Oral medicine — Update for the dental practitioner - Oral Cancer ...

PRACTICECauses of oral ulcerationUlcers and erosions can also be the final commonmanifestation of a spectrum of conditions. Theserange from: epithelial damage resulting fromtrauma; an immunological attack as in lichenplanus, pemphigoid or pemphigus; damagebecause of an immune defect as in HIV diseaseand leukaemia; infections such as herpesviruses,tuberculosis and syphilis; cancer and nutritionaldefects such as vitamin deficiencies and somegastrointestinal diseases (Tables 1 and 2).Fig. 6 Minor aphthous ulcerationUlcers of local causesAt any age, there may be burns from chemicalsof various kinds (Fig. 3), heat (Fig. 4), cold, orionising radiation or factitious ulceration, especiallyof the maxillary gingivae or palate.Children may develop ulceration of the lowerlip by accidental biting following dental localanaesthesia. Ulceration of the upper labialfraenum, especially in a child with bruised andswollen lips, subluxed teeth or fractured jaw canrepresent non-accidental injury. At any age, trauma,hard foods, or appliances may also causeulceration. The lingual fraenum may be traumatisedby repeated rubbing over the lower incisorteeth in cunnilingus, in recurrent coughing as inwhooping cough, or in self-mutilating conditions.Most ulcers of local cause have an obviousaetiology, are acute, usually single ulcers, lastless than three weeks and heal spontaneously.Chronic trauma may produce an ulcer with akeratotic margin (Fig. 5).Fig. 5 Traumatic ulceration, lateral tongueRecurrent aphthous stomatitis (RAS; aphthae;canker sores)RAS is a very common condition which typicallystarts in childhood or adolescence and presentswith multiple recurrent small, round or ovoidulcers with circumscribed margins, erythematoushaloes, and yellow or grey floors (Fig. 6).RAS affects at least 20% of the population,with the highest prevalence in higher socio-economicclasses. Virtually all dentists will seepatients with aphthae.AetiopathogenesisImmune mechanisms appear at play in a personwith a genetic predisposition to oral ulceration. Agenetic predisposition is present, and there is apositive family history in about one third ofpatients with RAS. Immunological factors are alsoinvolved, with T helper cells predominating in theRAS lesions early on, along with some naturalkiller (NK) cells. Cytotoxic cells then appear in thelesions and there is evidence for an antibodydependent cellular cytotoxicity (ADCC) reaction. Itnow seems likely therefore that a minor degree ofimmunological dysregulation underlies aphthae.RAS may be a group of disorders of differentpathogeneses. Cross-reacting antigens betweenthe oral mucosa and microorganisms may be theinitiators, but attempts to implicate a variety ofbacteria or viruses have failed.Predisposing factorsMost people who suffer RAS are otherwiseapparently completely well. In a few, predisposingfactors may be identifiable, or suspected.These include:1. Stress: underlies RAS in many cases. RAS aretypically worse at examination times.2. Trauma: biting the mucosa, and dentalappliances may lead to some aphthae.3. Haematinic deficiency (deficiencies of iron,folic acid (folate) or vitamin B 12) in up to 20%of patients.4. Sodium lauryl sulphate (SLS), a detergent insome oral healthcare products may produceoral ulceration.5. Cessation of smoking: may precipitate oraggravate RAS.6. Gastrointestinal disorders particularly coeliacdisease (gluten-sensitive enteropathy) andCrohn’s disease in about 3% of patients.7. Endocrine factors in some women whose RASare clearly related to the fall in progestogenlevel in the luteal phase of their menstrual cycle.8. Immune deficiency: ulcers similar to RAS maybe seen in HIV and other immune defects.9. Food allergies: underlie RAS rarely.Drugs may produce aphthous-like lesions (seebelow).Key points for dentists: aphthous ulcers• They are so common that all dentists willsee them• It is important to rule out predisposingcauses (sodium lauryl sulphate, certainfoods/drinks, stopping smoking or vitaminor other deficiencies) or conditions such asBehcet’s syndrome• Enquire about eye, genital, gastrointestinalor skin lesions• Topical corticosteroids are the maintreatmentBRITISH DENTAL JOURNAL VOLUME 199 NO. 5 SEPT 10 2005 261