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Oral ulcers(collection)
Oral ulcers(collection)
Oral ulcers(collection)
Oral ulcers(collection)
Oral ulcers(collection)
Oral ulcers(collection)
Oral ulcers(collection)
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Oral ulcers(collection)

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  • 1. OMD 421 ORAL ULCER
  • 2. Macule: flat and well-demarcated lesion of any size, characterized by color change in contrast to the surrounding skin. It is generally caused by alteration of melanin pigment.
  • 3. Papule: elevated, solid and circumscribed lesion, usually 1 cm or less in diameter.
  • 4. Plaque: elevated, flat-topped, firm and superficial lesion, usually greater than 1 cm in diameter; may be coalesced papules.
  • 5. Vesicle: elevated, thin-walled lesion; filled with serous (clear) fluid, less than 1 cm in diameter.
  • 6. Bulla: elevated lesion filled with clear fluid, greater than 1 cm in diameter .
  • 7. Pustule: elevated lesion filled with purulent fluid. The presence of the pustule does not necessarily signify the existence of an infection .
  • 8. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous Diseases Ulceration Without Preceding Vesiculation Infective: :Infective • Primary and recurrent Herpes simplex lesions. • Cytomegalovirus – associated ulceration • Herpes Zoster and Chickenpox • Hand-foot-and-mouth disease • Herpangina Non-infective: • Pemphigus vulgaris • Mucous membrane pemphigoid • Erythema multiform •Contact allergy • Some acute specific fevers • TB • Syphilis Non-infective: • Traumatic ulcers • Aphthous Stomatitis • Behcet’s disease • Reiter’s syndrome • Lichen planus •ANUG •Some mucosal drug reactions • Carcinoma
  • 9. Vesiculo-Bullous Diseases infective: Primary and recurrent Herpes simplex lesions. Herpes Zoster and Chickenpox Hand-foot-and-mouth disease Herpangina
  • 10. Herpes Simplex Virus Infection Herpes simplex type 1: Causes oral and pharyngeal infection, meningeoencephalitis and dermatitis above the waist. Herpes simplex type 2: Causes genital infection and dermatitis below the waist.
  • 11. Primary Herpetic Stomatitis HSV type 1 Transmission by close contact Most primary infections In non-immune Subclinical acute vesiculating stomatitis
  • 12. Clinical Picture Prodrome (1-2 days) Early lesion Vesicles (Any part (hard palate & dorsum of the tongue) – dome shaped 2-3 mm in diameter) Rupture Ulcers ( round, sharply defined, shallow, yellowish floor, red margins, painful) Gingival Margin Swollen, red, Regional L.N. (swollen, tender) Self limiting (week to 10 days)
  • 13. Primary herpetic gingivostomatitis: multiple ulcers on the tongue.
  • 14. Primary herpetic gingivostomatitis: erythema and multiple ulcers on the gingiva
  • 15. Differential diagnosis Aphthous ulcers (prodrome of fever and malaise, ulcers preceded by vesicles, pinpoint size, involve gingiva and a positive history of contact) Hand-foot-and-mouth disease (by absence of lesions on palms and soles) Herpangina (small vesicles limited to soft palate and oropharynx, while HSV affects anterior palate)
  • 16. Recurrent Herpes Simplex Lesion Recurrent Herpes Libialis Reactivation of latent virus (20-30 %) leading to cold sores. Prodrome (burning sensation – Parsesthesia) Erythema 1-2 hrs Vesicles (Clusters at the mucocutaneous junction of the lips – can extend) Enlarge, Coalesce & weep exudates 2-3 days Rupture & crust
  • 17. Recurrent herpes labialis
  • 18. Recurrent Herpes Simplex Lesion Recurrent Herpes Libialis Reactivation of latent virus (20-30 %) leading to cold sores. Recurrent Intra Oral Herpes Clusters of small vesicles Break into Prodrome (burning sensation – Parsesthesia) Ulcers ( 1-2 mm – On keratinized mucosa e.g. gingiva, hard palate) Erythema 1-2 hrs Vesicles (Clusters at the mucocutaneous junction of the lips – can extend) Chronic Herpes Simplex Immunocompromised patient • Skin & mucosa Enlarge, Coalesce & weep exudates 2-3 days Rupture & crust • As recurrent herpes but duration is weeks to months and develop into large ulcers (several Cm)
  • 19. Secondary herpetic stomatitis: small round ulcers on the palate.
