Diagnosis

acder ISLAMABAD 2013


• Full thickness loss of surface epithelium with exposed underlying connective tissue

or Simply


Epidemiology

Frequency

• very common. • prevalence

15% - 30%

• more common in women

• Frequency varies − fewer than 4 episodes per year (85% of all cases) − more than one episode per month (10% of all cases)


CLASSIFICATIONS

Ulceration,

Joseph A. Regezi, DDS, MS, James J. Sciubba, DMD, PhD, Richard C.K. Jordan, DDS, MSc, PhD, FRCD(C)

Saunders, An Imprint of Elsevier


CLASSIFICATIONS

Ulceration,

, Dept. of Otolaryngology SAM J. CUNNINGHAM, MD,PhD F R A N C I S B . Q U I N N , J R . , M D , FA C S


CLASSIFICATIONS The patient with,

Burket’s Oral Medicine Diagnosis & Treatment; 10th Edition; 2003 MARTIN S. GREENBERG, DDS







1. Chronic trauma − Single − can identify the cause and should improve after removal − Minimal pain

2. Malignancy − Single − Painless

3. Noncandidal fungal infections “deep mycoses” − Single − Painless


4. TB − −

Single ulcer in tongue / palate Associated symptoms (chronic cough, wt loss,..)

5. Mucous membrane pemphigoid − −

Multiple ulcers affecting mainly gingiva Blood filled blisters

6. Primary or tertiary syphilis


• Acute trauma − Single − can identify the cause and should improve after removal

• Viral infection (HSV) − Multiple − Associated symptoms (fever, malaise,…)

• Immune mediated disease − Erythema multiforme − RAS − Erosive


• Single − − − − −

Traumatic Primary or tertiary syphilis Deep mycosis TB Malignancy

• Multiple − Viral infection − Immune mediated disease • Erythema multiforme • RAS • Erosive lichen planus


• Yes  − Acute causes (trauma, viral, immune mediated)

• No − Chronic causes (trauma, deep mycosis, TB)


Can you relate them to any trauma or hot food? • Yes − Confirm traumatic ulcer − Remove the cause − Review after 1 week

• No − Look for other causes  ask further questions


Is it the first time or you had them before? • First time − Multiple  primary herpetic gingivostomatitis

• Recurrent  usually multiple − − − −

RAS Recurrent herpes infection Erythema multiforme pemphigus


Where are they located in the mouth? • RAS  movable non-keratinized mucosa • Recurrent intraoral herpes simplex  attached mucosa • Recurrent intraoral herpes zoster  palate + do not cross the midline

• Coxsackie virus (herpangina)  soft palate + tonsils • TB  palate / dorsum of tongue


Where are they located in the mouth? • ANUG  interdental papilla • Tertiary syphilis  palate/tonsils tongue

• Mucous membrane pemphigoid  gingiva • Pemphigus  buccal mucosa, palate & gingiva


Do they start as ulcer or as vesicle/bulla? • Vesicle − Viral (HSV) (HZV)

• Bulla − Mucous membrane pemphigoid  blood filled − Pemphigus  fragile (intraepithelial)


Do you get them anywhere else in the body? • No  think or oral conditions • Yes  Where? − Skin  mucocutanous disease • Lichen planus • Mucous membrane pemphigoid • pemphigus

− Different organs (genitalia, eyes)  systemic disease • Behcet’s disease


Things you need to look for  Site  Number  Size • Shape − Round ulcer  RAS − Angular or stellate  TB

• Base − Bleeding  malignancy

• Edge − Rolled margins  malignancy  chronic ulcer






• Self-inflicted. • Sharp teeth or restorations. • Iatrogenic.


• Self-inflicted. • Sharp teeth or restorations. • Iatrogenic.


• Appliances.

• Sharp teeth or restorations

• Iatrogenic.


• Appliances. • Self-inflicted

• Iatrogenic.


• Appliances. • Self-inflicted • Sharp teeth or restorations



Burns (chemical)

• Electric. • Heat. • Radiation.


Burns (chemical) • Chemical.

• Heat.

• Radiation.


Burns (chemical) • Chemical. • Electric.

