04/28/12

Abou-Elhamd

Oral ulcers

04/28/12

Dr. Kamal Abou-Elhamd MD Professor Abou-Elhamd MD Dr. Kamal in ENT Al-Ahsa College Professor in ENT of Medicine King Faisal University & Al-Ahsa College of Medicine Sohag College of Medicine King Faisal University Sohag University,Kamal375@yahoo.com Egypt Email: Email: Kamal375@yahoo.com Website: www.geocities.com/kamal375/papers.html
Abou-Elhamd

Oral Ulcers
Oral ulcers are inflammatory lesions of the oral mucosa that affect 20% of the population Causes of oral ulceration range from the relatively trivial, eg traumatic ulcers, to the serious, eg oral cancer or pemphigus vulgaris Oral ulcers can be a feature of various systemic disorders including inflammatory bowel disease

1. The number, shape, size and border 2. Onset of the lesions as acute or gradual 3. Duration of the lesions as acute (2 weeks) or chronic (more than 2 weeks) 4. Recurrence or progression of the lesions

Features of Ulcer

Features of Ulcer
1. Presence of vesicles, white or red lesions preceding the ulcers 2. Presence of skin, eye or genital lesions 3. Concurrence of systemic manifestations 4. Medication taken by the patient

Commonest causes of Ulcers

1. 2. 3. 4. Trauma Recurrent aphthous stomatitis Herpes virus group infections Dermatoses

Causes of Acute Ulcers

Causes of Acute Ulcers

Causes of Acute Ulcers

Chronic ulcers

If the ulcer lasts for > 2 weeks

Causes of Chronic Ulcers

Causes of Chronic Ulcers

Traumatic Ulcers
Single and located in an area subjected to injury Their centre are White or yellow with erythematous halo Painful and exhibit an elevated, rolled border which is firm when palpated

Traumatic Ulcers
Sharp teeth and tooth edges, can produce ulcers Self-inflicted lesions in children and patients with mental disorders Self-induced traumatic ulcers can also be caused by incorrect tooth brushing, biting of the tongue or lower lip Decubitus ulcers can be produced by dental prostheses

Abrasions from Teeth

Post-anaesthesia traumatic ulcer on lower lip

Ulcerative traumatic granuloma with stromal eosinophilia (Riga-Fede disease)

A decubitus ulcer is a pressure sore or what is commonly called a "bed sore".

Other types of Traumatic Ulcers

Chemical ulcers
Caustic ulcers are produced by direct contact of the oral mucosa with acids or strong alkalis. Oral mucosal ulcers have been related to topical acetylsalicylic acid, pancreatic supplements, potassium tablets, bisphosphonates, trichloroacetic acids

Chemotherapy induced oral mucositis

Drug induced oral ulcer

Recurrent aphthous stomatitis (RAS)

One or multiple recurrent and painful ulcers. Well-defined, round or oval ulcers covered by a white or greyish pseudomembrane and surrounded by an erythematous halo

Types of Recurrent aphthous stomatitis Minor aphthae are the most common (80%) Major aphthae (10%) Herpetiform aphthae (5 10%)

Minor Aphthae
They are characterized by the formation of 15 well-defined superficial ulcers that are round or oval with a diameter < 10 mm, covered by a white or greyish pseudomembrane and surrounded by an erythematous halo.

Minor Aphthae
They normally appear in the nonkeratinized mucosa and are rare in the keratinized gingiva, palate or tongue dorsum. Lesions appear over variable time periods and disappear in 1014 days without leaving scars

Aphthous Ulcers

Aphthous Ulcers

Major Aphthae
(also known as Suttons disease) They are similar to minor aphthae but are larger (> 10 mm) and very painful. They can occur as single or multiple ulcers. They may appear at any site but have a predilection for the lips, soft palate and throat. They can persist for 6 weeks and commonly leave scars

Herpetiform Aphthae
They are characterized by the presence of multiple (50100), small (23 mm) and painful ulcers throughout the oral cavity, which tend to coalesce and form ulcers of larger size. They usually heal within 710 days without leaving scars

BD is a systemic vasculitis characterized by recurrent oral and genital ulcers, skin lesions and ocular, musculoskeletal, cardiovascular, gastrointestinal and neurological symptoms. Onset is usually during the third and fourth decade of life. Genetic, environmental, infectious, immunological and haematological factors have been implicated in its aetiology.