  • 20. Recurrent intraoral herpes
  • 21. Herpetic Whitlow
  • 22. Varicella Zoster Infection Primary Varicella Zoster infection • Chicken pox Reactivation of the latent virus Herpes Zoster of the Trigeminal area Herpes Zoster of the Geniculate ganglion Herpes Zoster (reactivation of virus – adults) Ramsay Hunt Syndrome
  • 23. Chicken Pox Mild systemic symptoms Maculopapular lesions (Generalized – Puritic) Rapidly develop into Vesicles (on erythematous base) Rupture Ulcers
  • 24. Oral lesions  not diagnostic
  • 25. Herpes Zoster of the Trigeminal area Pain Vesicles (rash) Stomatitis In the related dermatome
  • 26. Trigeminal Nerve Ophthalmic division (Corneal scarring – Blindness) Maxillary (2nd) & Mandibular (3rd) divisions (Oral lesions)
  • 27. Herpes Zoster Prodrome (2-4 days) Sharp shooting pain, Parsesthesia, burning and tenderness along the course of the affected dermatome Vesicles Unilateral – often confluent L.N. enlarged and tender Pain continues until lesion crust over and heals
  • 28. Herpes zoster: clusters of vesicles on the palate.
  • 29. Secondary Infection Suppuration and scarring of skin Malaise and fever Herpes sine eruption Pain without rash or oral eruptions Post herpetic neuralgia
  • 30. Differential Diagnosis Herpes simplex (Unilateral distribution in HZ while HSV is bilateral)
  • 31. Ramsay Hunt Syndrome Herpes Zoster of the Geniculate Ganglion Affects Facial nerve (motor and sensory fibers)
  • 32. Prodrome (Facial pain – may radiate to jaws and misdiagnosed as toothache) Bell’s Palsy Herpetic Oticus (unilateral vesicles on the external ear) Oral mucosa (unilateral vesicles (Chorda Tympani ulcers on erythematous base) ant. 2/3 of tongue & soft palate) Complications (Permanent facial paralysis)
  • 33. Hand Foot and Mouth Syndrome Coxsackie A Virus Epidemic among school children Incubation period 3-10 days Causes oral ulcers and rash on the extremities. Highly infectious
  • 34. Oral Ulcers Small, scattered with little pain Affect Ant. Part of oral cavity Gingivitis is not a feature Systemic upset Mild or absent
  • 35. Hand-foot-and-mouth disease: shallow ulcers on the buccal mucosa
  • 36. Rash on the extremities Vesicles (occasionally bullae) Mainly around the base of fingers and toes, But can affect any part of the limbs.
  • 37. Differential diagnosis Aphthous ulcers Herpes simplex infection Herpangina (by presence of lesions on soles and palms)
  • 38. Herpangina Coxsackie A Virus Epidemic Children 3-10 years Incubation period 2-10 days
  • 39. Prodrome: Fever, chills, sore throat, anorexia, dysphagia On soft palate, tonsils and pharynx (posterior part of the mouth)  Papules & vesicles  Ulcers (1-2 mm) Heals within 7 days.
  • 40. Herpangina: numerous shallow ulcers on the soft palate
  • 41. Differential diagnosis Herpetiform ulcers - Aphthous ulcers (Prodrome of systemic illness) Primary herpes simplex infection (small vesicles limited to soft palate and oropharynx, while HSV affects anterior palate) Hand-foot-and-mouth disease. (by presence of lesions on soles and palms)
  • 42. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous Diseases Ulceration Without Preceding Vesiculation Infective: :Infective • Primary and recurrent Herpes simplex lesions. • Cytomegalovirus – associated ulceration • Herpes Zoster and Chickenpox • Hand-foot-and-mouth disease • Herpangina Non-infective: • Pemphigus vulgaris • Mucous membrane pemphigoid • Erythema multiform •Contact allergy • Some acute specific fevers • TB • Syphilis Non-infective: • Traumatic ulcers • Aphthous Stomatitis • Behcet’s disease • Reiter’s syndrome • Lichen planus •ANUG •Some mucosal drug reactions • Carcinoma
  • 43. Ulceration Without Preceding Vesiculation :Infective • Cytomegalovirus – associated ulceration • Some acute specific fevers • TB • Syphilis
  • 44. T.B Ulcer on mid dorsum or tip of tongue. Less common on lips and other parts Angular or stellate over-hanging edges & pale floor. Indurated base Painless in early stages.
  • 45. Syphilis (Primary syphilis (Chancre 3-4 weeks after infection with Triponema Pallidum. Affects lips and tip of the tongue. Firm nodule (1 cm) within few days surface breaks  Round ulcer with raised indurated edges, painless. LNs  enlarged and rubbery. Within 8-9 weeks  healing with no scar.
  • 46. Secondary syphilis 1-4 month after infection. Mild fever, malaise, headache, sore throat & generalized lymphadenopathy Followed by  rash & stomatitis Rash  starts at trunk, asymptomatic pinkish macules, symmetrical distribution, few hours to weeks. Stomatitis  lateral borders of the tongue, tonsils and lips. ulcers are flat, covered with grayish membrane, snail tract, may coalesce and form well defined round ulcer.
