oral ulcers

1. Oral ulcers
Presented by
Dr.Shaymaa H R Kotb
MRCSI ,MRCSEng, MRCSEd, MRCPSG,
university
Master Oral medicine ,periodontology AlAzhar

2. outlines
Definition
Classification of Oral ulcer (D.D)
New approach in classification (S – C - D)
Medical History /Family History
Chief Complain
Patient Examination
 Investigation
Management

3. Oral ulcer
• Def :
• Sorness in oral mucosal tissue
• Cause :Epith layer removed
Leaving tissue exposed

4. Classification of oral ulcers
• According to Etiological factors
• According to primary or secondary ulcers
• According to sign & symptoms
• New Diagnostic Approach (S-C-D)

5. 1.Etiological Factors
Physical Ulcer(trumatic,chemical ,Radiation)
Aphthous Ulcer
Nutritional Defecency
Microbial Ulcer ( Bacterial, viral , candidal )
Immunologic Ulcer (pemphigus ,L.P, SLE)
GIT Disturbances
Drugs
 Malignant Ulcer

6. Trumatic ulcer

7. Trumatic ulcer

8. Aphthous stomatitis ulcer
• Most common nontrumatic mucosal ulceration .
• Etiology :not known exactly
• Risk factors:
Immunolgic
factors
Microbial
factors
Nutritional
factors
Systemic
condition
Miscellanous
(truma/stress/
Menstruation)

9. Aphthous ulcer

10. Types of Aphthous ulcer
• Minor Major Herbitiform

11. Nutritional Deficency

12. Infectious Ulcer
Microbial /Bacterial Infection (T.B , syphilis ,candida)
T.B(star ,undermined ulcer )
Syphilis (Punched out ulcer)

13. Infectious Ulcer
• Candidal infection

14. 2.Classification of Primary or secondary
ulcers
Primary
ulcer
Physical agents
INFECTIONS
Neoplasm
BLOOD DISORDER
Secondary
ulcers
HSV
HZV
L.P
PEMPHIGOUS
PEMPHIGOID

15. Primary / Secondary Ulcers

16. 3.New Dignostic Approach
S - C - D
Simple
Complex
Destructive

20. 4.Classification According to clinical
features
• Onset
• Numbers
• Severity
• Size
• Border
• Recurrence / Progression
• Presence of Skin ,Eye ,Genital lesions
• Presence of systemic manifestation
• Associated with Medications taken (drug induced
ulcers)

21. Onset
 Acute (sudden ) last less than 2 weeks
 Chronic (gradual) lasts for 2 weeks or longer
Recurrent ( Remission ,Relapse )

22. Numbers
Solitary ( single )
Multiple

23. Size
• Minor
• Major
• Herpetiform

24. Border
• Sign of malignancy :
• Indurated
• Raised
• fixed
• Everted margin

25. Distribution
• Unilateral : (HZV)
• Bilateral : (L.P)

26. 5.Associated with Skin ,Eye ,Genital
Pemphigus
Mucous membrane pemphigoid
Behcets disease

27. 6.Specific feature associated with ulcer
• Generalized acute marginal gingivitis with
necosed papillae : ANUG
• Desqumative gingivitis :erthematous gingiva ex:
L.P/ PV /MMP/ SLE

28. 6.Associated with systemic conditions
• Nutritional defeciency
• Neutropenia
• Leukemia
• Irritable bowel diseases
• Chemotherapy /Radiotherapy
• Metastatic from grade IV cancer

29. 7.Drugs induced ulcers
• NSAID
• Chemotherapy
• Sulphonamides
• Hypertensive medications

30. Oral Ulcers
Acute
Acute solitary
Trumatic ulcer
Necrotizing
sialometaplasia
Acute multiple Virus infection

31. Oral Ulcers
Chronic ulcers
chronic Solitary
ulcer
T.B /SYPHILIS
/FUNGAL
Sq. cell carcinoma
Chronic multiple
ulcers
L.P/PEMPHIGUS
/Behcet /HSV

32. Oral Ulcers
Recurrent Ulcers
Solitary /Multiple ulcers
* Recurrent aphthous stomatitis
* HSV alone / HSV associated with EM
* Behcet diseases

33. Viral Infections
•
Primary Herpetic Gingivostomatitis :
• Transmitted by direct intimate contact with
lesions or secretions from an asymptomatic
carrier.
• Tiny vesicles on the perioral skin vermillion
border of the lips and oral mucosa.