• Radiation.


Burns (chemical) • Chemical. • Electric. • Heat.





acder

CHRONIC ULCER ACUTE ULCER

ISLAMABAD 2013

• • • • • • • • •

Pain Yellow base, red halo History of trauma Heals in 7 to 10 days if cause eliminated Little or no pain Yellow base, elevated margins (scar) History of trauma, if remembered Delayed healing if irritated, especially tongue lesions Clinical appearance mimics carcinoma and infectious ulcers



APHTHOUS ULCERS: POSSIBLE CAUSES Immunologic disorder: T cell mediated Neurogenic inflammation: neuropeptide (e.g., substance P) induced Mucosal healing defect: inhibition by cytokines Microbiological: viral, bacterial Nutritional deficiency: vitamin B12, folic acid, iron Chemical: preservatives, toothpaste components













Disease

Virus

Herpetic Stomatitis, Primary/Recurrent

Herpes Simplex Viruses, Type 1 and 2

Chicken Pox and Shingles

Varicella Zoster Virus

Herpangina

Coxsackie A Virus

Hand, Foot and Mouth Disease

Coxsackie A Virus

Infectious Mononucleosis

Epstein Bar Virus

Measles

Paramyovirus

Viral Warts

HPV

Oral Manifestation of HIV

HIV

Mumps

Paramyovirus

Cytomegalovirus

Cytomegalovirus


• common vesicular eruptions • HSV-1 and/or HSV-2 − Primary Infection (systemic) − Secondary Infection (localized)

• Both are self-limited

• recurrences of the secondary form virus can be sequestered within ganglionic tissue in a latent state












Usually secondary infection Primary infection: syphilis Tu b e rc u l o u s actinomycosis












• Oral lesions usually secondary to pulmonary lesions with hematogenous dissemination • Chronic ulcerations with necrosis, elevated nodular margins • May resemble squamous cell carcinoma • On the tongue, a cobblestone • Oral ulcers persist until treatment of systemic disease.


Diagnosis • Demonstration of organisms in biopsy specimen • Culture • Serologic demonstration of antigen or antibodies


Treatment • Sometimes none required • Amphotericin B

• Ketoconazole, fluconazole, itraconazole Prognosis • May recover spontaneously • Generally good unless immunosuppression present


• Candida − − − − − − −

Candida albicans Most common Normal flora Predisposing factors White creamy patches KOH prep Nystatin oral suspension


• Affects persons of Mediterranean, Middle Eastern, or Japanese decent • Immunodysfunction associated with certain HLA subtypes





• Squamous cell carcinoma (SCC) − − − −

Most common Irregular ulcers with raised margins May be exophytic, infiltrative or verrucoid Mimic benign lesions grossly

• Squamous cell carcinoma







• Inflammatory condition • Ischemia to minor salivary glands • Deep ulcers of the hard palate

• Resolves in 6 weeks

acder Sialometaplasia

ISLAMABAD 2013



• Contact stomatitis • Radiation mucositis • Cancer chemotherapy


• Erythema multiforme • Lichen planus • Benign mucous membrane pemphigoid • Bullous pemphigoid • Pemphigus vulgaris


− Rapidly progressive − Antigen-antibody complex deposition in vessels of the dermis − Target lesions of the skin − Diffuse ulceration, crusting of lips, tongue, buccal mucosa − Self-limited, heal without scarring



− Chronic disease of skin and mucous membranes − Destruction of basal cell layer by activated lymphocytes − Reticular: fine, lacy appearance on buccal mucosa (Wickman’s striae) − Hypertrophic: resembles leukoplakia − Atrophic or erosive: painful





− Tense subepithelial bullae of skin and mucous membranes − Rupture, large erosions, heal without scarring − Sloughing (Nikolsky sign)


• Cutaneous lesions more common

• Both show subepithelial clefting with dissolution of the basement membrane − IgG in basement membrane




− − − − − − −

Severe, potentially fatal Jewish and Italians Intraepithelial bullae and acantholysis Nikolsky’s sign Loss of intracellular bridges Autoimmune response to desmoglein 3 Intraepithelial clefting



