A brief overview of different ulcerative lesions seen in the oral cavity linked to the dangerous systemic diseases and preventive measures for the disease before it turns lerhal SDDCH, Parbhani

1. Solitary Oral Ulcers
Presented By:
Harsh S. Shah

2. Definition
• Ulcer has been defined as a deeper crater that
extends through the entire thickness of
surface epithelium and involves the
underlying connective tissue.

3. Parts of an ulcer
Margin :
Margin is the border or transitional zone of skin around an ulcer.
Edge:
Edge is the mode of union between the floor and the margin of
ulcer.
Floor:
Floor of ulcer is the exposed surface of the ulcer, we look for

4. Types of margins:
• Healing margin [white (outer) – blue (central) – red (Inner)]
• Inflamed margin (red, irregular margin with inflamed surrounding
skin)
• Fibrosed margin (thickened white)
Types of edges :
• Sloping edge → healing ulcer
• Punched edge → trophic ulcer , syphilic
• Undermined edge → tuberculous ulcer
• Everted edge→ malignant ulcer
• Raised edge → rodent ulcer

5. Classification
ACCORDING TO ETIOLOGY
Local Trauma
• Trauma due to sharp and malposed teeth
• Trauma due to restoration
• Trauma from injecting needle
Infections
Viral
• Herpes Simplex
• Herpes Zoster
• Chicken Pox
• Small Pox
• Measles
• Hand foot mouth disease
• Herpangina
• AIDS

6. Bacterial
• Tuberculosis
• Syphilis
• ANUG
Fungal Infection
• Candidiasis
• Histoplasmosis
• Blastomycosis

7. Allergy
• Local ( Stomatitis Venenata)
• Systemic ( Stomatitis medicamentosa)
Neoplastic
• Squamous cell carcinoma
• Mucoepidermoid carcinoma
• Basal cell carcinoma
• Melanoma
• Malignant Lymphoma
Systemic
Blood disorder
• Agranulocytosis
• Cyclic Neutropenia
• Leukemia

8. Traumatic Ulcer
• Most common oral ulcer
• Caused by : Mechanical , Chemical & Thermal

9. Etiology
• Repeated trauma from tooth brushing
• Drugs – Narcotic drugs
• Denture induced
• Self-inflicted in decerebrate and comatose
patients
• Placement of fixed acrylic tongue stent

10. Features :
• Tender in the area of lesion
• Borders : Raised and reddish
• Base : Yellowish white necrotic that can be
easily removed
• Ulcer on vermilion border of lip – crusted
surface because of absence of saliva

11. Management
• Heals in 10 days
• Fluocinonide (0.05 %) or triamcinolone (0.1 %)
acetonide in a emollient base before bedtime
• Base protects the denuded tissue from
contamination and corticosteroid therapy
tends to arrest inflammatory cycle
• Oral Bandage materials : Hydroxypropyl
methylcellulose also promote healing
• Chlorhexidine mouthrinse

12. RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS : Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae

13. Comparison of Clinical Features
RAU RIHS
Location:
Nonkeratinized mucosa Keratinized Mucosa
Initial Lesion :
Erythematous macule or papule
followed by necrosis and ulceration
Cluster of small discrete vesicles
without red erythematous halo.
Vesicles rupture to form
small,punctate ulcers
Mature lesion :
Shallow ulcer with yellow necrotic
center
Smooth border and red halo
Shallow ulcer but many in number
and border is scalloped

14. Recurrent Aphthous Ulcer
Minor RAU :
Most common RAU
Etiology :
• Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and
class II major histocompatibility complex antigens
• After this the oral mucosa permits additional
local factors to come into play
• Cause of destruction of epithelium : increase in
leukocyte TNF

15. Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC – I and MHC – II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium : Increase in leukocyte and TNF –α count

16. Minor RAU

17. Management
1. Heals in 7 – 10 days
2. Placement of tetracycline solution or a 0.12%
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3. Oral Bandage : Cyanoacrylate, Benzocaine
(Orabase), or hydroxypropyl cellulose (Zilactin)

18. Recurrent Intraoral Herpes Simplex
• After primary infection HSV enters a latent
stage and later becomes reactivated by
various stimulae and recur as a
vesiculoulcerative lesion on the skin, perioral
tissue, and oral mucosa

19. • Herpetic Whitlow is an occupational disease
of practising dentists and dental workers.
• This may be contracted while working on a
patient with the herpetic lesion
• Lesions of finger are recurrent and may spread
to whole hand

20. Diagnostic Difficulties
• Viruses are shed quickly after vesicles rupture,
HSV can be cultured from intact vesicles, and
cytologic smears from freshly ruptured
vesicles show typical MNG cells

21. Atypical RIHS Lesion
• RIHS of
gingival
papilla
• Persistent
infection
of gingival
papilla
• Persistent
enlarged
ulcers
• RIHS in
immuno-
incompete
nce

22. Major RAU
• Also known as Sutton’s disease or Periadenitis
mucosa necrotica recurrens
• Much larger than the minor type, upto 2cm
• Quite deep and very painful and persist for months
• Heal with formation of scar

23. Treatment modalities
• Excision with primary closure
• Cryosurgery
• Topical application of tetracycline followed by
cortisone (1% hydrocortisone) ointment
• Injection of corticosteroid directly into the
lesion alone or with prednisolone

24. Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue;
(b) intralesional injection of corticosteroids;
(c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids;
(d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole.

