Aetiology

• Stress  
• Sodium lauryl sulphate  
• Smoking cessation  

– May be because  of a lack of the keratinisation provided by smoking  
– Or because of the stress associated with cessation  

• Microbial factors:

– Bacterial infections
– Viral infections

• Systemic:  

– Haematinic deficiencies
– GI Disorders:  e.g. Celiac, Chrons or Ulcerative colitis
– HIV

• Syndromic:

– Behcet’s syndrome

• Trauma:

– Such as from brushing or site of injection

• Genetic:  

Clinical Manifestations

Minor

Number	1-5
Site	Non-keratinised mucosa Dorsum of tongue
Size	Less than 1 cm
Shape	Oval
Colour	Grey-yellow floor Red margins
Duration	1-2 weeks

Major

Number	1-3
Site	Keratinised mucosa Non-keratinised mucosa A diagnostic feature is that they often manifest posteriorly in the mouth e.g. soft palate, tonsils
Size	More than 1 cm
Shape	Oval
Colour	Grey-yellow floor Red margin Surrounding oedema (differentiates it from minor)
Duration	2 weeks – 3 months

Herpetiform

Number	1-100
Site	Non-keratinised mucosa Floor of mouth Lateral/ventral surface of tongue
Size	Pinpoint ~1mm
Shape	Oval
Colour	Grey floor Often coalesce leading to erythema surrounding it
Duration	1-2 weeks

Investigations

• Haematinics  levels checked (iron/folate/B12)
• Full blood count 
• A tissue transglutaminase tTg-IgA test (test for coeliac)
• ESR/CRP  (to assess for inflammation)
• Biopsy to rule out squamous cell carcinoma
• Patch testing if allergy suspected

Treatment

Range of medication can be given listed below, there is no particular order recommended, clinicians and patient choice. Treatment is to alleviate the symptoms. (FROM SDCEP) 

Local measures (to be used in first instance): 

• Advice patient to rinse mouth with salt water mouthwash 

If more severe, can also prescribe: 

Simple mouthwash: 

• Sodium chloride mouthwash  

Antimicrobial mouthwash: 

• Chlorhexidine mouthwash 0.2%  
• Hydrogen peroxide mouthwash 6% 

Tetracycline mouthwash: 

• Doxycycline tablets – (dissolved in water, effective especially against RAS) 

Analgesics: 

• Benzydamine hydrochloride mouthwash or spray 
• Lidocaine ointment or spray  

Topical corticosteroids: 

• Beclomethasone inhaler (good for tongue and accessible lesions) 
• Betamethasone tablets (dissolved in water + used as a mouthwash, good for extensive ulceration) 
• Hydrocortisone oromucosal tablets (allowed to dissolve next to lesion)

Clinical Manifestation

• Epithelial blistering, ulcers and erosion 
• Blisters rapidly break down forming ulcers/erosions  
• Can be cutaneous or mucosal 
• Found on gingiva, palate, lips or buccal mucosa 
• Ulcers are produced when the blisters burst which  
• If occurs on the gingiva it is called desquamative gingivitis 

Pathology

• IgG antibodies attack the desmosomes between cells (in stratified squamous epithelium) leading to loss of cell to cell contact which is known as acantholysis and thus causing intra-epithelial vesiculation 

Diagnosis

• Nikolsky sign– A lesion can follow minor trauma. This is called a Nikolsky sign: cells pull apart and blister, and a lesion develops because the adhesion between cells is weakened. The formation of a Nikolsky sign following minor lateral force on mucosa or gingiva can be a diagnostic aid. If a lesion develops, the patient almost certainly has PV (pemphigus) or MMP (pemphigoid)) 
• Biopsy with direct immunofluorescence evaluation:
  • It shows fluorescence in between all the cells due to presence of antibodies

Nikolsky sign via @dentistry.world

Treatment

Currently there is no cure available so treatment focuses on management of symptoms.

Systemic corticosteroids remain the gold standard treatment to prevent the body from further damaging healthy tissue.

Immunosuppresants e.g. Azithioprine/ Methotrexate

Plasmaphoresis may be a useful alternative if the patient is not responding to systemic corticosteroids/immunosuppressants or when their use is contraindicated.

Maintaining good oral hygiene is further emphasised in such patients.

Types

2 main types: 

1. Mucous membrane pemphigoid (usually affects the mouth) 
2. Bullous pemphigoid (rarely affects the mouth) 

Clinical Manifestation

• Affect mainly the gingiva and palate  
• Consist of blood-filled vesicles – remain for several days 
• Ulcers are produced when the blisters burst which if occurs on the gingiva is called desquamative gingivitis 
• Erythema can occur in patches as opposed to continuous 
• Can affect eyes and genital region  
• If it affects the eyes it can cause blindness. 

Pathology

Patients will have circulating IgG and C3 antibodies directed towards the epithelial basement membrane zone attacking the hemi-desmosomes leading to a sub-basilar split  

Diagnosis

• Biopsy with Direct immunofluorescence  

– It shoes deposits of antibodies (fluorescence) at the basement membrane.  

• Nikolsky sign – positive and a vesicle appears on the mucosa/skin after gently stroking the mucosa 

Treatment

Currently there is no cure available so treatment focuses on management of symptoms.

Systemic corticosteroids remain the gold standard treatment to prevent the body from further damaging healthy tissue.

Immunosuppresants e.g. Azithioprine/ Methotrexate

Maintaining good oral hygiene is further emphasised in such patients

Referral to ophthalmology  as it can lead to  conjunctival scaring

Overview

This is a disease that causes inflammation of blood vessels and tissues around the body. A significant characteristic of it is mouth ulcers.

Diagnosis

No set method exists at the moment in definitively diagnosing the disease. However a confident diagnosis can be made that the patient is suffering from Behcet’s syndrome if the following symptom are present:

RAS over the last 12 months followed by at least 2 of the following:

• Genital ulcers
• Eye inflammation
• Skin lesions e.g. growths
• Pathergy

Causes

Unknown but most likely thought to be an auto-inflammatory condition where the immune system attack it’s own blood vessels and tissues.

2 factors are thought to trigger this automimmune response:

• Genetics – it is far more common in Mediterranean, far east and middle east countries
• Environmental factors – those from at risk ethnic groups that live outside their native countries are statistically less likely to have the disease

Treatment

Currently there is no cure available so treatment focuses on management of symptoms.

Medication given to alleviate symptoms:

• Steroids – anti-inflammatory
• Immunosuppresents – reduce immune system activity

Please refer to NHS treatment for a more detailed approach to Behcet’s syndrome

Overview

Erythema multiforme is a common cause of oral ulcers. It is a hypersensitive skin reaction that is triggered by an infection, most commonly HSV (see viral infections).

Drugs such as Penicillin and NSAID’s can also induce the reaction.

Clinical Features

• Skins rash’s
• Rash’s can become raised over time
• Oral ulcers
• Genital ulcers
• Feeling generally unwell

Treatment

• Treat the underlying cause
• Antihistamines – treat the itching
• Steroids – treat the inflammation
• Benzydamine hydrochloride mouthwash – alleviate the soreness
• Refer to NHS for more

Dental Updates: Oral Medicine – Ulcers: Aphthous and other Common Ulcers:
https://www.dental-update.co.uk/issuesThreeArticle.asp?aKey=1055

Scully, C. (1999). Handbook of oral disease. London: Martin Dunitz.

Jordan, R. and Lewis, M. (2004). A colour handbook of oral medicine. New York: Thieme

Cawson. R A, Odell. E W. (2008). Cawson’s Essentials of Oral Pathology and Oral Medicine. 8th Edition