Ulcers of the oral Cavity
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Transcript of Ulcers of the oral Cavity
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Ulcers of the oral Cavity
Dr: Arshad M.MalikAssociate Professor Surgery
LUMHS
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ORAL CAVITY• LIPS• TEETH• GINGIVA• ORAL MUCOUS MEMBRANES• PALATE• TONGUE• ORAL LYMPHOID TISSUES
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Oral Ulcers• Definations• Classifications• Causes
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Definition• Injury to the oral mucosa may result
in a localized defect of the surface in which the covering epithelium is destroyed leaving an inflammed area of exposed connective tissue. Such defects or erosions are called Ulcers.
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Classification• Traumatic• Recurrent apthous stomatitis (RAS).• Ulcers associated with systemic
diseases and vesicolobulous disease(Pemphigus,pemphigoid,erythema multiform)
• (Dermatitis herpetiformis epidermolysis bullosa)
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Causes of Oral ulceration1. Infective, viral, bacterial, fungal.2. Traumatic.• Mechanical• Thermal• Chemical• Factitious injury• Radiation• Eosinophilic ulcer or traumatic granuloma3. Idiopathic• Recurrent apthous stomatitis (RAS)• Minor apthous ulcers• Major apthous ulcers• Herpitiform ulcers
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Causes contd;4. Associated with systemic diseases• Hematological diseases• Gastrointestinal diseases• Behcet syndrome• HIV infection• Other diseases5. Associated with dermatological conditions• Lichen Plannus• Chronic discoid lupus erythromatous• Vesiculobullous dseases6. Neoplastic• Squamous cell carcinoma• Other malignant tumors
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Traumatic UlcersCheek Biting
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Trauma:• Ill-Fitting dentures
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Trauma:Chemical Burns
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Trauma:Abrasions from Teeth
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Recurrent Aphthous Stomatitis(RAS)
• Most common ulcerative lesion of oral cavity
• Recurrent, painful ulcers• Confined to soft mucosa• Subdivided into three types:–Minor aphthae–Major aphthae– Herpetiform aphthae
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Apthous ulcers contd:• Etiology• A. Not understood but damaging immune response in
increasingly implicated. Some of the factors are related to the cause
1. Immunological factors2. Heredity factors3. Microbiological factors4. Emotional stress5. Nutritional deficiencies6. Allergic disorders7. Hematological factors8. Gastrointestinal factors.
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Recurrent apthous ulcer stomatitis contd:
• C/F Minor apthous ulcers1. Prodromal signs appear hours before with
burning and itching.2. Comprise more than 80%3. May be shallow and round affecting the4. Non-keratinized part of the oral epithelium.5. Diameter of ulcer is less than 10mm with red
margin.6. Heal without scarring within 7-10 days. 7. Tend to recur with in 1-4 months.8. Site is usually the tongue, buccal mucosa, soft
palate.
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Minor apthous ulcer
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Recurrent apthous stomatitis Contd:
• Major apthous ulcer1. Larger than the minor ulcers more than 10
mm in diameter.2. Site is usually similar to minor pathos ulcer.3. Also involves the keratinized part of oral
mucosal epithelium.4. Vary in number from 1-10.5. Take 4-6 weeks to heal6. Heal with scarring.7. Recur in less than a month time.
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Major apthous ulcers
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Recurrent apthous ulcer contd:• Herpitiform ulcers1. Multiple small pin head size. Each ulcer 1-2 mm
in size.2. Can occur at any part of the oral cavity and as
many as hundreds of small ulcers may be present.
3. The ulcers are present in the form of clusters or crops and some times they join to form a big ulcer.
4. The also heal with scarring.5. Recur in less than a month time6. Associated with extreme pain and discomfort.
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Herpetiform ulcers
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Recurrent appthous ulcer contd:• Histopathology( Minor, Major, Herpetiform)1. Mononuclear cells are found in the sub
mucosa in the pre-ulcerative stage.2. These mono-nuclear cells are the T4
lymphocytes and soon are outnumbered to T8 lymphocytes when ulcerative stage develops.
3. Macrophages and mast cells are also present in the base of ulcer.
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Treatment• Major,Minor,Herpetiform ulcers.1. Minor apthous ulcers require no treatment only
topical gels are used to minimize the pain, as the ulcer is self limiting and heals with in 7-10 days.
2. Anti inflammatory gels and mouth washes are also used to prevent any further infection and to control the inflammation caused by the ulcer.
3. For major apthos ulcers topical steroids may be used.
4. In extreme severe cases systemic steroids such as prednisolone in doses 20-40 mg daily have giving promising results.
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Behcet’s• Symptom complex of:– Recurrent aphthous ulcers of the mouth– Painful genital ulcers– Uveitis or conjuctivitis
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Herpesvirus Infection• HSV-1 and/or HSV-2– Primary Infection– Secondary Infection
• Varicella zoster virus (HHV-3)
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Herpesvirus Infection• Primary Infection– Herpetic gingivostomatitis– Younger patients– Often asymptomatic–May be associated with fever, chills,
malaise– Vesicles-ulcers-crusting– Anywhere in the oral cavity
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Herpesvirus Infection
Primary Infection
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Herpesvirus Infection• Secondary Infection– Reactivation of latent virus– Not associated with systemic symptoms– Small vesicles – Occur only on the hard palate and
gingiva– Prodromal signs
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Herpesvirus Infection
Secondary infection
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Secondary infection• Varicella zoster
virus (HHV-3)– Latent infection– Oral ulcers– Dermatomal
distribution
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Infection• Rare• HIV/AIDS patients• Bacterial• Deep mycotic infection• Candida
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Infection• Bacterial– Usually secondary infection– Primary infection: syphilis, tuberculous,
or actinomycosis
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Infection
Bacterial-Syphilis
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Infection• Mycotic– Blastomycosis– Histoplasmosis
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Histoplasmosis
Histoplasmosis
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Infection• Candida– Candida albicans–Most common– Normal flora– Predisposing
factors–White creamy
patches – Nystatin oral
suspension
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Infection• Candida
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Neoplasm• Squamous cell carcinoma (SCC) –Most common– Irregular ulcers with raised margins–May be exophytic, infiltrative or
verrucoid–Mimic benign lesions grossly
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Neoplasm• Squamous cell carcinoma
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Dermatologic Disorders• Erythema multiforme– 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
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Dermatologic Disorders
Erythema multiforme
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Dermatologic Disorders• Lichen planus– 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
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Dermatologic Disorders• Benign mucous
membrane pemphigoid– Tense subepithelial bullae
of skin and mucous membranes
– Rupture, large erosions, heal without scarring
– Sloughing (Nikolsky sign)• Bullous pemphigoid
– Cutaneous lesions more common
• Both show subepithelial clefting with dissolution of the basement membrane– IgG in basement
membrane
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• Pemphigus vulgaris– Severe, potentially
fatal– Jewish and Italians– Intraepithelial
bullae and acantholysis
– Nikolsky’s sign– Loss of intracellular
bridges– Autoimmune
response to desmoglein 3
– Intraepithelial clefting
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Thanks for your attention