolone acetonide (in adhesive paste)
Betamethasone valerate (mouthwash)
Beclomethasone dipropionate (spray)
Budesonide (spray)
Triamcinolone (with or without
chlortetracycline) mouthwash
Topical antibiotics Chlortetracycline mouthwash
Systemic immunomodulators Predmisolone
Azothioprine
Colchicine
Ciclosporin
Thalidomide
Miscellaneous Cimetedine
Carbenoxolone (mouthwash and systemic)
5 amino-salicylic acid
Dapsone
Pentoxphylline
Low-energy laser
Levamisole

References
 Tyldesly’s Oral Medicine 5th Edition
 Oral Pathology 4th Edition by J. V. Soames

Written by:
Izaz Ullah
3rd Year BDS
KMU-IDS, Kohat