Oral Ulcers
Oral Ulcers
Oral Ulcers
Abou-Elhamd
Oral ulcers
04/28/12
Dr. Kamal Abou-Elhamd MD Professor Abou-Elhamd MD Dr. Kamal in ENT Al-Ahsa College Professor in ENT of Medicine King Faisal University & Al-Ahsa College of Medicine Sohag College of Medicine King Faisal University Sohag University,[email protected] Egypt Email: Email: [email protected] Website: www.geocities.com/kamal375/papers.html
Abou-Elhamd
Oral Ulcers
Oral ulcers are inflammatory lesions of the oral mucosa that affect 20% of the population Causes of oral ulceration range from the relatively trivial, eg traumatic ulcers, to the serious, eg oral cancer or pemphigus vulgaris Oral ulcers can be a feature of various systemic disorders including inflammatory bowel disease
1. The number, shape, size and border 2. Onset of the lesions as acute or gradual 3. Duration of the lesions as acute (2 weeks) or chronic (more than 2 weeks) 4. Recurrence or progression of the lesions
Features of Ulcer
Features of Ulcer
1. Presence of vesicles, white or red lesions preceding the ulcers 2. Presence of skin, eye or genital lesions 3. Concurrence of systemic manifestations 4. Medication taken by the patient
Chronic ulcers
Traumatic Ulcers
Single and located in an area subjected to injury Their centre are White or yellow with erythematous halo Painful and exhibit an elevated, rolled border which is firm when palpated
Traumatic Ulcers
Sharp teeth and tooth edges, can produce ulcers Self-inflicted lesions in children and patients with mental disorders Self-induced traumatic ulcers can also be caused by incorrect tooth brushing, biting of the tongue or lower lip Decubitus ulcers can be produced by dental prostheses
Chemical ulcers
Caustic ulcers are produced by direct contact of the oral mucosa with acids or strong alkalis. Oral mucosal ulcers have been related to topical acetylsalicylic acid, pancreatic supplements, potassium tablets, bisphosphonates, trichloroacetic acids
Types of Recurrent aphthous stomatitis Minor aphthae are the most common (80%) Major aphthae (10%) Herpetiform aphthae (5 10%)
Minor Aphthae
They are characterized by the formation of 15 well-defined superficial ulcers that are round or oval with a diameter < 10 mm, covered by a white or greyish pseudomembrane and surrounded by an erythematous halo.
Minor Aphthae
They normally appear in the nonkeratinized mucosa and are rare in the keratinized gingiva, palate or tongue dorsum. Lesions appear over variable time periods and disappear in 1014 days without leaving scars
Aphthous Ulcers
Aphthous Ulcers
Major Aphthae
(also known as Suttons disease) They are similar to minor aphthae but are larger (> 10 mm) and very painful. They can occur as single or multiple ulcers. They may appear at any site but have a predilection for the lips, soft palate and throat. They can persist for 6 weeks and commonly leave scars
Herpetiform Aphthae
They are characterized by the presence of multiple (50100), small (23 mm) and painful ulcers throughout the oral cavity, which tend to coalesce and form ulcers of larger size. They usually heal within 710 days without leaving scars
BD is a systemic vasculitis characterized by recurrent oral and genital ulcers, skin lesions and ocular, musculoskeletal, cardiovascular, gastrointestinal and neurological symptoms. Onset is usually during the third and fourth decade of life. Genetic, environmental, infectious, immunological and haematological factors have been implicated in its aetiology.
Behcets disease
Major, minor and herpetiform aphthae appear in the oral cavity in this disease, generally on oral mucosa, gingiva, lips, soft palate and pharynx
Behcets disease
Behcets Syndrome
Viral Ulcers
1. Herpes simplex virus 2. Varicella zoster virus infection (chickenpox) 3. Coxsackie virus produces Herpangina 4. EpsteinBarr virus 5. Cytomegalovirus 6. Measles virus 7. Human immunodeficiency virus
Oral features consist of gingivitis, followed after 23 days by the formation of vesicles that readily rupture, giving rise to painful ulcers covered with a yellowish membrane, which tend to coalesce. They are mainly localized to the lips, tongue, oral mucosa, palate and pharynx.
