Oral_cavity_ulcers in otolaryngology .ppt

Ent and head neck surgery

1. Diseases of oral cavity
including oral ulcers
Dr Nabin Lageju
2
nd
Year Resident, MS-ENT(ORL-HNS)
GMS Academy of ENT &HN studies

2. Road Map
•Classification of diseases of oral cavity
•Congenital lesions
•Acquired lesions
•Aphthous ulcers

3. 1. Developmental Anomalies
–Cleft lip and palate
–Ankyloglossia
–Fordycesgranules
2. Genetic Diseases
–DyskeratosisCongenita
–EpidermolysisBullosa
–Oral mucosa Hyperkeratosis Syndrome
Classification

4. 3) Infections
Viral
–Herpes
–HFM Disease
–Measles
–Infectious
Mononucleosis
–Molluscum
contagiosum
–HIV
Bacterial
–Erysipelas
–Scarlet fever
–Syphilis
–Cancrumoris
–TB
Fungal
–Candidiasis
–Histoplasmosis
–Blastomycosis
–Paracoccidiodomycosis
–Mucormycosis
–Aspergillosis
–Cryptocosis

5. 4)Autoimmune Diseases
–DLE,SLE
–Sclerderma
–Dermatomyositis
–Sjorgen’s syn
–GVH
–Primary Biliary Cirrhosis
–Lupoid hepatitis
5

6. 5) Systemic Diseases
Hematological
Disorders
•Iron deficiency
•PV syndrome
•Pernicous anaemia
•Thallassemia
•Neutropenis
•Agranulocytosis
•ITP
•Myelodysplastic
syndrome
•Plasminogen def.
Metabolic disorders
–Amyloidosis
–Hurler’s Syndrome
–Porphyrias
–Hemochromatosis
–Langerhans
Histiocytosis
–Cystic Fibrosis
–Xanthomas

7. •Systemic diseases
contd….
Endocrinologic
diorders
–Adrenocortical
insufficiency:dark
brown pigmentation
–Hypercortisolemia
–Hypothyroidism
–1
0
Hyperparathyroidism
–Acromegaly
Dermatological
disorders
–Erythema multiforme
–S J Syndrome
–Pemphigus Vulgaris
–Cicatrical pemphigoid
–Dermatts
herpetiformis
–Lichen planus
–Psoriasis
–Mucocutaneous L.N.
Syndrome

8. 6) Nutritional Disorders
–Vit B12, folate
deficiency
–Iron deficiency
–Pellagra
–Scurvy
7) Precancerous Lesions
–Leukoplakia
–Erythroplakia
–Candid Leukoplakia
–Submucous Fibrosis
–Lichen Planus
–P V Syndrome
–Xeroderma Pigmentosa
8) Soft tissue Cysts
–Mucocele
–Ranula
–Dermoid cysts
–Eruption cyst
–Nsolabial cyst
–Gingival cyst
–Palatine papilla cyst

9. 9) Periodontal Diseases
–Paque induced
gingivitis
–Chronic periodontitis
–Aggressive
periodontitis
–Periodonal abscess/
fistula
–Gingivitis
–Plasma cell gingivitis
–Desquamative
gingivitis
10)Diseases of Tongue
–Median Rhomboid
Glossitis
–Geographical tongue
–Fissured tongue
–Hairy tongue

10. 11) Granulomatous
Diseases
–Sarcoidosis
–Crohn’s disease
–Melkerson Rosenthal
syn
–Orofacial
granulomatosis
–Wegener’s
granulomatosis
12) Salivary Gland
Diseases
13) Tumour like Lesions
–Pyogenic Granuloma
–Pregnancy Granuloma
–Post extraction
Granuloma
–Fistula Granuloma
–Peripheral Giant Cell
Granuloma
14) Non neoplastic
Disorders of Jaw
–Fibrous Dysplasia
–Paget’s Disease

11. 15) OdontogenicTumours
–Ameloblastoma
16) Neoplasm of Oral Cavity
1.Lips
2.Upper &Lower alveolus
3.Buccalmucosa
4.Floor of mouth
5.Tongue
6.Retromolartrigone
7.Hard palate
Classification contd….

