1. Acute multiple oral ulcers can be caused by primary herpes simplex infection, herpangina caused by coxsackievirus A4, hand-foot-and-mouth disease caused by coxsackievirus A16, chickenpox caused by varicella zoster virus, or herpes zoster infection. 2. Chronic multiple ulcers can be caused by pemphigus vulgaris, characterized by thin-walled bullae and erosions that extend peripherally, or mucous membrane pemphigoid, presenting mainly with desquamative gingivitis and erosions. 3. Recurrent oral ulcers include recurrent aphthous stomat

1. Oral ulcers Diagnosis
• A-Multiple ulcers:
• 1-acute
• 2- chronic
• B-recurrent ulcers
• C-single ulcer

2. Acute multiple ulcers

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

5. 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

7. 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

9. 4-Chicken pox
1ry infection of
varicella –zoster
virus:
Cutaneous lesions:
Maculopapular
lesion then turn to
vesicles on
erythematous base
Oral lesions ,not
diagnostic

10. 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

13. 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

14. • 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)

16. B-Chronic multiple ulcers

17. 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

18. 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)

19. 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

20. 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.

22. C-recurrent oral ulcers

23. 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

24. 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

25. •
•
•
•
•
•
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

26. Pathergy test

27. 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)