Oral ulcers

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Oral ulcers

  1. 1. Oral ulcers Diagnosis • A-Multiple ulcers: • 1-acute • 2- chronic • B-recurrent ulcers • C-single ulcer
  2. 2. Acute multiple ulcers
  3. 3. 1 -1ry herpes simplex Onset: after 6 months ,Peak within 2-3 years Clinical features: 1-Prodrome :1-2 days before appearance of local lesions fever ,headache ,lymphadenopathy, malaise ,vomiting) 2-generalized acute marginal gingivitis 3-multiple vesicles turn to painful, bilateral ulcers surrounded by erythtematous halo 4-mainly keratinized gingiva 5-mainly at anterior area of oral cavity
  4. 4. 2-Herpangina By coxsackievirus A4 Affect children from 3-10 years ,peak from June to October Clinical picture : 1-prodrome ,milder than herpes simplex (fever ,anorexia ,malaise) 2-sore throat ,dysphagia 3-ulcers mainly at post .area of oral cavity (soft palate ,fauces ,tonsils ,posterior pharynx) 4-ulcers smaller than herpes 5 -at post area and more painful. 6-no marginal gingivitis 7 -mainly in epidemics
  5. 5. 3-Hand- foot and mouth disease Caused by coxsakievirus A16,from 8 months to 33 years ,75%under 4 years. Clinical picture: 1-low grade fever 2-oral vesicles and ulcers more extensive than herpes(mainly palate ,buccal mucosa) 3-macules and papules on extensor surface of hand and feet. 4-examine hands and feet for maculopapular lesions and vesicles if there is acute stomatitis and fever
  6. 6. 4-Chicken pox 1ry infection of varicella –zoster virus: Cutaneous lesions: Maculopapular lesion then turn to vesicles on erythematous base Oral lesions ,not diagnostic
  7. 7. 5-Herpes zoster (shingles) Clinical picture: 1-Prodrome: 2-4 days (shooting pain, paresthesia,burning sensation) along the course of the nerve 2-unilateral vesicles on erythematous base ,appears as clusters along the course of the nerve. the most diagnostic manifestation is the unilateral appearance of lesions
  8. 8. 6-Erythema multiforme Affects children and young aged Rare after 50 Clinical picture : No prodrome ,systemic and local lesions appear together, with very rapid onset. oral lesions 1 - bullae or vesicles on erythematous base ,then rupture. 2-lesions orally are anywhere but lips are more prominent, and rare gingival involvement most diagnostic), where lips are extensively eroded and large portion are denuded of epithelium. 3-E.M lesions are large, irregular, deep and often bleeds and there are tissue remnants
  9. 9. • Cutaneous lesions: • • • -Appears on hands and feet ,extensor surface. -Macules ,papules ,vesicles, or bullae -target lesion or Iris lesion (central bulla or pale surrounded by edema or erythema)
  10. 10. B-Chronic multiple ulcers
  11. 11. 1-Pemphigus vulgaris • • • • • • 1-Cutaneous lesions: Thin walled bullae arising on normal skin and mucosa. Bullae breaks rapidly leaving erosions and continuously spread peripherally. The mostly diagnostic manifestation: A -apply pressure to intact area leads to formation of new lesion (KOEBNER PHENOMENA) B -apply pressure to bullae extend peripherally
  12. 12. 2-oral lesions: usually presents 4 month before cutaneous lesions Clinical manifestations: classical bulla on uninflammed area ,then rapidly breaks leaving irregular erosions and ulcers ,that extend peripherally. -leaves denuded area Mainly at buccal mucosa (N.B: E.M : mainly lips)
  13. 13. Differential diagnosis 1- Its chronic appearance differentiate it from (H.S, H.Z and E.M) 2-From R.A.S that its lesions are recurrent and heals rapidly, but pemphigous lesions extends peripherally and takes a period of weeks to months. 3-lesions of pemphigous are not small ,rounded and symmetrical like R.A.S and viral ulcers, and there is detached epithelium at the peripheries. 4-+ve nikolysks sign AND KOEBNER PHENOMENA 5-bullae extend peripherally
  14. 14. 2-Mucous membrane pemphigoid • • • • • • • Age over 50. Mainly mucosal surfaces( oral cavity) Clinical manifestation: 1-Desquamative gingivitis. 2-vesicles that rupture leaving erosions that spread peripherally more slowly and self limited than pemphigus. 3- +ve nikolyskis sign 4- no cutaneous involvement.
  15. 15. C-recurrent oral ulcers
  16. 16. 1-Recurrent aphthous stomatitis • Mostly begin during the 2nd decade • Clinical picture: 1-Prodrome :from 2-48 hrs before ulcer appear burning sensation) 2-Localized erythema then small white papule then ulcerates 3-not preceded by vesicles, uniform, rounded ,painful covered by yellowish membrane and surrounded by erythematous halo about 10mm). 4-no tissue remnants on borders, (there are no vesicles.) 5-mainly on lining mucosa rare on keratinized mucosa Minor
  17. 17. Major aphthous: (1- 5cm) Appears on keratinized and non keratinized mucosa. • -Indurated base ,everted edges, very painful and leave scar. • Takes more than a month to heal. major major Herpetiform (least common) • Dozens or hundreds of ulcers about 1-2 mm,very painful surrounded by erythematous halo. herpetiform
  18. 18. • • • • • • 2-Behcets disease Between 20-40 Diagnosis: oral recurrent ulcers (minor aphthae)at least 3 times within 12 months + 2 of the following A-recurrent genital ulcers B-eye lesions: (uveitis,retinal vasculitis , corneal inflammation) C-skin lesions: maculoppapular lesions,erythema nodosum (reddish ,painful, tender lumps ) D-+ve pathergy test :cutaneous hyperactivity to intra-cutaneous injection, within 24 hrs) (appearance of small red bump or pustule) Erythema nodosum
  19. 19. Pathergy test
  20. 20. 3-Recurrent herpes simplex 1 -recurrent herpes labialis common (cold sores, fever blisters( PPt. by fever ,menstruation ,u.v,emotional stress Clinical picture: Prodrome, tingling and burning sensation then edema and clusters of vesicles at mucocutaneous junction and spread to skin ,then coalesce and weep exudate and then rupture and crust 2-recurrent intraoral herpes: vesicles turn to ulcers ,mainly keratinized mucosa (gingiva –hard palate)

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