12. Congenital lesions of oral cavity

13. Fordyce spots

15. Hereditoryhemorrhagic
telangiectasia

16. Haemangioma

17. Natural history Haemangioma
(phases)
–GROWTH
•Newborn to 14 months (average 8 months)
•Grows rapidly (puffs out) and the color -bright red.
–RESTING
•8-14 months old
•No change in size and the skin less shiny.
–SHRINKING (INVOLUTION)
•1-5 years
•Lesion shrinks and color changes to purple and gray
and may fade completely.

18. Treatment
•Obervation
•Intervention
–Propranolol
–Steroids: useful during growth phase as it slows
the growth rate
–Regranex(becaplermin) gel
–Vincristine
–Cryotherapy
–Laser therapy
–Surgical excision

19. Hereditary angio-oedema/HANE
•Due deficiency of C1-Esterase inhibitor
•Edema of
–Mouth
–Lips
–Face
–Neck
–Extremities
–Gastrointestinal
•Triggered by minor trauma & lasts for hrs
to days

20. Diagnosis
•History of
–Recurrent angio-oedema
(without urticaria)
–Recurrent episodes of
abdominal pain and
vomiting
–Laryngeal oedema
–Positive family history of
angio-oedema

21. HANE(Contd…)
•Treatment
–Airway
–C1-INH concentrate: Berinert
•Prophyllaxis
–Danazol
–Antifibrinolytics –Epsilon-amino capronic
acid, tranexamic acid

22. Lymphangioma
•Capillary
•Cavernous –most
commonly oral cavity
–Tongue most common
present as macroglossia
•Cystic hygroma

23. Contd…
•Treatment
–Observation: 15% spontaneous regression
Al-Khattebet al, 2007
–Repeated aspirationto relieve symptoms till
awaiting for definite treatment
–Sclerosingagents–macrocystic
–Surgery–microcysticand cavernous
–CO2 laser
–Cautery

24. Lingual thyroid

25. Embryology

26. Contd…
•Presentation
–Asymptomatic with lump
–Discomfort
–Dysphagia
–Cough
–Pain
–Rarely airway obstruction
•Complications-haemorrhage,
-cystic degeneration
-malignancies (papillary ca)

27. Contd..
•Management
–USG neck
–Thyroid scan
•75%-only functioning thyroid tissue
Baik et al,2002
–Observationif asymptomatic , euthyroid
provided patient informed about
complications
–Surgical excision
–Co2 laser
–In elder, unfit : radioiodine ablation

28. Gorlin –Goltz syndrome/
Focal dermal hypoplasia
•X-linked
•Multiple odontogenic keratocysts
•Along with various cutaneous, dental,
osseous, ophthalmic, neurological, and sex
organ abnormalities
•Oral
–Oral papilloma ,
–Dental hypoplasia
–Cleft lip, palate

29. White sponge nevus/ Cannon’s
disease
•Confuse with leukoplakia
•Buccal mucosa, tongue-painless,folded
white lesions
•Benign , no treatment required

30. Acquired oral lesions

31. Classification
•Blisters
•Pigmented lesions
•Red lesions
•Swellings
•Oral soreness or pain
•White lesions
•Ulcers

32. Blisters
•Mucocele
•Burns
•Pemphigoid
•Angina bulloushemorrhagica
•Viral
–Chickenpox
–Herpes simplex stomatitis
–Herpangioma
–Hand,mouthand foot disease

33. Mucocele
•Disease of minor salivary gland
–Mucous retensioncyst
–Mucous extravasationcyst
•Lower lip(commonest), buccalmucosa,
ventral surface tongue, floor of mouth, upper
lip ( least common)
•When in floor of mouth
–Ranula
•Simple
•plunging

34. Pathogenesis
•Mucous extravasationcyst (3 phases )-post trauma
•In the first phase,
–mucous spills diffusely from the excretory duct into
conjunctive tissues where some leucocytes and histiocytes
found.
•Second phase
–appear during the resorptionphase due to histocytes,
macrophages
–giant multinucleated cells associated with a foreign body
reaction.
•In the final phase or third phase
–connective cells form a pseudocapsulewithout
epithelium around the mucosa.

