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THE MANAGEMENT OF CHRONIC ULCERS ON BOTH
188 INTRODUCTION
Recurring oral ulcers are among the most common problems seen by clinicians who manage diseases of the oral mucosa. There are several diseases that should be included in the defferential diagnosis of a patient who present with a history of recurring ulcers of the mouth, including recurrent aphthous stomatitis ( RAS ) 1,2.
Recurrent Aphthous Stomatitis is a disorder characterized by recurring ulcers confined to the oral mocusa, in patients with no other sign of disease. Many specialists and investigators in oral medicine no longer consider RAS to be a single disease, but rather, several pathologic states with similar clinical manifestations. Immunologic disorders, hematologic, deficiencies, and allergic or psychological abnormalities have all been implicated in cases with RAS 1,3.
Multiple ulcers are often present, but the number, size and frequency of them vary considerably. The buccal and labial mucosa are the most commonly involved. Lessions are less common on the heavily keratinized palate or gingival 1-4 .
Most patient with RAS, have between two to six lesions at each episode and experience several episodes a year. The disease is an annoyance for the majority of patients with mild RAS, but it can be disabling for patients with severe frequent lesions, especially those classified as major aphthous ulcers. Patients with major aphthous ulcers develop deep lesions, that are larger than 1 cm in diameter and may reach 5 cm. Large portion of the oral mucosa may be covered with large deep ulcers that can become confluent. The lesions are extremely painful and interfere with speech and eating. Many of these patients continually go from one clinician to another, looking for a “cure”. The lesions may last for months, and sometimes be misdiagnosed as squamous cell carcinoma, chronic granulomatous disease or pemphigoid.
The lesions heal slowly and leave scars that may result in decreased mobility of the ovula, tongue, and destruction of portion of the oral mucosa 1-3
The purpose of this paper was wanted to show the management of the chronic ulcer on both of the lateral posterior border of the tongue.
The patient recoqnized the lesion shortly after her husband passed away, that’s was about 5 years ago. Formally there was only a small ulcer at the lateral border of the posterior left tongue. The pain is still bareable. As the time passed by, the ulcer became larger and multiples, so the pain was much more severe. She look for a help, after this condition unbareable.
189 Many medicaments have been used by her, whether traditionally or fabricated. The result didn’t seem good, so she looked for another solution. She came to Surabaya, met two Oral Medicinists at RSGM, FKG UHT, who were in charge.
CASE
The case was a 54 years old female, complain of a pain in all of her oral mucosa. The pain was recurrent ever since her husband passed away, about 5 years ago. She had already visited some doctors, taken many medicines, whether modern or traditional. The ulcers still persist ever since.
Fig 1. Clinically feature of this case
CASE MANAGEMENT
The management of the case was, according to the clinical appearance, the suspected diagnosis was major RAS. A detailed history and examination by knowledgeable clinicians should distinguish RAS from primary acute lesions such as viral stomatitis, or from chronic multiple lesions such as pemphigoid, such as connective tissue disease, drug reactions and dermatologic disorders. The history should emphasize symptoms of blood dyscrasias, systemic complain, and associated skin, eye, genital or rectal lesions. Laboratory
190 investigation should be used when ulcers worsen or begin past the age of 25 years. Biopsies are only indicated when it is necessary to exclude other diseases, particularly granulomatous diseases, such as Crohn’s diases or sarcoidosis 4-8.
Patients with severe major aphthous ulcers should have known associated factors investigated, including connective tissue diseases and abnormal levels of serum iron, folate, vitamin B 12, andferritin. Patients with abnormalities of these values should be referred to an internist, to rule out malabsorption syndromes and to initiate proper replacement therapy. The clinician may also choose to have food allergy or gluten sensitivity investigated in severe cases resistant to other forms of treatment 5-8.
The patient was sent to be examined by Fine Needle Aspiration Biopsies ( FNAB ) at The Dr. Ramelan’s Hospital, Surabaya. The result was a chronic supurative inflammatory reaction. The medication prescribtion should relate to the severety of the disease. She received mouth-gargle, antacid, vitamin and corticosteroid orally.
Fig 2. Clinically feature after treatment DISCUSSION.
On the first visit of the patient, the clinician examined her thouroughly. The medical histories were taken systematically, so were the clinical examinations. The knowledgeable
191 clinicians were able to make a suspect diagnosis, after the procedures above were taken.
According to the length of the lesions, the locations and the severe, the suspect diagnosis was squamous cell carcinoma 1-7.
For the perfect diagnosis, the patient was sent to Dr.Ramelan’s Hospital, to be examined by FNAB. While waiting for the result, she got mouth gargle, antacid, vitamins and corticosteroid orally. The medicaments were prescribed supported by the histories of her illness. She complained of mouth each, all of her oral mucosa were ill, although she had taken many medicines. This condition make her discomfort for the oral fungtion, so her nutritional intake was low. She looked thin and sick. The pain on her stomach, she named it gastritis enable her get normal food or nutritions.
According to the major ulcers in all of her oral mucosa, the knowledgeable clinicians were given her potent moth gargle and corticosteroid orally. All of the medicaments prescribed above, were supposed to reduce her complain of illness, to regain her health, so the ulcers will be healed.
The result of the FNAB examination , that were taken from the ulcers on the lateral border of the tongue and the upper buccal fold; were chronic supurative inflammatory reaction. This condition was supported by the researchers 1-5,that the length of the duration time of lesion, may result in a differential diagnosis of the granulomatous conditions.
On the second visit, the lesion were less a bit, not totally healed yet. She was told to follow the rule of the treatment willingly, just to help her regain her illness.
On the third visit, the lesion much better, so she wanted to go home (outer island, Balikpapan/ KalTim). On her way home she was warned to take the medicine propperly, and as regular as it had to be.
She phoned after some times, about a month later, that her lesion were recurred, because she couldn’t avoid some food she used to eat. She was adviced to take a sensitivity test for some medicines and foods, but no more contact.
CONCLUSSION
The therapy of some chronic ulcerations in the posterior lateral border of the tongue had to be supported by an HPA’s examination.
SUGGESTION
As a General Practitioner, had to be very familiar with the changes in the oral mucosa, to avoid a severe and dangerous progress of the lesions.
192 ACKNOWLEDGEMENT
The authors will thank you very much to the patient for her permission of her case to be presented in this event
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