Episodes of paraesthesia, erythema, vesiculation, pustulization and ulcers at the mucocutaneous junctions of the lips and/or nose The ulcers usually heal spontaneously after 10 days with no sequelae and are accompanied by submandibular lymphadenitis, swallowing difficulties and halitosis
Herpesvirus Infection
Secondary infection
Papular and pustular skin lesions develop, with vesicles and ulcers on the trunk. Depending upon the severity of the disease, vesicles can appear on the palate. the virus remains in nerves and may be reactivated in adulthood, giving rise to mononeuropathies or polyneuropathies that present as herpes zoster (shingles). The most common sequela is posttherapeutic neuralgia.
Herpangina
EpsteinBarr virus Ulcers Infectious mononucleosis with fever syndrome, oral ulcers, palatal petechiae and systemic disorders
Other virus Ulcers Cytomegalovirus can cause large and chronic oral
ulcers in immunodepressed patients. Measles virus can affect the oral cavity during systemic infection, causing Kopliks spots, gingivitis and pericoronaritis alongside the typical systemic features. Human immunodeficiency virus causes oral lesions, which can occasionally be the first sign of the disease. Large, deep ulcers appear, mainly involving the vestibular and pharyngeal mucosae. This ulceration is related to opportunistic pathogens in the oral cavity.
Bacterial Ulcers
Syphilis is associated with skin and mucosal lesions in its acute phase. A chancre, a deep nonpainful ulcer 1-2 cm with increased and indurated borders, appears during the initial stage of primary syphilis. The ulcers can be genital or oral, and heal spontaneously.
Chancre
Secondary syphilis: oval-tocrescenteric erosions or shallow ulcers of about 1 cm diameter, covered by a grey mucoid exudate and with erythematous haloe Tertiary syphilis is characterized by the presence of syphilitic gummas (painfree ulcerated nodular lesions on hard palate or tongue) and nerve and
Bacterial Ulcers
Bacterial Ulcers
Gonorrhoea presents with several oral features, ranging from mild erythema to deep ulcers covered by a pseudomembrane. Fever, foetid breath and viscous saliva may be seen Neisseria gonorrhea is commonly isolated from the pharynx of subjects practicing oral sex
NS is an uncommon disease that gives rise to extensive, deep ulcers with indurated borders , mainly localized to the hard and or soft palate. It is a benign and self-limiting necrotizing inflammatory disease of the minor salivary glands but can simulate a malignant Neoplasm. The cause is believed to be an ischaemia Secondary to trauma or to damage from a chemical or biological agent.
Necrotizing sialometaplasia
Allergic Ulcers
Allergic reactions, ranging from erythma to ulceration, can appear in the oral mucosa after the topical application of numerous substances and medicines (contact stomatis)
Erythema multiforme Ulcers The minor form is acute and selflimiting and can be episodic or recurrent. Typical target lesions symmetrically cover < 10% of the body surface area (BSA). The mucosae are sometimes involved, most commonly the oral mucosa, with erythema, vesicles and ulcers and involvement of the lip in almost all cases, leaving
Erythema Multiforme
Steven-Johnson Syndrome
Erythema Multiforme
PFAPA syndrome
PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenopathy) The symptoms do not regress with antibiotic and antipyretics Corticosteroids (2 mg kg) are effective in shortening the duration and severity of attacks Tonsillectomy is effective in reducing recurrences
1. Anaemias 2. Lymphoproliferative disease: Leukaemias (almost all), NonHodgkins lymphoma & Hodgkins lymphoma (rare) 3. Myeloproliferative disease: (usually multiple myeloma) 4. Myelodysplasias 5. Neutropenia (any cause)
Gastroenterologi cal oral ulcers causes 1.Gluten-sensitive enteropathy 2.Crohns disease and related disorders 3.Dermatitis herpetiformis 4.Ulcerative colitis
Dermatologic Disorders
Lichen planus
Pemphigus Vulgaris
Pemphigoid
Cicatricial Pemphigoid
Bullous Pemphigoid
Immunological oral ulcers causes 1. Wegeners granulomatosis 2. Sarcoidosis 3. Immunodeficiency (usually defects of neutrophil number or function)
1. Lichenoid drug reactions (e.g. b-blockers, antimalarials, NSAIDs, interferon) 2. Erythema multiforme (e.g. barbiturates, carbamazepine, sulphonamides) 3. Pemphigus (e.g. penicillamine, ACE inhibitors, rifampicin) 4. Lupus (e.g. minocycline, statins, terbinafine) 5. Pemphigoid (e.g. clonidine, psoralens) 6. Drug-induced neutropenia/anaemia (e.g. azathioprine, carbamazepine) 7. Drug-induced mucositis (e.g. cyclophosphamide, methotrexate) 8. Others (e.g. nicorandil)
Quinns Rule for Stomatitis: Call it aphthous stomatitis. Treat it for two weeks. If it is still there, biopsy it.
