ORAL MEDICINE

1. GOOD
MORNING

2. SEMINAR

3. SINGLE ULCERS
YA S M I N M O I D I N
2 0 0 8 B ATC H
A L A Z H A R D E N TA L C O L L E G E
THODUPUZHA

4. INTRODUCTION
 The most common cause of single ulcers on the
oral mucosa is trauma

5. TYPES
 Traumatic ulcer
 Eosinophilic ulcer of tongue
 Histoplasmosis
 Blastomycosis
 Mucormycosis
 Syphilitic ulcer

6. TRAUMATIC ULCER
 Most common oral mucosal ulcer
 Types of trauma
 Mechanical
 Chemical
 Thermal
 Radiation
 Self-inflicted
 Iatrogenic

7.  CLINICAL FEATURES
 Tenderness or pain in the area of lesion
 Sites : tongue, lips, mucobuccal fold, gingiva and palate
 Persist for few days or lasts for weeks
 Vary in size and shape
 Borders are raised and reddish
 Bases are yellowish necrotic surface
 Frequently, a painful regional lymphadenitis occur as a result of
contamination of ulcer by oral flora

8.  DIFFERENTIAL DIAGNOSIS
 Carcinomatous ulcer
 Recurrent aphthous ulcerations
 MANAGEMENT
 Removal of traumatic factor
 Most traumatic ulcer become painless within 3 to 4 days
 After the injury producing agent has been eliminated, most heal
with 10 days

9.  Less serious varieties, treat with triamicinolone acetonide
with emolient
before bed time and after meals usually
relieves the pain and hastens the healing
 Orabase
protects
the
denuded
CT
from
continued
contamination by oral liquids and cortisone component
tend to arrest the inflammatory cycle
 Persistent ulcers are surgically excised

10. EOSINOPHILIC ULCER OF TONGUE
 ETIOLOGYAND
PATHOGENESIS
 Inflicting crush injury on
tongue-most common site
 Deep and penetrating

11.  RIGA-FEDE DISEASE
 Lesion seen on ventral tongue
 Infants
 Cause-
tongue rasping against newly erupted
primary incisors

12.  CLINICAL MANIFESTATIONS
 Bimodal age distribution
 1st group- in 1st 2 years of life-lesion associated with
erupting primary dentition
 2nd group – adults – 5th and 6th decades

13.  ORAL FINDINGS
 Children
– anterior ventral or dorsal tongue
associated with erupting mandibular or maxillary
incisors
 Adults – posterior and lateral aspect of tongue
 Ulcer – not painful & persist for months
 History of trauma

14.  Appear cleanly punched out, with surrounding
erythema & whiteness
 Size – 0.5cm
 Surrounding tissue is indurated
 5 % - multifocal and recurrences are not uncommon
 In some cases , lesions are ulcerated , mushroom-
shaped , polypoid mass on the lateral tongue

15.  DIFFERENTIAL DIAGNOSIS
 Recurrent aphthous ulcers
 Squamous cell carcinoma
 T-cell lymphomas

16.  LABORATORY FINDINGS
 Biopsy is needed to make diagnosis
 MANAGEMENT
 Intralesional steroid injections
 Wound debridement
 Use of nightguard on lower incisor – reduce nighttime
trauma

17. HISTOPLASMOSIS
 ETIOLOGY AND PATHOGENESIS
 Caused by fungus Histoplasma capsulatum
 Infection results from inhaling dust contaminated
with droppings, from infected birds or bats

18.  CLINICAL MANIFESTATIONS
 The expression of the disease depends on the quantity of
spores inhaled, the immune status of the host and the
strains of the organism
 Asymptomatic and mild flulike illness for 1 to 2 weeks
 The inhaled spores are ingested by macrophages within
24 to 48 hours and specific T lymphocyte immunity
develops in 2 to 3 weeks

19.  TYPES
 Acute histoplasmosis
 Self –limited pulmonary infection
 Acute
symptoms
are
fever, headache, myalgia, nonproductive cough, anorexia
 Patient is ill for 2 weeks
 Calcification of hilar lymph nodes

20.  Chronic histoplasmosis
 Primarily affects the lungs
 Affects
older,
emphysematous,
white
men
or
immunosuppressed patients
 Patients
typically
exhibit
cough,
weight
loss, fever, dyspnoea, chest pain, hemoptysis, weakness
and fatigue

21.  Disseminated histoplasmosis
 Less common
 It is characterized by progressive spread of the infection
to extrapulmonary sites
 It occurs in older, debilitated, immunosuppressed
patients and patients with AIDS
 Tissues that affect include: spleen , adrenal
glands, liver, lymph nodes, GIT, CNS, kidneys and oral
mucosa

22.  Common sites – tongue, palate, buccal mucosa
 It appears as a solitary, painful ulceration of several
weeks duration
 Some lesions appear erythematous or white with an
irregular surface
 Ulcerated lesions have firm, rolled margins

23.  ORAL FINDINGS
 Oral lesion begin as an area of erythema , becomes
papule & forms Painful , granulomatous –appearing
ulcer
 Cervical lymph nodes are enlarged and firm
 Patients with HIV has an ulcer with
border, seen on gingiva , palate , tongue
indurated