35. Contd…
•Retention mucoceles
–dilation of the ductsecondary to its obstruction or
caused by a sialolith or dense mucosa.
–The majority of retention cysts develop in the ducts of
the major salivary glands

36. Simple ranula

37. Plunging ranula / diving ranula

38. Histopathology
–Extravasated mucous
surrounded by a layer of
inflammatory cells and then by
a reactive granulation tissue of
fibroblasts
–Pseudocapsule –granulation
tissue

39. Treatment
•Simple ranula
–Excision
–Marsupialization
•Plunging ranula
–Excision via intraoral and cervical approach
•Cryosurgery
•Co2 laser-due capacity to absorb water
•Intralesional steroid Luiz et al,2008

40. Recurrence rates :
Incision and drainage, 71-100%
Ranula excision: 0-25%
Marsupialization : 61-89%
Complete excision of the ranula with the sublingual
gland: 0-2%
Zhao YF et al.,2005

41. Pigmented lesions
•Generalized hyperpigmentation
–Food induced-red wine, coffee, tea, liquorice
–Smoking tobacco/smoker’s melanosis
–Chewing betel nut
–Drugs
•Chlorhexidine
•Iron
•Griseofulvin
•Cocaine
•Minocycline
•Bismuth subcitrate
•Antimalarials
•Lansoprazole
•HRT
•Busulfan
•Gold

42. Contd…
•Localized hyperpigmented
•Incontnentia pigmenti
•Amalgam tattoos
•Nevi
•Melanoma
•Kaposi, sarcoma
•Furred , brown and black hairy tongue
•Purpura

43. Black hairy tongue
•Hypertrophy of filiform papillaeresembling
hair like projections
•Associated with
–heavy tobacco use
–mouth breathing
–antibiotic therapy
–poor oral hygiene, general debilitation
–radiation therapy
•Treatment
–Oral hygiene, brush with tooth brush
–Sodium bicarbonate mouth wash
–Topical tretinoin

44. Smoker’s melanosis/melanoplakia

45. Red lesions
•Geographical tongue
•Candidiasis
–denture related stomatitis
–acute candidiasis
–HIV associated candidiasis
•Median rhomboid glossitis
•Angular stomatitis
•Erythroplakia
•Radiation mucositis

46. Geographical tongue
•Benign migratory glossitis/
Lingual erthema migrans/glossitis
areata exfoliativa/wandering rash of
the tongue
–Map like atrophic red areas
with surrounding borders of
increased thickness of filiform
papillae
–Pattern change from day to day
even in hours

47. Geograhical tongue(Contd…)
–Asymptomatic or sore tongue
–Cause
•Idiopathic
•May with family history
•Some associated with hayfever or allergy to
food or stress
–Treatment:
•Reassurance
•Topical anaesthetics for temporary relief

48. Erythroplakia
•“any lesion of the oral mucosa that presents as
bright red velvety plaques which cannot be
characterized clinically or pathologically as any
other recognizable condition” WHO, 1978
•Usually asymptomatic
•Fiery red, well demarcatedplaquewith a smooth and
velvety surface
•Floor of the mouth, retromolar area, soft palate, and
tongue
•Associated with white spots or small plaques
representing foci of keratosis
•50 and 70 years.

49. ELSEVIER, oral oncology; 2005

50. Erythroplakia ( contd…..)
•Over 91% of erythroplakias histologically
demonstrate severe dysplasia, carcinoma in situ, or
early invasive squamous-cell carcinoma at the time of
diagnosis. Shafer et al.,1975
Erythroplakia of oral caviy: cancer
•Histopathological examination
•Treatment
Surgical excision
Laser therapy
Cryosurgery

51. Red lesions due to Candidiasis

52. Denture related stomatitis/ denture
sore mouth
•Treatment
–Remove denture during night
and store in antiseptic
–Brushing palate
–Topical antifungal

53. Acute candidiasis
•Immuno-compromised state
–Prolonged use of
•Steroid
•Broad spectrum antibiotics
–Post chemotherapy,
radiotherapy
–Diabetes

54. HIV-associated candidiasis
•Sites
–Dorsum of tongue
–Buccal mucosa
–Palate
•Can be first manifestation HIV
•In palate may show fingerprint pattern
•Tongue depapillated areas
•Treatment: antifungal

