ORAL MUCOSAL ULCERATIONS
Transcript of ORAL MUCOSAL ULCERATIONS
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ORAL MUCOSAL ULCERATIONS
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Pathogenesis of Oral Ulcers• Trauma• Infection
– Viral– Granulomatous Bacterial or Fungal
• Immunopathologic• Ischemic• Neoplastic• Metabolic
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THE FOCAL ULCER
• Traumatic Ulcer• Traumatic Ulcerative Granuloma• Atypical Histiocytic Granuloma• Necrotizing Sialometaplasia• Traumatic Bony Sequestrum• Bisphosphonate Induced Sequestrum• Granulomatous Ulcer• Squamous Cell Carcinoma
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Traumatic Ulcers
• Acute• Chronic Irritation• Heal within 10-12 days• Removal of Irritant• Nonspecific Inflammation
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Traumatic Ulcer
• Lip bite • palate
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Facticial Injury
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Traumatic Ulcerative Granuloma with Stromal Eosinophilia
• Trauma or ? Etiology• Dorsal or Lateral Tongue• Large Dimensions, Symmetrical• Histocytes, Eosinophils• Inflammation into muscle
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Traumatic Ulcerative Granuloma with Stromal Eosinophilia
Clinical Histopathology
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Atypical Histiocytic Granuloma
• Variant of TUGSE• Elderly• Lips, Buccal Mucosa, Tongue• Asymmetrical, Irregular and Large• Granulation Tissue• Atypical Pleomorphic Mononuclear Cells• Mitotic Figures• Eosinophilia
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Atypical Histiocytic Granuloma
Clinical Histopathology
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Kimura’s Disease
• Ulcer or Subcutaneous/Submucosal Nodule
• Facial Skin• Common in Asia• Prominent Vessels• Lymphoid Aggregates with Germinal
Centers• Stromal Eosinophilia
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Necrotizing Sialometaplasia
• Ischemic Necrosis of Salivary Tissue• Deep Ulcer, Flat Borders• Central Grey, Granular Necrosis• Palate• Young Adults• Acinar Coagulation Necrosis• Ductal Squamous Metaplasia• Confused with Squamous Cancer
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Necrotizing Sialometaplasia
Clinical Histopathology
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Focal Sequestration
• Isolated foci of ulceration and sequestration • Lingual Mandible (mylohyoid ridge): develop
following trauma from intubation during general anesthesia
• Sequestra occur spontaneously among patients treated with Bisphosphonates for osteoporosis or as adjunct chemotherapy in patients with cancer.
• Tx: sequestrectomy with debridement
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Osteochemonecrosis (bisphosphonates)
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Granulomatous Ulcer
• Tuberculosis (Miliary)• Deep Fungus• Nonhealing, Painless• Rolled Margins• Palatal Perforation• Bone Erosion• Specific Granulomatous
Inflammation with Giant Cells/Special Stains
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Granulomatous UlcerClinical
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Granulomatous Ulcer
Clinical, Histoplasmosis
H&E, PAS stain
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Squamous Cell Carcinoma
• >50 years• Smoke Tobacco >75%• Alcholol• Lateral Tongue, FOM, Gingiva• Rolled Borders• Tumefactions
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Squamous Cell Carcinoma
Clinical Histopathology
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Squamous Cell Carcinoma
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Deep Osseous Destructive Ulcers
• Mucormycosis (Phycomycosis)• Antral Carcinoma• Tertiary Gummatous Syphilis• HIV associated Histoplasmosis• Midline Lethal Granuloma
– Angiocentric T Cell Lymphoma– Wegener’s Granulomatosis
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Mucormycosis
• Type I IDDM• Immunocompromised Patients
– Hematologic Malignancies• Oral Perforation• Hyphael Vascular Invasion• Osseous Necrosis
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Mucormycosis
Radiographic H&E, GMS stain
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Antral Carcinoma
• Elderly• Nasal stuffiness• Oral Perforation (OA Fistula)• Squamous Cell CA• Silent Tumor• Superoposterior Region of Sinus
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Antral Carcinoma
Palatal perforation Sinus opacity due to CA
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Gummatous Necrosis in Tertiary Syphilis
• Palatal perforation• 30-50 years post exposure• Necrotic foci are sterile (no spirochaetes)• Other manifestations of tertiary syphilis
– Aortic Aneurysm– Neurosyphilis– Tabes dorsalis– Other foci of gummatous necrosis
• No treatment, prosthetic obturator
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Gummatous Necrosis
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HIV, Histoplasmosis
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HIV Periodontitis, Necrotizing Stomatitis
• HIV +• Low CD4 counts• Skip lesions
– Spared regions alternate with affected regions• No Periodontal Pockets
– Both soft and hard tissues necrose and slough• Aggressive Debridement, Betadyne and
Chlorhexidine Rinses
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HIV Periodontitis (HIV-P)
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Necrotizing Stomatitis (HIV)
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Wegener’s Granulomatosis
• Vasculitis, Fibrinoid Necrosis• Palatal perforation• Gingival “strawberry gums”• Lung, Renal Lesions• ANCA (antineutrophil cytoplasmic Abs)• Potentially Fatal• Chemotherapy (Cytoxan, prednisone)
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Wegener’s Granulomatosis
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Multiple Ulcers
• Aphthous Stomatitis• Acute Necrotizing Ulcerative Gingivitis• Viral Ulcerations• Immediate Hypersensitivity• Erythema Multiforme• Agranulocytosis
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Recurrent Aphthae
• Minor• Major• Herpetiform• Systemic Disease Associations
– Gluten Enteropathy– B Vitamin and Folate Deficiency– HIV– Cyclic Neutropenia
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Minor Aphthae
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Recurrent Aphthae Minor
• Silver Nitrate
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Recurrent Aphthae Major
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Recurrent Aphthae Herpetiform
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Acute Necrotizing Ulcerative Gingivitis
• Ulcerations of Interdental Papillae• Periodontal Bone Loss not a feature• Fetid Odor• Stress is Predisposing Factor
– Physical, nutritional, emotional stresses• Acute onset• Low Grade Fever or Afebrile• Spirochaetes and Fusiform Bacteria• Debridement, Peroxide Rinses
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Acute Necrotizing Ulcerative Gingivitis
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Agranulocytosis
• Idiopathic• Pancytopenia/Aplastic Anemia• Chemotherapy
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Agranulocytosis
Clinical
• WBC – 2800
– PMNS 30%– LYMPHOCYTES 60%– MONOCYTES 6%– EOSINOPHILS 3%– BASOPHILS 1%
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HIV Oral Ulceration
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HIV Infectious Ulcers
• CMV • CMV inclusions
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Viral Vesicles to Ulcers• Herpes simplex
– Gingivostomatitis– Intraoral– labialis
• Varicella-zoster– Chichenpox– Shingles
• Coxackievirus/Enteroviruses– Hand Foot and Mouth – Herpangina– Enterovirus stomatitis
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Viral Ulcers, HSV, Coxsackie
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Allergic Stomatitis