Behcets disease

Major, minor and herpetiform aphthae appear in the oral cavity in this disease, generally on oral mucosa, gingiva, lips, soft palate and pharynx

Behcets disease

Behcets Syndrome

Uveitis in Behcets Patient Major Aphthous Ulcer in Behcets Patient

Viral Ulcers
1. Herpes simplex virus 2. Varicella zoster virus infection (chickenpox) 3. Coxsackie virus produces Herpangina 4. EpsteinBarr virus 5. Cytomegalovirus 6. Measles virus 7. Human immunodeficiency virus

Oral features consist of gingivitis, followed after 23 days by the formation of vesicles that readily rupture, giving rise to painful ulcers covered with a yellowish membrane, which tend to coalesce. They are mainly localized to the lips, tongue, oral mucosa, palate and pharynx.

Herpes simplex virus Ulcers

Episodes of paraesthesia, erythema, vesiculation, pustulization and ulcers at the mucocutaneous junctions of the lips and/or nose The ulcers usually heal spontaneously after 10 days with no sequelae and are accompanied by submandibular lymphadenitis, swallowing difficulties and halitosis

Herpes simplex virus Ulcers

Herpes simplex virus Ulcers

Herpesvirus Infection
Secondary infection

Herpes simplex virus Herpes labialis isUlcers the first feature of

secondary infection which occurs as vesicles and ulcers on the lip and lip vermilion that leave scabs after spontaneous healing within 710 days. Recurrent intraoral herpes is the second feature of this secondary infection, with very painful ulcers mainly localized to the keratinized gingiva and hard palate. They spontaneously disappear after 710 days.

Papular and pustular skin lesions develop, with vesicles and ulcers on the trunk. Depending upon the severity of the disease, vesicles can appear on the palate. the virus remains in nerves and may be reactivated in adulthood, giving rise to mononeuropathies or polyneuropathies that present as herpes zoster (shingles). The most common sequela is posttherapeutic neuralgia.

Varicella zoster virus )infection (chickenpox Ulcers

Varicella Zoster Chicken Pox

Herpangina Ulcers by vesicles Fever and sore throat followed

in the oropharynx, mainly in pillars over the soft palate, uvulae, palate and amygdales. These vesicles disappear spontaneously in 45 days. Hand, foot and mouth disease, common in school-age children, is characterized by vesicles in the oral cavity, palms of hands and soles of feet. It disappears without treatment within a week.

Herpangina

EpsteinBarr virus Ulcers Infectious mononucleosis with fever syndrome, oral ulcers, palatal petechiae and systemic disorders

Other virus Ulcers Cytomegalovirus can cause large and chronic oral
ulcers in immunodepressed patients. Measles virus can affect the oral cavity during systemic infection, causing Kopliks spots, gingivitis and pericoronaritis alongside the typical systemic features. Human immunodeficiency virus causes oral lesions, which can occasionally be the first sign of the disease. Large, deep ulcers appear, mainly involving the vestibular and pharyngeal mucosae. This ulceration is related to opportunistic pathogens in the oral cavity.

HIV associated Kaposis sarcoma

Deep, necrotic ulcer in HIV infection

Vincents disease, Trench mouth, acute ulcerative gingivitisd

Bacterial Ulcers
Syphilis is associated with skin and mucosal lesions in its acute phase. A chancre, a deep nonpainful ulcer 1-2 cm with increased and indurated borders, appears during the initial stage of primary syphilis. The ulcers can be genital or oral, and heal spontaneously.

Chancre

Secondary syphilis: oval-tocrescenteric erosions or shallow ulcers of about 1 cm diameter, covered by a grey mucoid exudate and with erythematous haloe Tertiary syphilis is characterized by the presence of syphilitic gummas (painfree ulcerated nodular lesions on hard palate or tongue) and nerve and

Bacterial Ulcers

Bacterial Ulcers
Gonorrhoea presents with several oral features, ranging from mild erythema to deep ulcers covered by a pseudomembrane. Fever, foetid breath and viscous saliva may be seen Neisseria gonorrhea is commonly isolated from the pharynx of subjects practicing oral sex

NS is an uncommon disease that gives rise to extensive, deep ulcers with indurated borders , mainly localized to the hard and or soft palate. It is a benign and self-limiting necrotizing inflammatory disease of the minor salivary glands but can simulate a malignant Neoplasm. The cause is believed to be an ischaemia Secondary to trauma or to damage from a chemical or biological agent.