55. Median rhomboid glossitis/ central
papillary atrophy tongue
•Depapillated rhomboidal area dorsum of tongue anterior to
sulcus terminalis
•Kissing lesion in palate
•Associated with
–candida infection
–Smoking,Denture
–HIV,Diabetes
•Biopsy to r/o neoplasm esp in nodular form
•Treatment Cessation smoking
antifungal

56. Angular stomatitis/ Angular
cheilitis/Perleche
•Skin and contiguous labial mucosa
•Causes
–Mechanical : denture
–Infective: staphylococcus, candida
–Nutritional: deficiency riboflavin, iron , PEM
–Immune deficiency: HIV, diabetes

57. Presentation
•Triangular area of erythema
•Edemaangles of mouth
•Linear furrows or fissures
radiating from angle of mouth :
rhagadesesp in deture wearers
•Treatment
–Correction of pathology

58. Iatrogenic mucositis
•Follwingradiotherapy or chemotherapy or
chemoradiotherapy
•Earlier in chemothan radiotherapy
•After 3-15 days
•Invariably with ext beam radiation
•In chemotherapy around in 90%
•Cyclophosphamide
•Pain , odynophagia, ulceration, bleeding
•Sepsis

60. Soreness
±erythema
Erythema,
ulcers;
patient can
swallow
solid food
Mucositis
to the extent
that
alimentation
is not
possible
Ulcers with
extensive
erythema;
patient
cannot
swallow food
Grade 2 Grade 3
Severe Mucositis
Grade 1 Grade 4
World Health Organization’s Oral Toxicity Scale
WHO’s Oral Toxicity Scale

61. Radiation mucositis (contd….)
•Management
–Relieve pain
–Hasten healing
–Prevent infective complications
•Oral hygiene
–Mainstay treatment
–Frequent mouth cleaning with salt water 2-4hrly
–Donot use chlorhexidine, hydrogen peroxide

62. Radiation mucositis (contd….)
•Analgesics in form of controlled release
opioids, benzydamine
•Oral cooling with ice chips(cryotherapy)
•Antibiotics , antifungals
•Under trial
–Amifostine and other antioxidants, growth
factors, cytokines, and glutamine

63. Swellings
Crispian et al,Scott-Brown’s-7
th
edition

64. Torus mandibularis

65. Pyogenic granuloma
•Eruptive hemangioma/Granuloma
gravidarum/Lobular capillary
hemangioma/Pregnancy tumor
•Misnomer as no infection, no pus
•Inflammatory hyperplasia
•Due
–Local irritation
–Trauma
–Hormonal
•Gingiva,buccalmucosa, dorsum of tongue skin,
nasal septum

66. Contd..
•Presentation
–Red/pink mass with smooth or lobulated
–Bleeding
–During pregnancy as frequent nasal bleed started
from first trimester upto third trimester
•Treatment
–Excision and cauterisation
–Laser -Nd: YAG
–Cryosurgery
–Intralesional ethanol, steroid, STD
–In pregnancy spontaneous healing
–Only if symptomatic treatment indicated

67. Contd..
•Prevention
–Good oral hygiene
–Removal of dental plaques
–Use of soft toothpastes

68. Denture induced hyperplasia /
denture granuloma/epulis
fissuratum

69. Oral pulse granuloma

70. Herniation of buccal fat pad/
Traumatic pseudolipoma

71. Oral allergy syndrome
•Oral pruritus, irritation, swelling of lips
palate tongue
•Associated with other allergic disorders like
rhinoconjunctivitis, asthma, urticaria,
anaphylaxis
•Precipitated by fresh foods like fruits ,
vegetables
•Treatment
–Antihistaminics

72. Oral soreness or pain

73. Crispian et al,Scott-Brown’s-7
th
edition

74. Glossodynia / glossopyrosis/ oral
dysesthesia/ burning mouth syndrome
•Middle aged , elderly women
•Spontaneous burning, discomfort, pain,
irritation, or rawness of the tongue
•No identifiable etiology most of the time