25. Herpetiform Aphthae
• More common in female patients and cause is
unknown
• Many small, painful, punctate ulcers over the
mucosal surfaces, sometimes in clusters
• Management by mouthrinse only.

26. Behcet’s Syndrome
• Oral ulcers
• Recurrent ulcers of genital region
• Ocular lesions including conjunctvitis, retinitis,
and uveitis.

27. Ulcer from Odontogenic Infections
• The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may
be the site of a superficial space abscess that has
spontaneously ruptured
• Ulcer generally occurs on alveolar ridge on buccal
or lingual surface, near the mucobuccal fold and
rarely on palate

28. Sloughing, Pseudomembranous ulcers
• Crushing type of traumatic ulcers
• Acute necrotizing ulcerative gingivitis
(Interdental papillae)
• Candidiasis
• Gangrenous Stomatitis

29. Squamous Cell Carcinoma
• Most common persistent ulcer in the oral
cavity or on the lips
• Patient is usually unaware as the ulcer is
painless
• Craterlike lesion having a velvety base and a
rolled, indurated border
• Intraoral ulcer is usually devoid of the necrotic
material and is situated in the highrisk Oval

30. • This region includes the lower lip, floor of the
mouth, ventral and lateral borders of the
tongue, retromlar areas, tonsillar pillars and
lateral soft palate

31. • The base and borders are firm on palpation.
When deep infiltration occurs and tumor is on
“movable” mucosa, mucosa becomes fixed to
deeper structures

32. Syphilitic Ulcer
• Veneral disease caused by motile spirochete
Treponema Pallidum
• Primary Lesion – Chancre (solitary)
• Secondary lesions – numerous macules,
papules, condylomas, or combinations
• Tertiary lesions – Gumma and interstitial
glossitis

34. Chancre
• Develop 3 weeks after inoculation and may
persist upto 2 months
• Primary oral lesion occurs most often on the
lips, on tip of the tongue, in tonsillar region, or
on the gingivae – commencing as macules and
papules and then ulcerate

35. • Mature chancre measure from 0.5-2cm and
have narrow, copper coloured, slightly raised
borders with reddish brown base or center
• Chancre is extremely contagious
• Management : Systemic Penicillin from the
early days

36. Gumma
• Occur in midline of the palate or tongue
starting as small firm nodular masses and
often growing to several centimeters
• Necrosis commences within the nodules and
produces ulceration in the surface epithelium

37. Occasionally necrosis is destructive, causing
perforation of palate and formation of
persistent oronasal fistula.

38. Ulcer secondary to systemic disease
• Uncontrolled Diabetes
• Uremia
• Blood Dyscrasias ( Pancytopenia, Leukemia,
Neuropenia, sickle cell anemia)
• The ulcers are tender, usually demarcated, and
shallow with a narrow erythematous halo and
yellowish necrotic material
• A painful regional cervical lymphadenitis is
almost invariably present.

39. • In SCA, ulcers form in regions of chemical
infarcts, caused by plugging of small blood
cells by sickle cell thrombi
• Such ulcers are usually painless and frequently
involve marginal gingiva and interdental
papillae

41. • Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
• Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels.
• Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia, to neutralize ammonia and the condition of acidosis. Additional treatment
may include vitamin supplements, antiseptic mouthwashes and antimicrobial/antifungal agents
against microbial or fungal infections .
Uremic Stomatitis

42. Some Chronic oral ulcer
Diagnosis Clinical features
Drug-induced ulcers
Single, isolated ulcers, located on the side of the tongue,
surrounded by an erythematous halo and resistant to usual
treatments
Erosive lichen planus
Areas of atrophy, erosions or painful ulcers, generally resistant
to conventional treatments
Pemphigus vulgaris
Bullae appear in oral cavity (posterior region), forming painful
ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoid
Spontaneous onset of bullae that readily rupture, giving rise to
a highly painful ulcerated area (most common areas are palate
and gingiva)
Lupus erythematosus
Erythema and oral ulcers, without induration and
accompanied by whitish striae and a tendency to bleeding
Reiter's syndrome
Arthritis, urethritis, conjunctivitis and oral ulcers similar to
those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis: deep, irregular, persistent and painful
ulcer on the tongue, with rolled border and granulation tissue
in the fundus
Secondary tuberculosis: chronic ulcer, painful and indurated

43. Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris

44. Management of pemphigus vulgaris:
1. High doses of systemic corticosteroids
(1-2mg/kg/dl).
2. Adjuvant therapy : adjuvant drugs are
immunosuppressie drugs like
mycophenolate mofetil, azathioprine,
cyclophosphamide, and
cyclophosphamide pulse therapy
3. Prednisolone tablets
4.Dapsone
5. Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus :
PNPP - multiorgan disease with
underlying neoplasm
Castleman disease and Waldenstrom
macroglobulinemia are associated
with PNPP
Oral lesions : ulcers & erythema
Hemoorhagic crusts on lips are
characteristic

45. Erythema Multiforme
• It is an acute, self-limited, inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa.
• It represents a hypersensitivity reaction to infectious agents (HSV,
mycoplasma and Chlamydia pneumonia) or medications (NSAIDS,
anticonvulsants)
• Classic skin lesions : ‘target’ or ‘iris’ lesions
• Ulceration and crusting is common in lip and ulcers on oral mucosa

46. Histoplasmosis
• Most common fungal disease caused by
organism Histoplasma Capsulatum
• Three forms :
• Acute Histoplasmosis
• Chronic Histoplasmosis
• Disseminated Histoplasmosis
• Most oral lesions of histoplasmosis occur with
the disseminated form of the disease

47. • Solitary, variably painful ulcerations of several
weeks duration
• Margins : Firm, rolled margins
• Clinically it may be confused with malignancy.

48. Drug induced ulcers
• Single, isolated ulcers, located on the side of
the tongue, surrounded by an erythematous
halo and resistant to usual treatments
• widespread mucositis and ulceration, mainly
caused by cytotoxic drugs used for anti-tumor
chemotherapy

49. • cytotoxic drugs include 5-fluorouracil,
methotrexate, bleomycin, and cisplatin.
• NSAIDs are popular drugs that are well-known
to induce oral ulcerations

50. Leukemic ulcer
1. Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4), and acute myelocytic (M1, M2) leukemias. Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease .
2. Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells.
3. Oral cavity usually is involved as part of a widespread disease; however, oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis.

51. Differential Diagnosis
• Short Term Ulcers (Shallow and not raised)
• Persistent Ulcers (Extensive borders and
bases)

52. Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU, RIHS, and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or
vesiculobullous disease
Ulcer secondary to noninfectious systemic disease

53. Differential List of Persistent Ulcer
Differential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities

54. Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer

55. Management
• Amphotericin B is indicated ( More potent )
• Daily Itraconazole for 6-18 months ( Less potent :
indicated in nonimmuno-compromised patients )

56. RARITIES
• Actinomycosis
• Adenoid squamous cell
carcinoma
• Animal diseases
• Basal cell carcinoma
• Botryomycosis hominis
• Cancrum oris
• Child abuse
• Contact allergy
• Crohn's disease
• Eosinophilic ulcer
• Foot-and-mouth
disease
• Fungal infections
• Aspergillosis,
• blastomycosis,
• coccidioidomycosis,
• cryptococcosis,
• histoplasmosis,
• paracoccidioidomycosis
• sporotrichosis
• Gastrointestinal disease
• Glycogen storage disease
• Gonococcal stomatitis
• Graft-versus-host disease
• Granuloma inguinale
• Granulomatous disease of the
newborn
• Hand-foot-and-mouth disease
• Helminthic infection
• Herpangina
• Herpes zoster infection
• Leishmaniasis Leukemia
• Lymphoma
• Median rhomboid glossitis-
ulcerative variety
• Metastatic tumor
• Neurotrophic ulcer
• Phycomycosis
• Self-mutilation wounds
• Waldenstrtim's
macroglobulinemia
• Warty dyskeratoma

57. Conclusion
• Ulcerations seen in the oral cavity should
never be diagnosed without a proper medical
history of the patient
• Ulcer are diagnostic for many of the diseases
which are asymptomatic before they attain
lethal stages.
• Proper clinicopathological investigation may
help in avoiding these lethal diseases

58. References
• – Norman K. Wood , Paul W. Goaz : Solitary oral ulcers and
fissures , Textbook of Differential Diagnosis in oral medicie and
Radiology
• Oral ulcerations due to drug medications : Yoshinori Jimbu ,
Toshio Dimitsu
• Siegel RD, Granich R: Letter to editor, Oral Surgery 76:406,1993
• J Indian Soc Periodontol. 2009 Sep-Dec; 13(3): 157–159.
doi: 10.4103/0972-124X.60230 PMCID: PMC2848788 :Oral
histoplasmosis Karthikeya Patil, V. G. Mahima, and R. M.
Prathibha Rani
• Regression of Major Recurrent Aphthous Ulcerations Using a
Combination of Intralesional Corticosteroids and Levamisole: A
Case Report Bruna Lavinas Sayed Picciani, Geraldo Oliveira Silva-
Junior, Davi Silva Barbirato, Ruth Tramontani Ramos, and Marilia
Heffer Cantisano
• Web Sources