Necrotizing sialometaplasia

Allergic Ulcers
Allergic reactions, ranging from erythma to ulceration, can appear in the oral mucosa after the topical application of numerous substances and medicines (contact stomatis)

Erythema multiforme Ulcers The minor form is acute and selflimiting and can be episodic or recurrent. Typical target lesions symmetrically cover < 10% of the body surface area (BSA). The mucosae are sometimes involved, most commonly the oral mucosa, with erythema, vesicles and ulcers and involvement of the lip in almost all cases, leaving

Erythema Multiforme

Steven-Johnson Syndrome

Erythema Multiforme

Erythema multiforme Ulcers

Toxic Epidermal Necrolysis (TEN) is characterized by erythematous patches, skin lesions at atypical target sites, severe mucosal erosions and bullae and epidermal detachment of > 30% of the BSA

Toxic Epidermal Necrolysis

PFAPA syndrome
PFAPA (periodic fever, aphthous stomatitis, pharyngitis and adenopathy) The symptoms do not regress with antibiotic and antipyretics Corticosteroids (2 mg kg) are effective in shortening the duration and severity of attacks Tonsillectomy is effective in reducing recurrences

Blood diseases Ulcers

Oral ulcers may appear in diseases associated with blood deficiencies, e.g. anaemias, leukaemias, lymphomas, multiple myeloma and neutropenias, especially cyclic neutropenia, which causes ulcers similar to those of recurrent aphthous disease

Systemic diseases which cause oral ulcers

Systemic diseases which cause oral ulcers

1. Haematological 2. Gastroentrological 3. Dermatological 4. Immunological 5. Drug induced

1. Anaemias 2. Lymphoproliferative disease: Leukaemias (almost all), NonHodgkins lymphoma & Hodgkins lymphoma (rare) 3. Myeloproliferative disease: (usually multiple myeloma) 4. Myelodysplasias 5. Neutropenia (any cause)

Haematological oral ulcers causes

Gastroenterologi cal oral ulcers causes 1.Gluten-sensitive enteropathy 2.Crohns disease and related disorders 3.Dermatitis herpetiformis 4.Ulcerative colitis

Irregular superficial ulcers on ventral surface of tongue in Crohns disease

Aphthus Like Ulcer minor in patient with Coeliac Disease

Dermatological oral ulcers causes 1. Lichen planus

2. Pemphigus usually vulgaris, rarely vegetans, folacous or paraneoplastic 3. Pemphigoid usually mucous membrane, occasionally bullous 4. Linear IgA disease 5. Epidermylosis bullosa

Dermatologic Disorders
Lichen planus

Pemphigus Vulgaris

Pemphigoid

Cicatricial Pemphigoid

Bullous Pemphigoid

Immunological oral ulcers causes 1. Wegeners granulomatosis 2. Sarcoidosis 3. Immunodeficiency (usually defects of neutrophil number or function)

Gingival enlargement in sarcoidosis

1. Lichenoid drug reactions (e.g. b-blockers, antimalarials, NSAIDs, interferon) 2. Erythema multiforme (e.g. barbiturates, carbamazepine, sulphonamides) 3. Pemphigus (e.g. penicillamine, ACE inhibitors, rifampicin) 4. Lupus (e.g. minocycline, statins, terbinafine) 5. Pemphigoid (e.g. clonidine, psoralens) 6. Drug-induced neutropenia/anaemia (e.g. azathioprine, carbamazepine) 7. Drug-induced mucositis (e.g. cyclophosphamide, methotrexate) 8. Others (e.g. nicorandil)

Drug induced oral ulcers causes

Drug-induced (nicorandil) oral ulcers on lateral border of tongue

Diagnosis of acute ulcer

Things to Consider: Most Likely: Aphthous ulcer, HSV, Trauma Less Likely: Varicella Zoster, Autoimmune disease, Fungal infection, Malnourishment Must Rule Out: Malignancy, Immunosuppresion, Bacterial/Fungal disease

Diagnosis of acute ulcer

Investigate: 1. Complete blood cell count 2. Serum levels of ferritin and 3. Vitamin B12

