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Evaluation Of Oral Ulcerations

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Evaluation Of Oral Ulcerations

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Evaluation Of Oral Ulcerations

  1. 1. Ulcer – is a break in the continuity of the covering epithelium – skin or mucous membrane. It may follow molecular death of surface epithelium or traumatic removal
  2. 2. Margin – junction between normal epithelium and ulcer Edge – area between margin and floor of ulcer Floor – exposed surface of ulcer Base - where ulcer rests on
  3. 3. Shape: › Oval – generally tuberculous › Circular to serpiginous - syphilitc › Irregular - carcinomatous Number: › Multiple ulcers – herpetic ulcers › Usually single – syphilitic & tuberculous ulcers Position: › Tuberculous ulcers common in area of adenopathy › Carcinomatous can occur anywhere
  4. 4. Edge: › Spreading ulcer –inflamed and edematous › Healing ulcer – red granulation tissue to blue zone(growing epit.) to white zone (fibrosis) › Undermined – tuberculous ulcer › Punched out – syphilitic ulcer › Sloping – healing ulcer › Raised & beaded – rodent ulcer › Rolled out and everted – squamous cell carcinoma
  5. 5. Floor: › Slough – stage of extension › Red granulation tissue - healing ulcer › Smooth pale granulation – stage of healing › Watery granulation tissue - tubercular ulcer › Floor above surface – malignant ulcer › Wash leather slough – gummatous ulcer Discharge : › Purulent – bacterial infection › Watery – tuberculous › Bloody – malignancy
  6. 6. Tenderness: › Exquisitely tender - acute › Slightly tender - chronic › Never tender – neoplastic Base: › Using thumb and index finger – attempt to pick up ulcer › Slight induration – chronic ulcer › Marked induration – malignancy
  7. 7. Relation with deeper structures: › Malignant ulcer – fixed to deeper tissues Surrounding skin/mucosa: › Increased temp. and tenderness – inflammatory › Fixity to deeper structures – malignant ulcer
  8. 8. Causes of Oral Ulcers Acute < 3 weeks Chronic > 3 weeks Neoplastic Non- neoplastic
  9. 9. Acute Ulcer •Traumatic ulcer •Acute necrotising ulcerative gingivitis •Herpetic ulcer •Minor aphthous ulcer •Shingles •Primary syphilis
  10. 10. Chronic Ulcer Neoplastic Non-neoplastic •Tuberculous ulcer •Major aphthous ulcer •Lichen planus •Secondary & tertiary syphilis •Pemphigus •Cicatricial pemphigoid
  11. 11. Acute Ulcers • Sharp tooth, badly decayed tooth • Roughened prostheses & sharp edges • Chemicals – aspirin • Iatrogenic Etiology Traumatic Ulcer
  12. 12. • Pain, inflammation • Acute - covered with yellow whitish fibrinous exudate surrounded by erythematous halo • Chronic – yellow membrane – raised margins • Whitish surrounding mucosa Clinical Features • History and examination • Chronic – 2 week examination – biopsy Diagnosis: • Solitary ulcer – bacterial origin – suppurative • Chancre – indurated • TB ulcer – systemic ulcer Differential diagnosis:
  13. 13. • Fusiform bacillus • Borrelia vincentii Etiology Acute Necrotising Ulcerative Gingivitis Precipitating factors: Stres s Poor oral hygiene Poor nutritional status Immunosu ppression
  14. 14. • Painful punched out craterlike lesions – interdental papilla • Grayish pseudomembrane covering • Bleed when touched • Fetid odour • Headache , malaise, low-grade fever • Metallic taste • Lymphadenopathy Clinical Features:
  15. 15. Investigation Smears show fusiform bacilli and spirochetes with gram staining
  16. 16. Etiology Herpes Simplex Virus 1 • By droplet spread or contact of lesion Herpetic Ulcer
  17. 17. Clinical Features Fever, pain on swallowing, regional lymphadenop athy Yellowish fluid filled vesicles – ragged and well delineated Along sensory nerve distribution Ruptures and covered by gray membrane and erythematous halo Common – lips, tongue, palate, buccal mucosa Heals within 7-10 days Recurrent in immuno- comprom ised
  18. 18. Primary infection VZV Chicken pox Virus becomes dormant Reactivation Shingles Varicella Zoster Virus
  19. 19. • Acute ulcers along division trigeminal nerve • V1 – upper eyelid, forehead, scalp • V2 – midface & upper lip • V3 – lower face & lower lip Clinical Features • V2 – prodrome of pain, burning – palate • Unilateral distribution • 1-5 mm clustered ulcers – painful • Coalesce form larger • Heal -10-14 days Ulcers
  20. 20. • Ramsay hunt syndrome - bells palsy, loss of taste sensation in anterior 2/3rd and vesicles of external ear Complication • Smear – no difference HSV, VZV • Fluorescent antibody tests • PCR Investigations
  21. 21. • Autoimmune response • B12/Folic acid deficiency • Psychologic factors - stress • Allergic factors • Familial tendency Etiology Minor Aphthous Ulcer
  22. 22. • 1-5 shallow, round/oval ulcer • 2-10mm gray/yellow base – erythematous margin • Heal 7-10 days no scarring • 1-2 a month – buccal mucosa, tongue, soft palate Clinical Features
  23. 23. Treponema Pallidum Primary Syphillis • Solitary ulcer 3-90 days after contact • Oral chancre • Common – lip and anterior part of tongue • Painful • Starts as firm nodule and surface breaks after a few days • Rounded ulcer with indurated edges • Regional lymphadenitis Clinical Features