Lichen Planus
Cutaneous Lesion
Dermatologic Disorders
Lichen planus
Pemphigus Vulgaris
Spontaneous onset of bullae that readily rupture, giving rise to a highly painful ulcerated area (most common areas are palate and gingiva) This group of immunological diseases mainly affects mucosae, with subepithelial bullae and deposits of immunoglobulin G, immunoglobulin A or complement fraction C3 throughout the basal membrane
Pemphigoid ulcers
Pemphigoid
Cicatricial Pemphigoid
Bullous Pemphigoid
Erythema and oral ulcers, without induration and accompanied by whitish striae and a tendency to Bleeding Lupus erythematosus (LE) is an autoimmune disease of the connective tissue that appears in two forms: systemic LE and discoid LE
Reiters syndrome ulcers Arthritis, urethritis, conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis Positive reaction for human leucocyte antigen B27
Primary tuberculosis: deep, irregular, persistent and painful ulcer on the tongue, with rolled border and granulation tissue in the fundus (undermined edges and a granulating floor) Secondary tuberculosis: chronic ulcer, painful and indurated
Tuberculosis ulcers
Tuberculosis ulcers
Fungi ulcers
Mycoses give rise to chronic ulcers on the oral mucosa, commonly in immunocompromised pts Rhizomucor or Mucor produce zygomycosis, a fungal infection that can give rise to ulcers with a necrotic halo on the palate (painful but non-specific; they progress rapidly, destroying the bone tissue and surrounding facial muscles)
Bacterial ulcers
Klebsiella rhinoscleromatis is an aerobic cocobacillus that causes a chronic granulomatous infection known as oral or respiratory scleroma, which can involve the oral cavity
Parasitical ulcers
Leishmaniasis is a parasitical disease caused by protozoa of the Leishmania genus. It produces ulcers on the hard or soft palate. It is rare in developed countries and is most commonly observed in patients with HIV infection
Eosinophilic ulcers
Large ulcer, generally in the tongue, with raised, indurated borders and white-yellowish fundus that may resemble a malignant lesion. Persists for weeks or months It is traumatic granuloma
Leukoplakia
Erythroplakia
Can produce ulcers (exophytic, endophytic or mixed). Metastatic lesions can appear as ulcers in the oral cavity A biopsy (or second opinion) should obtained for suspicious lesions and ulcers that persist after the removal of possible causal agents, as these are the only reliable methods for establishing a definite diagnosis
Verrucous Carcinoma
Palate Melanoma
Indications for biopsy of an oral ulcer The specimen must include part of
the ulcer and the perilesional tissue, including the unaffected surrounding epithelium. The centre of the ulcer alone usually does not show diagnostic features. Scalpel or punch biopsies are preferred; other techniques (e.g. lasers, electrical scalpels) are not recommended.
Conclusions
Oral ulcers are lesions occurring in the oral mucosa. Aphthae and traumatic ulcers are the most common, but the most serious are those associated with oral cancer. In many cases, it is not possible to establish a definitive diagnosis without histological examination of a biopsy,
Conclusions
A biopsy should be taken from any lesion persisting for > 2 weeks or any with a suspicious appearance. Histological examination of a biopsy should confirm whether the ulcer is a possible malignant lesion, and establish both the definitive diagnosis and correct treatment
Conclusions
1. Check labs (ensure not immunocomprimised) finger stick glucose in office, CBC, CMP, A1c 2. Rule out infection: Send swab and biopsy for HSV testing (smear, PCR) as well as gram stain and possible culture (viral/bacterial)
Oral Ulcers
Thank You
Dr. Kamal Abou-Elhamd MD Professor in ENT Al-Ahsa College of Medicine King Faisal University & Sohag College of Medicine Sohag University, Egypt
04/28/12 Abou-Elhamd
Email: [email protected]
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