24.  DIFFERENTIAL DIAGNOSIS
 Traumatic ulcerative granuloma
 Squamous cell carcinoma
 Lymphoma

25.  LABORATORY FINDINGS
 Biopsy – stained with PAS OR methanamine silver –
reveal presence of fungi
 MANAGEMENT
 Immunocompromised patients -IV amphotericin B
 AIDS – itraconazole & maintenance therapy
 Immunocompetent – itraconazole or ketoconazole for 6 to 12
months

26. BLASTOMYCOSIS
 ETIOLOGY AND PATHOGENESIS
 Caused by Blastomyces dermatitidis
 Infection
results from inhalation and is found in
agricultural and construction workers

27.  CLINICAL MANIFESTATIONS
 It is acquired by inhalation of spores , particularly after
rain
 The spores reach the alveoli of lungs, where they begin to
grow as yeasts
 The infection is halted and contained in the lungs
 The
sites
of
dissemination
include
skin, bone, prostate, meninges, oropharyngeal mucosa
and abdominal organs

28.  Types
 Acute blastomycosis
 Resembles pneumonia, characterised by high fever, chest
pain, malaise, night sweats and productive cough with
mucopurulent sputum
 Rarely, the infection may precipitate life-threatening
adult respiratory distress syndrome

29.  Chronic blastomycosis
 More common
 Characterisezd by low grade fever, night sweats, weight loss and
productive cough
 Chest radiographs shows diffuse infiltrates or pulmonary or hilar
masses
 Calcification is not typically present
 Lesion begins as erythematous nodules that enlarge , becoming
verrucous or ulcerated

30.  ORAL FINDINGS
 It
may
result
from
either
extrapulmonary
dissemination or local inoculation with the organism
 Lesions have an irregular, erythematous or white
intact surface
 Appear as ulcerations with irregular rolled borders
and varying degree of pain

31.  LABORATORY FINDINGS
 Diagnosis by biopsy and culture demonstrates presence
of multinucleated yeast cells with dark cytoplasm &
colorless cell walls with characteristic of B.dematitidis
 TREATMENT
 Disseminated or progressive – ketoconazole , fluconazole
, itraconazole for mild to moderate
 Amphotericin B – sever disease

32. MUCORMYCOSIS
 ZYGOMYCOSIS/ PHYCOMYCOSIS
 ETIOLOGY AND PATHOGENESIS
 Caused by saprophytic fungi
 Occurs in soil or as a mold on decaying food
 Fungus is nonpathogenic

33.  CLINICAL MANIFESTATIONS
 Rhinocerebral zygomycosis
 Patient
experiences
nasal
obstruction,
bloody
nasal
discharge, facial pain or headache, facial swelling or cellulitis
and visual disturbances with concurrent proptosis
 With
progression
of
disease
into
the
cranial
vault, blindness, lethargy and seizures may develop followed
by death

34.  If maxillary sinus is involved, the initial presentation
may seen as intraoral swelling of maxillary alveolar
process & palate
 If
the
condition
is
untreated,
palatal
ulceration, appears as black and necrotic and
massive destruction

35.  ORAL FINDINGS
 Ulceration of the palate
 Lesion is large & deep, causing denudation of underlying
bone
 Other sites- gingiva, lip , alveolar ridge
 Initial manifestation confused with dental pain or
bacterial maxillary sinusitis caused by
maxillary sinus
invasion of

36.  LABORATORY FINDINGS
 Biopsy is split into culture & histopathology
 Histopathologic findings- necrosis & nonseptate
hyphae
 Necrosis & occlusion of vessels is present

37.  MANAGEMENT
 Combination of surgical debridement of the infected
area
 Amphotericin B for 3 months
 Observed for renal toxicity
 Posaconazole , antifungal agent is used for patients
unable to tolerate toxicity of amphotericin

38. SYPHILITIC ULCER
 Syphilis is a sexually transmitted disease , caused by
Treponema pallidum
 CHANCRE
 Seen in genital region
 Other sites- lips , tongue, palate, tonsillar regions
 In initial stage- papule seen which subsequently erodes
 Typical
syphilitic ulcer is punched-out, non
tender, indurated and associated with yellowish
discharge

39.  Associated nodes are firm & non tender on palpation
 Self-limiting & last for 2 weeks
 Heal with minimum scar formation
 MUCOUS PATCHES
 Appears after a latency period of 6 months
 Patient complains of fever, headache, bodyache & sore
throat
 Cutaneous
maculopapular
lymphadenopathy
rashes
associated
with

40.  Oral lesions are characterised by appearance of oval red
macules (palate) or papules (buccal mucosa &
commissures) and mucous patches
 Mucous patches are seen as raised erosive areas covered by
a grayish white pseudomembraneous and surrpunded by an
erythematous halo
 Measure about 1 cm in diameter
 Small lesions join together to give rise to snail track ulcers
 severe & generalised form – lues maligna, also termed
ulceronodular disease

41.  Oral mucosa reveals shallow crater like ulcers
 Common sites – palate , buccal
mucosa, tongue, lower lip, and gingiva
 GUMMA
 It is a highly destructive lesion
 It occurs 8 to 10 years after initial infection
 Common sites – hard palate , tongue

42.  MANAGEMENT
 Parenteral pencillin G
Allergic to pencillin, treated with doxycycline

,
tetracycline , erythromycin