Treatment of Acute Ulcers

The appropriate (antiviral Zovirax ointment, antibiotic Terramycin ointment or antifungal Nystatin ointment) topical and or systemic treatment available. For oral ulcers of unknown origin or related to autoimmune diseases: Topical Corticosteroids (TC)

Treatment of Acute Ulcers In cases of oral ulcers confined to

single locations, use of TC in an adherent vehicle such as orabase (carmellose sodium) Patients prescribed TC in an adherent vehicle should be instructed to apply a small amount to the target area after meals (34 times per day), and not to eat or drink for at least 30 min after

Treatment of Acute Ulcersseveral In cases of multiple oral ulcers affecting

locations, aqueous TC solution mouthwashes are preferred. These are recommended to be used 34 times per day, after meals, and patients should not to eat or drink for at least 30 min after use. The patient should hold the liquid in the mouth without swallowing for as long as possible, generally for 1015 min. If pain is present, 2% lidocaine can be added to the formulation. In cases of long-term treatment, the addition of nystatin to the formulation is recommended to

Treatment of Acute Ulcers

Silver nitrate is beneficial in cauterizing the central portion of the ulcer for pain relief. Tetracycline 250 mg in 10 cc syrup is recommended as an oral rinse, four times per day for up to two weeks Chlorhexidine is an antibacterial mouth rinse which promotes healing of ulcers Colchicine has beneficial effects due to the drugs actions on various leukocyte functions, including microtubular function of PMN leucocytes and adhesion molecule expression

Treatment of Acute Ulcers

Ciprofloxacin 500mg orally in gonorrhea Doxycycline 100mg twice daily for 10 days in syphilis If the ulcer is large and refractive to treatment, intra-lesional triamcinalone can be injected into the site

Facts on acute ulcers

Recurrent aphthous ulcers are the most common To date, no principal cause has been discovered Diagnosis is entirely based on history and clinical criteria RAU may be a marker of an underlying systemic illness such as coeliac disease, or may present as one of the features of Behcets disease Pain, recurrence and self-limitation seem to be the ultimate outcomes There is no curative therapy to prevent the recurrence of ulcers All available treatment modalities can only reduce the frequency or severity of the lesions

Facts on acute ulcers

Quinns Rule for Stomatitis: Call it aphthous stomatitis. Treat it for two weeks. If it is still there, biopsy it.

Causes of Chronic Ulcers

Lichen planus ulcers

Lichen planus (LP) is a chronic disease that affects the skin and mucosa. It can appear in the oral mucosa as whitish striae (reticular LP), or as areas of atrophy, erosions or painful ulcers (erosive LP) The aetiology of this disease has been related to a cytotoxic T cell-mediated attack on basal keratinocytes. LP is considered a precancerous lesion

Lichen Planus

Cutaneous Lesion

White Striae of Reticular Type

Lichen planus ulcers

Differentiating LP from pemphigus vulgaris (PV) and mucous membrane pemphigoid (MMP) is difficult, and the final diagnosis requires histological confirmation of a biopsy

Initial treatment is usually with corticoids,

but erosive LP is commonly resistant to these drugs, requiring the application of topical immunosuppressants (e.g. tacrolimus) that inhibit the response of cytotoxic T cells

Dermatologic Disorders
Lichen planus

Pemphigus vulgaris ulcers

Bullae appear in oral cavity (posterior region), forming painful ulcers with necrotic fundus and erythematous halo PV is an immune-mediated chronic vesiculobullous mucocutaneous disease Histological examination of a biopsy shows acantholytic intraepithelial vesicles and Tzanck cells. Direct immunofluorescence study of the tissue reveals the presence of IgG or IgM and complement fragments in intercellular spaces

Pemphigus Vulgaris

Spontaneous onset of bullae that readily rupture, giving rise to a highly painful ulcerated area (most common areas are palate and gingiva) This group of immunological diseases mainly affects mucosae, with subepithelial bullae and deposits of immunoglobulin G, immunoglobulin A or complement fraction C3 throughout the basal membrane

Pemphigoid ulcers

Pemphigoid

Cicatricial Pemphigoid

Bullous Pemphigoid

Erythema and oral ulcers, without induration and accompanied by whitish striae and a tendency to Bleeding Lupus erythematosus (LE) is an autoimmune disease of the connective tissue that appears in two forms: systemic LE and discoid LE