34. Primary Herpetic Gingivostomatitis

35. Primary Herpetic Gingivostomatitis
• Most common viral infection especially in
childhood ,adolescent .
• Preceded by prodromal symptoms.
• Redness mucosa turn to vesicles then to shallow
painful ulcers
• Self limiting / pain managed by supportive therapy
• After healing virus is transported from mucosal or
cutaneous nerve endings by neurons to ganglia
where HSV viral genome remains in Latent form
• Reactivation of the latent virus results in localized
lesions (Herpes libialis).

36. Recurrent herpes simplex virus
infection

37. Varicella Zoster Virus (VZV)
• A-Chickenpox (varicella) :Prodromal symptoms
• (Fever, Sore throat ,Malaise ,Headache)
• generalized intense pruritic macuolopapular
eruptions, developed into vesicles ruptured into
ulcers.
• oral ulcers also present.
• Looklike aphthous like ulcer
• Ulcer/notpainful
• Heal with scar
• self limiting treated
symptomatically

38. Complication of Herpes zoster virus
• Facial paralysis
• Viscular eruption in oral cavity &oropharynx
• Pain external auditory meatus,Ear
• Hoarseness of voice
• Tinnitus
• Vertigo

39. Shingles (herpes zoster [HZ])
• Reactivation of HZV which latent in dorsal root
ganglia of spinal nerves /ganglia of cranial n.
• Sever neurologic pain
• Clinical feature: Prodromal syptoms (fever,malaise
,painful lymphadenopathy)
• Cluster of vesicles on one side of face follow course
of sensory nerve ,while other side completely free of
symptoms.
• Vesicular rupture leaving painful ulcer
• Ulcer heal with scar.
• self limiting treated symptomatically

40. Herpes zoster virus
Intraoral Extraoral

41. Coxsackievirus Infections
Herpangina
Hand ,foot ,mouth syndrom

42. Erythema Multiforme
acute inflammatory disease of the skin and M.M
 .Immune-mediated disease initiated by various
triggers(HSV ,Drugs ,Malignancy
,Menstruation ,Prgnancy )
Large, irregular, deep, ulcers with bloody
crusted lip .
Target lesion ,iris target ,
concentric ring

43. Erythema Multiforme

44. Behcet's syndrome.
Recurring oral ulcers (aphthous-like ulcers)
Recurring genital ulcers
Eye lesions

45. Pemphigus vulgaris
• Autoimmune disorder affecting skin and M.M.
• Life threatening condition
• Flacid Bullae
• + Nikolsky sign

46. Reiter's syndrome
Arthritis,
 urethritis,
conjunctivitis
and mucocutaneous lesions.
Psorasis patient
Ulceration on buccal mucosa ,lip ,tongue
Ulcer on tongue give geographic appearance

47. lichen planus
• A common chronic immunologic inflammatory
mucocutaneous disorder with varies appearance
• Pruritis in flexture surface.
• Bilateral distibution
• Linear , Annular
• Reticuar ,
• plaque,
• Bullous &Atrophic
• Network lines (wikhams stria)

48. Lichen planus

49. Pemphigoid
• Mucous membrane pemphigoid :
• predominantly involves the mucosa
• most commonly the oral mucosa, followed by
conjunctiva, skin, pharynx, external genitalia,
nasal mucosa, larynx, anus, and esophagus.

