Oral ulcers(collection)

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.

Papule: elevated, solid and circumscribed lesion, usually 1 cm or less in diameter.

Plaque: elevated, flat-topped, firm and superficial lesion,
usually greater than 1 cm in diameter; may be coalesced papules.

Vesicle: elevated, thin-walled lesion; filled with serous (clear) fluid, less than 1 cm
in diameter.

Bulla: elevated lesion filled with clear fluid, greater than 1 cm in diameter .

Pustule: elevated lesion filled with purulent fluid. The presence of the pustule does
not necessarily signify the existence of an infection .

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

infective:
Primary and recurrent Herpes simplex
lesions.
Herpes Zoster and Chickenpox
Hand-foot-and-mouth disease
Herpangina

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.

Primary Herpetic Stomatitis
HSV type 1
Transmission by close contact
Most primary infections
In non-immune

Subclinical

acute vesiculating
stomatitis

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)

Primary herpetic gingivostomatitis: multiple ulcers on the tongue.

Primary herpetic gingivostomatitis: erythema and multiple ulcers on the gingiva

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)

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

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)

Secondary herpetic stomatitis: small round ulcers on the palate.

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

Chicken Pox
Mild systemic symptoms
Maculopapular lesions
(Generalized – Puritic)
Rapidly develop into
Vesicles (on erythematous base)
Rupture
Ulcers

Oral lesions  not diagnostic

Herpes Zoster of the Trigeminal area
Pain
Vesicles (rash)
Stomatitis

In the related dermatome

Trigeminal Nerve
Ophthalmic division
(Corneal scarring – Blindness)
Maxillary (2nd) & Mandibular (3rd) divisions
(Oral lesions)

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

Herpes zoster: clusters of vesicles on the palate.

Secondary Infection
Suppuration and scarring of skin
Malaise and fever
Herpes sine eruption
Pain without rash or oral eruptions
Post herpetic neuralgia

Differential Diagnosis

Herpes simplex
(Unilateral distribution in HZ while HSV is
bilateral)

Ramsay Hunt Syndrome
Herpes Zoster of the Geniculate Ganglion

Affects Facial nerve
(motor and sensory fibers)

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)

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

Oral Ulcers
Small, scattered with little pain
Affect Ant. Part of oral cavity
Gingivitis is not a feature
Systemic upset Mild or absent

Hand-foot-and-mouth disease: shallow ulcers on the buccal mucosa

Rash on the extremities
Vesicles (occasionally bullae)
Mainly around the base of fingers and toes,
But can affect any part of the limbs.

Aphthous ulcers
Herpes simplex infection
Herpangina
(by presence of lesions on soles and palms)

Herpangina
Coxsackie A Virus
Epidemic
Children 3-10 years
Incubation period 2-10
days

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.

Herpangina: numerous shallow ulcers on the soft palate

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)

Ulceration Without Preceding
Vesiculation
:Infective
• Cytomegalovirus – associated
ulceration
• Some acute specific fevers
• TB
• Syphilis

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.

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.

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.

(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.

Ulceration Without Preceding
Vesiculation
Non-Infective:
Traumatic ulcers
Aphthous Stomatitis
Behcet’s disease
Reiter’s syndrome
Lichen planus
Some mucosal drug reactions
Carcinoma

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

Recurrent Aphthous Stomatitis
Onset  In childhood
Peak  Adolescence
Recurrent
In healthy patient
Prodrome: Burning sensation 2-48 hrs with localized
erythema

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.

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.

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.

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

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)

Oral ulcers
(aphthous
like ulcer)

Skin lesion
(erythema nodosum)

Pathergy test
+ve pathergy test:
when needle
puncture
Cause pustule
formation after
48h

Stevens–Johnson syndrome
Erythema Multiform
Reiter syndrome
Recurrent aphthous ulcers

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

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

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

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

: Non-infective
Pemphigus vulgaris
Mucous membrane pemphigoid
Erythema multiform
Contact allergy

Erythema multiform
Acute
Inflammatory
Mucocutaneous disease
Oral lesions (most prominent or the only one
seen)

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.

Central zone of
erythema

Middle zone of
edema (paler)

Outer ring
of erythema
(well
defined)
Typical target- or iris-like lesions of the skin.

Oral manifestations of EM
Mucous membrane
Extensive bullae formation Followed by
Erosions
and a grayish white membrane.
Lips
Show characteristic hemorrhagic crusting.

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.

Stevens–Johnson syndrome: severe erosions on the lips, tongue, and
nose in an 8-year-old boy

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.

Pemphigus Vulgaris
Uncommon
40-60 y
Autoimmune disease
Causing vesicles or bullae on skin and mucous membrane
Fatal if untreated

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

Skin Lesions
Vesicles or flaccid bullae
Ruptures

Erosions
(painful, ragged)
Positive Nikolsky’s sign
Death due to electrolyte imbalance and secondary infection.

Pemphigus vulgaris: severe lesions of the skin of the face.

: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

Direct immunoflouresence
Show binding of
antibodies to
intercellular
substance

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.

(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

Eye lesion:
 Conjunctival erosion
 Corneal ulcers may
heal by scarring
 symblepharon

:Diagnosis confirmed by
Biopsy
Direct
immunoflourescence

Oral ulcers(collection)

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