  • 47. (Tertiary syphilis (gumma 3 or more years after infection. Insidious onset. Affects palate, tongue, tonsils. Swelling with yellowish center (several inches)  Necrosis  painless deep ulcer Ulcer is rounded, soft, punched out edges, floor is depressed and pale. Heals with sever scarring  distort tongue and soft palate, destroy uvula, perforate hard palate.
  • 48. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous Diseases Ulceration Without Preceding Vesiculation Infective: :Infective • Primary and recurrent Herpes simplex lesions. • Cytomegalovirus – associated ulceration • Herpes Zoster and Chickenpox • Hand-foot-and-mouth disease • Herpangina Non-infective: • Pemphigus vulgaris • Mucous membrane pemphigoid • Erythema multiform •Contact allergy • Some acute specific fevers • TB • Syphilis Non-infective: • Traumatic ulcers • Aphthous Stomatitis • Behcet’s disease • Reiter’s syndrome • Lichen planus •ANUG •Some mucosal drug reactions • Carcinoma
  • 49. Ulceration Without Preceding Vesiculation Non-Infective: Traumatic ulcers Aphthous Stomatitis Behcet’s disease Reiter’s syndrome Lichen planus Some mucosal drug reactions Carcinoma
  • 50. Traumatic ulcers Obvious cause as sharp edge of denture or a broken tooth cause traumatic ulcer on tongue and/or buccal mucosa. Single Acute onset and Short duration No systemic features Painful, yellowish floor, red margins Removal of the cause  healing within 7-10 days If not  Biopsy
  • 51. Recurrent Aphthous Stomatitis Onset  In childhood Peak  Adolescence Recurrent In healthy patient Prodrome: Burning sensation 2-48 hrs with localized erythema
  • 52. Minor Most common type Non keratinized mucosa Shallow, rounded, 5-7 mm with red margins and yellowish floor Can be one or many Healing with no scar formation in 7-14 days Major Herpetiform Uncommon Uncommon Keratinized & non keratinized mucosa Non keratinized mucosa Several centimeters, deep and sometimes with indurated base & everted edges 1-2 mm Persistent for several month Healing with scar formation Dozens or hundreds (may cluster  Large ulcers). Wide spread bright erythema around the ulcers.
  • 53. Minor Aphthous ulcer
  • 54. Major Aphthous ulcer
  • 55. Herpetiform Aphthous ulcer
  • 56. Differential diagnosis Pemphigus and mm pemphigoid by absence of vesicles and healing in 7-14 days, and the well defined appearance, absence of epithelial tags. Erythema Multiforme As above + uniform appearance and size, also no lip crusting. Atrophic candidiasis predisposing factors in candidiasis, most cases pass through white necrotic phase or have a minor keratotic component.
  • 57. Primary herpetic gingivostomatitis Prodrome of fever and malaise, ulcers preceded by vesicles, pinpoint size, involve gingiva and a positive history of contact. Recurrent Intra oral herpes Involve keratinized mucosa, while RAU involves non keratinized mucosa.
  • 58. Behcet’s disease Triad of  Oral ulcers – Genital ulcers – Uveitis  Oral & genital ulcers (aphthous like ulcer)  Eye lesion (conjunctivitis, Uveitis)  Skin lesion (erythema nodosum, acneiform eruptions)  +ve pathergy test
  • 59. It has Four patterns 1. Mucocutaneous (oral & genital ulcers) 2. Arthritic (joint involvement with or without 1) 3. Neurological (with or without 1 & 2) 4. Ocular (with or without 1,2 & 3)
  • 60. Eye lesion
  • 61. Oral ulcers (aphthous like ulcer)
  • 62. Skin lesion (erythema nodosum)
  • 63. Pathergy test +ve pathergy test: when needle puncture Cause pustule formation after 48h
  • 64. Differential diagnosis Stevens–Johnson syndrome Erythema Multiform Reiter syndrome Recurrent aphthous ulcers
  • 65. Reiter’s Syndrome Triad of  uritheritis, arthritis, conjunctivitis Oral manifestations Painless white lesions which may ulcerate  Aphthous like ulcer Geographic tongue like lesion Purpuric rash on palate Self limiting
  • 66. Geographic tongue Characteristically, the lesions persist for a short time in one area, then disappear completely and reappear in another area. The condition is usually asymptomatic
  • 67. Purpuric rash on palate
  • 68. Squamous cell carcinoma Deep & large Indurated base Raised everted edge Necrotic fetid floor Painless unless invade nerve Metastatic L.N: Large Painless Hard Fixed to underlying tissues