50. Pemphigoid
• Bullous pemphigoid:
• predominantly involves the skin and less
commonly the mucous membranes
• Tense bullae

51. Many of these diseases have a similar
clinical appearance
• How to reach the accurate diagnosis ??
Record Patient medical history is a must
clinical Examination
Investigation

52. Recording the patient history
• Biographic and Demographic information:
(Name ,age ,sex)
• Diseases mainly affect male /female
• Diseases mainly affect Diseases mainly affect
young / Old ages

53. Chief complaint and its History
• Painful
• Onset
• Size
• Distribution
• Associated phenomena
• Associated systemic condition
• Remission &relapse
• History of prodromal symptoms

54. Medical history
• systemic conditions have oral ulceration:
Blood disorders: Leukemia
GIT diseases : Inflammatory bowel disease
Neoplasms : Metastatic ulcerative lesions
Chemotherapy
Diabetes mellitus

55. Family History
• Diseases that have genetic predisposition:
Behçet’s syndrome
Reiter's syndrome
Lupus erthymatosis

56. Patient examination
• Intraoral Examination
• Extraoral Examination

57. Patient Examination
•Attention for
Examination
,Prevent
Complication

58. Laboratory investigations
• 1.Cytological examination
• HSV: multinucleated gaint cell ,nuclear bodies in epth
,balloning degeneration in nuclous
• Pemphigus : Tznac cells (Acantholytic cells)
• 2.Bacterial smear :
• (ANUG): fusospirochates
• Pemphigus : intraepith vesicles
• Pemphigoid: subepith vesicles, separation between epith
&C.T
• L.P: hyperkeratosis ,saw teeth rete pegs ,liquifaction
degeneration in basal cell layer,lymphocyte bannd in C.T

59. Laboratory investigations
• Immunoflurescent test : to detect autoantibodies in autoimmune
diseases
• Direct :biobsy from patient tissue
• Indirect :from patient serum
• Pemphigus :circulating antibodies against intercellular desmosome
between keratocytes and cement tissue
• Pemphigoid :autoantibodies against desmosome in cell membrane
• +Nikolsky sign :vesicle formation on applied normal tissue pressure
which cause sliding to superficial layer
• Patch test : place allergens in aluminum disk on skin for 24 h
• No reaction : negative response
• Inflamatory reaction (erthema ,edema,vesicles): Positive
• Biobsy : sq cell carcinoma : show epith dysplasia

60. Management
• Aim:
• Reduce pain intensity
• Reduce ulcer severity
• Reduce duration
• Reduce size

61. Management
• Syptomatic treatment
• Mild : Analgesic
• Resistant : topical ,intralesional corticosteroid
• Refractory : laser , tissue grafting ,TERM
• Meticulous oral hygene
• Antiseptic Mouthwash
• Avoid smoking
• Avoid spicy food

62. Important Notes
• Any persistant non healing ulcer more than 3
weeks should be refered (suspect cancer )

63. Oral Cancer Awarness
• One of most common cancer all over the world
• Squamous cell carcinoma is the most common oral cancer.
• Affect especially older age
• Evaluation of head &neck area is a fundamental part in patient
examination
• Dentist play critical role in detect sinister sign in head & neck
region
•

64. RED Flages Sign
• Nonhealing ulcer
• Indurated ulcer
• Painless persistant ulcer more than 3 weeks
• Numbeness in mouth/face
• Non healing sore in lip
• Exophytic ,proliferative , papillomatous lesions

66. How to deal
• Emergency referal to oral maxillofacial oncology
specialist
• Ensure patient
• Advice, Eat healthy balanced diet /Drink plenty
water
• Avoid junk food
• Avoid soft drinks
• Avoid smoking /tobacco
• Avoid spicy food
• Meticulous oral Hygene

67. References
• 1. Scully C. Clinical practice: aphthous ulceration. N
Engl J Med. 2006 Jul 13;355(2):165-72
• 2. Arduino PG, Porter SR. Oral and Perioral Herpes
simplex virus type 1 (HSV-1) infection. Overview of
its management. Oral Dis 2006; 12: 254–70.
• 3. Chattopadhyay A, Shetty KV. Recurrent
aphthous stomatitis. Otolaryngol Clin North Am.
2011 Feb;44(1):79-88, v. doi:
10.1016/j.otc.2010.09.003. PMID: 21093624.

68. Thank you
• By
Dr . Shaimaa H R Kotb
M RCSI ,M RCSEng ,M RCSEd ,M RCPSG,
Master degree in Oral Medicine ,Periodontology ,Oral Diagnosis
and Dental Radiology