Lupus erythematosus ulcers

Lupus erythematosus ulcers

Reiters syndrome ulcers Arthritis, urethritis, conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis Positive reaction for human leucocyte antigen B27

Primary tuberculosis: deep, irregular, persistent and painful ulcer on the tongue, with rolled border and granulation tissue in the fundus (undermined edges and a granulating floor) Secondary tuberculosis: chronic ulcer, painful and indurated

Tuberculosis ulcers

Tuberculosis ulcers

Deep ulcerative lesion located on tongue

Fungi ulcers
Mycoses give rise to chronic ulcers on the oral mucosa, commonly in immunocompromised pts Rhizomucor or Mucor produce zygomycosis, a fungal infection that can give rise to ulcers with a necrotic halo on the palate (painful but non-specific; they progress rapidly, destroying the bone tissue and surrounding facial muscles)

Bacterial ulcers
Klebsiella rhinoscleromatis is an aerobic cocobacillus that causes a chronic granulomatous infection known as oral or respiratory scleroma, which can involve the oral cavity

Parasitical ulcers
Leishmaniasis is a parasitical disease caused by protozoa of the Leishmania genus. It produces ulcers on the hard or soft palate. It is rare in developed countries and is most commonly observed in patients with HIV infection

Eosinophilic ulcers
Large ulcer, generally in the tongue, with raised, indurated borders and white-yellowish fundus that may resemble a malignant lesion. Persists for weeks or months It is traumatic granuloma

Oral Premalignancy Leukoplakia ulcers Whitish plaque that cannot be scrapped

off 5-20% malignant potential Microscopic examination reveals hyperkeratosis and atypia Lesions on lateral tongue, lower lip, and floor of mouth more likely to progress to malignancy Erythroplakia Red patch or macule with soft, velvety texture Much higher chance of harboring malignancy 60-90% of untreated cases

Leukoplakia

Erythroplakia

Area of Squamous Cell Carcinoma Surrounded by Erythroplakia

Can produce ulcers (exophytic, endophytic or mixed). Metastatic lesions can appear as ulcers in the oral cavity A biopsy (or second opinion) should obtained for suspicious lesions and ulcers that persist after the removal of possible causal agents, as these are the only reliable methods for establishing a definite diagnosis

Oral squamous cell carcinoma ulcers

Squamous Cell Carcinoma of The Tongue

Alveolar Ridge SCCa

Verrucous Carcinoma

Palate Melanoma

Indications for biopsy of an oral ulcer A biopsy is indicated in a case of

ulcer (i)of unknown origin that remains without signs of healing after 2 weeks; (ii)of probable known aetiology (after clinical examination and diagnostic tests) that do not respond to appropriate treatment after 2 weeks; and

Indications for biopsy of an oral ulcer

In small ulcers (< 5 mm in diameter) an excisional biopsy is recommended (including 2 mm of perilesional tissue), whereas in larger ulcers (> 5 mm in diameter) an incisional biopsy is preferred.

Indications for biopsy of an oral ulcer The specimen must include part of
the ulcer and the perilesional tissue, including the unaffected surrounding epithelium. The centre of the ulcer alone usually does not show diagnostic features. Scalpel or punch biopsies are preferred; other techniques (e.g. lasers, electrical scalpels) are not recommended.

Conclusions
Oral ulcers are lesions occurring in the oral mucosa. Aphthae and traumatic ulcers are the most common, but the most serious are those associated with oral cancer. In many cases, it is not possible to establish a definitive diagnosis without histological examination of a biopsy,

Conclusions
A biopsy should be taken from any lesion persisting for > 2 weeks or any with a suspicious appearance. Histological examination of a biopsy should confirm whether the ulcer is a possible malignant lesion, and establish both the definitive diagnosis and correct treatment

Conclusions
1. Check labs (ensure not immunocomprimised) finger stick glucose in office, CBC, CMP, A1c 2. Rule out infection: Send swab and biopsy for HSV testing (smear, PCR) as well as gram stain and possible culture (viral/bacterial)

Oral Ulcers

Thank You
Dr. Kamal Abou-Elhamd MD Professor in ENT Al-Ahsa College of Medicine King Faisal University & Sohag College of Medicine Sohag University, Egypt
04/28/12 Abou-Elhamd

Email: Kamal375@yahoo.com

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