  • 69. A.N.U.G  Painful gingivitis  Redness  Swelling  Gingival bleeding  Punched out lesion on interdental papillae  M.m covered with greyish necrotic membrane  Bad breath(foetid oris)  Bad taste  lymphadenopathy
  • 70. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous Diseases Ulceration Without Preceding Vesiculation Infective: :Infective • Primary and recurrent Herpes simplex lesions. • Cytomegalovirus – associated ulceration • Herpes Zoster and Chickenpox • Hand-foot-and-mouth disease • Herpangina Non-infective: • Pemphigus vulgaris • Mucous membrane pemphigoid • Erythema multiform •Contact allergy • Some acute specific fevers • TB • Syphilis Non-infective: • Traumatic ulcers • Aphthous Stomatitis • Behcet’s disease • Reiter’s syndrome • Lichen planus •ANUG •Some mucosal drug reactions • Carcinoma
  • 71. Vesiculo-Bullous Diseases : Non-infective Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy
  • 72. Erythema multiform Acute Inflammatory Mucocutaneous disease Oral lesions (most prominent or the only one seen)
  • 73. E.M. Minor )(80% of cases Skin lesions Maculopapular lesion (dull red – flat or slightly raised) Remains small or reach 1-3 cm within 48 hrs Often involve the hands selectively Kobner phenomenon Target (iris) lesions: Typical: Less than 3 cm in diameter. Consist of 3 zones. Atypical: Consist of only 2 zones.
  • 74. Central zone of erythema Middle zone of edema (paler) Outer ring of erythema (well defined) Typical target- or iris-like lesions of the skin.
  • 75. Koebner phenomenon
  • 76. Oral manifestations of EM Mucous membrane Extensive bullae formation Followed by Erosions and a grayish white membrane. Lips Show characteristic hemorrhagic crusting.
  • 77. EM Major ((Steven Johnson Syndrome Onset :sudden, may be preceded by a prodrome 1-13 days. Organs involved Mouth (100%) Eye Bullae formation may occur – corneal ulceration is frequent – these changes often regress completely, rarely cause blindness. Skin variable – typical maculopapular lesion – bullous lesions – rarely pustular. Male genitalia Anal MM Bronchitis.
  • 78. Stevens–Johnson syndrome: severe erosions on the lips, tongue, and nose in an 8-year-old boy
  • 79. Differential diagnosis Primary herpetic gingivostomatitis. Involve gingiva Aphthous ulcers. By absence of vesicles and healing in 7-14 days, and the well defined appearance, uniform appearance and size, also no lip crusting. Pemphigus vulgaris. Ulcers lacking erythema, Positive Nikolsky’s sign, flaccid bullae.
  • 80. Pemphigus Vulgaris Uncommon 40-60 y Autoimmune disease Causing vesicles or bullae on skin and mucous membrane Fatal if untreated
  • 81. Oral manifestations Appears first in mouth spread to skin. Vesicles (fragile) Erosions (superficial, ragged, painful, tender) Peeling off of oral epithelium due to lateral movement. Desquamative gingivitis Positive Nikolsky’s sign
  • 82. Desquamative gingivitis
  • 83. Skin Lesions Vesicles or flaccid bullae Ruptures Erosions (painful, ragged) Positive Nikolsky’s sign Death due to electrolyte imbalance and secondary infection.
  • 84. Pemphigus vulgaris: severe lesions of the skin of the face.
  • 85. :Diagnosis confirmed by Smear taken from base of vesicle (tzank smear) show tzank cells (acantholytic cells) High titre of circulating antibodies(IGg4) against intracellular cementing substance Direct immunoflouresence
  • 86. Direct immunoflouresence Show binding of antibodies to intercellular substance
  • 87. Differential diagnosis Cicatricial pemphigoid & Viral diseases o Bullae in pemphigus is smaller than mm pemphigoid and considerably larger than viral diseases such as herpes and hand-foot-and-mouth disease. o By immunoflorescence Erythema Multiforme. Aphthous ulcers.
  • 88. Immunofluorescence PV MMP
  • 89. (b.m.m.pemphigoid (autoimmune Old age Oral lesion:    Non keratinized mucosa Desquamative gingivitis vesicles that rupture leaving erosions that spread peripherally more slowly and self limited than pemphigus. Skin lesion:  Large tense bullae  Stay long time rupture leaving eroded area  Nikolsky’s sign is +ve
  • 90. erosions on the buccal mucosa
  • 91. Desquamative gingivitis
  • 92. Eye lesion:  Conjunctival erosion  Corneal ulcers may heal by scarring  symblepharon
  • 93. conjunctivitis
  • 94. :Diagnosis confirmed by Biopsy Direct immunoflourescence
  • 95. Thank you

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