  24. 24. Diagnosis History of sexual contact Lab Diagnosis • Spirochetes in Dark field illumination/ Silver stained smears
  25. 25. • Mycobacterium tuberculosis Etiology • Fever, chills, malaise, cough , loss of weight • Deep painful ulcer • Undermined edge • Watery discharge • Palpable matted lymph nodes Clinical Features: Chronic Ulcers Tuberculous Ulcer
  26. 26. Acid fast bacilli in sputum Chest x-ray Tuberculin test – 0.1 ml – 5 tuberculin units purified protein derivative - >10mm induration ELISA & PCR Investigations
  27. 27. • Seen after 6 weeks of primary lesion • With fever, headache, sore throat, lymphadenopathy • Common – palate, tonsils, lateral border tongue and lip • Lesions – irregularly linear (snail track ulcers)Mucous patches – multiple grayish white plaque Clinical Features Secondary Syphilis
  28. 28. Lab Diagnosis: VDRL test FTA-Abs test
  29. 29. • After 3 years initial infection • Gumma – focal granulomatous inflammatory process with central necrosis • Nodular mass with yellowish center • Necrotizes to leave deep painless ulcer Clinical Features Tertiary Syphillis
  30. 30. Etiology Autoantibodies DSG 3 - desmosomes Weakens intercellular connection Pemphigus • Pressure to apparently normal area – forms new lesion • Nikolsky sign – peeling of upper layer of epithelium Clinical Features
  31. 31. • Bulla breaks – shallow irregular ulcer • Edges extends peripherally over time • Start – buccal mucosa – along areas of trauma in occlusal plane • Painful – difficult to eat or drink Clinical Features • Positive nikolsky sign • Biopsy – suprabasilar acantholysis – stratum spinosum • Direct immunofluorescence – IgG presence Investigation
  32. 32. Etiology Autoantibodies of IgG Against hemi- desmosomes Cicatricial Pemphigoid • Bullae are thick-walled – ruptures 24-48 hours • Leaves raw eroded bleeding surface • Ulceration and scarring Clinical Features
  33. 33. • Desquamative lesions – common on gingivae Clinical Features • Biopsy – subepidermal vesicles and bullae • Absence of nikolsky sign Investigations
  34. 34. T lymphocyte- mediated disorder Etiology Dental restorations – amalgam Drugs – NSAIDs Stress Viral infection Lichen Planus
  35. 35. Clinical Features: Atrophic – smooth, red areas Erosive - painful, with a yellowish slough Striae radiate from margins of erosions Common - buccal mucosa, dorsum of tongue, gingiva Usually bilateral
  36. 36. Etiolog y Autoimmune response B12/Folic acid deficiency Psychologic factors - stress Allergic factors Familial tendency Major Aphthous Stomatitis & Recurrent Herpetiform Ulcer
  37. 37. • 1-10 number – large painful • Yellow necrotic center erythematous halo • Cheeks, tongue, soft palate – dysphagia • >10mm – persist >3 weeks and scars Major Aphthous Ulcer • Multiple ulcer – 1-100 • 1-2mm at any site and coalesce • Painful and heals in 2-3 weeks – no scar Recurrent herpetiform ulcer:
  38. 38. Etiology Tobacco Alcohol Infection – HPV 16 Chronic irritation UV radiation Genetic predisposition Neoplastic Ulcers
  39. 39. • Single ulcer – rolled,raised and everted border • Painless usually – non-healing • Induration on palpation • Local pain or paresthesia in nerve involvement • Referred earache, trismus, dysphagia, halitosis, enlarged cervical nodes Clinical Features: • Symptoms > 3 weeks • Ulcer without healing 7-10 days – biopsy • Biopsy – mitotic figures, keratin pearls, pleomorphism, connective tissue involvement Diagnosis:
  40. 40. • Non-healing ulcer > 3 weeks • Induration & lack of inflammation surrounding • Rolled & thickened edge • Smoking & alcohol • Male 2:1 & Age > 50 years • History premalignant lesion in area • No local factors Suspicion of Malignancy • Ulcers – multiple & synchronously • Clustering ulcer • Blister formation • Associated sore and bleeding gums • Identifiable local cause • Recurrent ulceration Reduced Suspicion of Malignancy
  41. 41. Ulcer > 3 weeks Features suggesting malignancy - Solitary ulcer - Proliferative appearance Optimise general health Refer through 2 week wait route Features that do not suggest malignancy Isolated ulcer - Trauma Managed in primary care if confident of diagnosis Recurrent ulcer - Aphthous ulcer Managed in primary care if confident of diagnosis Widespread oral ulcer - Oral lichen planus Refer
  42. 42. • Oral ulceration - common and mostly benign • Some oral ulcers may be associated with systemic disease or particular drugs • A systematic approach to examination of the oral cavity with good lighting and retraction of mobile tissues is critical Conclusion
  43. 43. • A minority of oral ulcers are malignant • Ulcer that persists for more than three weeks should be referred; suspected malignancy requires urgent referral to a specialist • Non-malignant oral ulceration may be investigated and treated in primary care or referred • A benign ulcer is not referred, re- evaluate the lesion to ensure that healing has occurred Conclusion

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