Oral ulcers(collection)

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Oral ulcers(collection)

  1. 1. OMD 421 ORAL ULCER
  2. 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. 3. Papule: elevated, solid and circumscribed lesion, usually 1 cm or less in diameter.
  4. 4. Plaque: elevated, flat-topped, firm and superficial lesion, usually greater than 1 cm in diameter; may be coalesced papules.
  5. 5. Vesicle: elevated, thin-walled lesion; filled with serous (clear) fluid, less than 1 cm in diameter.
  6. 6. Bulla: elevated lesion filled with clear fluid, greater than 1 cm in diameter .
  7. 7. Pustule: elevated lesion filled with purulent fluid. The presence of the pustule does not necessarily signify the existence of an infection .
  8. 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. 9. Vesiculo-Bullous Diseases infective: Primary and recurrent Herpes simplex lesions. Herpes Zoster and Chickenpox Hand-foot-and-mouth disease Herpangina
  10. 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. 11. Primary Herpetic Stomatitis HSV type 1 Transmission by close contact Most primary infections In non-immune Subclinical acute vesiculating stomatitis
  12. 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. 13. Primary herpetic gingivostomatitis: multiple ulcers on the tongue.
  14. 14. Primary herpetic gingivostomatitis: erythema and multiple ulcers on the gingiva
  15. 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. 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. 17. Recurrent herpes labialis
  18. 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. 19. Secondary herpetic stomatitis: small round ulcers on the palate.
  20. 20. Recurrent intraoral herpes
  21. 21. Herpetic Whitlow
  22. 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. 23. Chicken Pox Mild systemic symptoms Maculopapular lesions (Generalized – Puritic) Rapidly develop into Vesicles (on erythematous base) Rupture Ulcers
  24. 24. Oral lesions  not diagnostic
  25. 25. Herpes Zoster of the Trigeminal area Pain Vesicles (rash) Stomatitis In the related dermatome
  26. 26. Trigeminal Nerve Ophthalmic division (Corneal scarring – Blindness) Maxillary (2nd) & Mandibular (3rd) divisions (Oral lesions)
  27. 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. 28. Herpes zoster: clusters of vesicles on the palate.
  29. 29. Secondary Infection Suppuration and scarring of skin Malaise and fever Herpes sine eruption Pain without rash or oral eruptions Post herpetic neuralgia
  30. 30. Differential Diagnosis Herpes simplex (Unilateral distribution in HZ while HSV is bilateral)
  31. 31. Ramsay Hunt Syndrome Herpes Zoster of the Geniculate Ganglion Affects Facial nerve (motor and sensory fibers)
  32. 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. 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. 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. 35. Hand-foot-and-mouth disease: shallow ulcers on the buccal mucosa
  36. 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. 37. Differential diagnosis Aphthous ulcers Herpes simplex infection Herpangina (by presence of lesions on soles and palms)
  38. 38. Herpangina Coxsackie A Virus Epidemic Children 3-10 years Incubation period 2-10 days
  39. 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. 40. Herpangina: numerous shallow ulcers on the soft palate
  41. 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. 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. 43. Ulceration Without Preceding Vesiculation :Infective • Cytomegalovirus – associated ulceration • Some acute specific fevers • TB • Syphilis
  44. 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. 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. 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. 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. 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. 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. 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. 51. Recurrent Aphthous Stomatitis Onset  In childhood Peak  Adolescence Recurrent In healthy patient Prodrome: Burning sensation 2-48 hrs with localized erythema
  52. 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. 53. Minor Aphthous ulcer
  54. 54. Major Aphthous ulcer
  55. 55. Herpetiform Aphthous ulcer
  56. 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. 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. 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. 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. 60. Eye lesion
  61. 61. Oral ulcers (aphthous like ulcer)
  62. 62. Skin lesion (erythema nodosum)
  63. 63. Pathergy test +ve pathergy test: when needle puncture Cause pustule formation after 48h
  64. 64. Differential diagnosis Stevens–Johnson syndrome Erythema Multiform Reiter syndrome Recurrent aphthous ulcers
  65. 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. 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. 67. Purpuric rash on palate
  68. 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. 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. 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. 71. Vesiculo-Bullous Diseases : Non-infective Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy
  72. 72. Erythema multiform Acute Inflammatory Mucocutaneous disease Oral lesions (most prominent or the only one seen)
  73. 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. 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. 75. Koebner phenomenon
  76. 76. Oral manifestations of EM Mucous membrane Extensive bullae formation Followed by Erosions and a grayish white membrane. Lips Show characteristic hemorrhagic crusting.
  77. 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. 78. Stevens–Johnson syndrome: severe erosions on the lips, tongue, and nose in an 8-year-old boy
  79. 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. 80. Pemphigus Vulgaris Uncommon 40-60 y Autoimmune disease Causing vesicles or bullae on skin and mucous membrane Fatal if untreated
  81. 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. 82. Desquamative gingivitis
  83. 83. Skin Lesions Vesicles or flaccid bullae Ruptures Erosions (painful, ragged) Positive Nikolsky’s sign Death due to electrolyte imbalance and secondary infection.
  84. 84. Pemphigus vulgaris: severe lesions of the skin of the face.
  85. 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. 86. Direct immunoflouresence Show binding of antibodies to intercellular substance
  87. 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. 88. Immunofluorescence PV MMP
  89. 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. 90. erosions on the buccal mucosa
  91. 91. Desquamative gingivitis
  92. 92. Eye lesion:  Conjunctival erosion  Corneal ulcers may heal by scarring  symblepharon
  93. 93. conjunctivitis
  94. 94. :Diagnosis confirmed by Biopsy Direct immunoflourescence
  95. 95. Thank you

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