75. Contd…
•Etiology
–Idiopathic, Infection, Allergic/contact
hypersensitivity, Mechanical trauma
–Xerostomia, Geographic tongue/ Fissured
tongue
–Vesiculobullous disease, temporomandibular
dysfunction
–Referred pain from teeth or tonsils
–Drugs-Antibiotics, psychiatric medications,
chemotherapy
•Treatment-reassurance

76. Fissure tongue
•Normalvariant seen in 5-11%
individuals
•Numeroussmall irregular fissures
oriented laterally on the dorsal
tongue
•Also seen in
Melkersson-Rosenthal syndrome
•Psoriasis
•Down syndrome
•Acromegaly
•Sjogren’ssyndrome

77. Deficiency glossitis/ atrophic
glossitis
•Deficiency
–Vit B12
–Iron
–Folic acid
•Plummer Vinson
Syndrome

78. White lesions of oral cavity

79. Classification
•Developmental
–Leukodema
–White sponge nevus
–Hereditary Benign Intraepithelial Dyskeratosis
–DyskeratosisCongenita
•Inflammatory
–lineaalba
–Traumatic keratosis
–Cheek chewing

80. Classification (contd…)
–Chemical injuries
•aspirin , silver nitrate, sod hypochloride,hydrogen
peroxide , mouthwashes
–Actinic keratosis( cheilitis)
•Infection induced white lesions
–Oral hairy leukoplakia
–Candidiasis

81. Classification contd….
•Idiopathic
–Leukoplakia
–Oral lichen planus
–Lichenoid drug eruptions
•Lupus erythematosus
•Miscellaneous
–Geographical tongue
–Oral submucosal fibrosis
–Epithelial peeling

82. Chronic cheek bitting/ Morsicatio
buccarum

83. Burns

84. Lichen planus
•Idiopathic
•Associated with denture,
GVHD,NSAIDS, diabetes, liver
disease , hepatitis C
•May be reticular
( commonest),papular, plaque-like,
erosive
•Non reticular –risk of malignancy later-5%

85. Lichen planus( contd…)
•Diagnosisby biopsy with
immunofluorescence to exclude
–Keratosis
–Chronic ulcerative stromatitis
–Lupus erythematosus
–Malignancy
•Treatment
–Correction of predisposing factors
–Topical corticosteroid or topical tacrolimus

86. Acute pseudomembranous
candidiasis/ oral thrush /Moniliasis
•Seen in
–Neonates before immunity to candida
–Immuno-compromised
–Xerostomia
•Treatment
–Topical antifungals, Gentian violet
–Use as suspension : first mouth wash followed by
swallowing for oropharyngeal, oesophagiallesions

87. Chronic candidiasis/ candida
leucoplakia/chronic hyperplastic
candididasis

88. Leukoplakia
•White patch or plaque, firmly attached to the oral
mucosa cannot be classified as any other disease
entity
•Precancerous lesion
•Etiology
–Exact etiology unknown
–Tobacco (almost in 80%)
–Alcohol
–Chronic local friction
–Candida
–Human papilloma virus (HPV)

89. Presentation
•Three clinical varieties
–homogeneous (common)
–speckled (less common)
–verrucous (rare)
•Speckled and verrucous form :
greater risk of malignancy
•Malignant transformation : 4%
and 6%
•Common Sites : buccal mucosa,
tongue, floor of the mouth,
gingiva, and lower lips

90. Leukoplakia (Contd…)
•Diagnosis
–Clinical
–HPE study
•D/D
–lichen planus,
–lesions caused by cheek biting,
–frictional keratosis,
–smokeless tobacco–induced keratosis,
–nicotinic stomatitis,
–leukoedema, and
–white sponge nevus

91. Leukoplakia (Contd…)
•Treatment
–Elimination of predisposing factors
–Surgical excision : treatment of choice
–Laser ablation : CO2 laser
–Cryosurgery
–Systemicretinoid compounds : beta carotene
under study with promising results

92. Submucosal fibrosis
•Chronic, debilitating disease of the
oral cavity characterised by
–inflammation
–progressive fibrosis of the lamina
propria and deeper connective tissues of
buccal mucosa
–Juxtaepithelial inflammatory reaction in
the oral mucosa
•Malignant potential

93. OSMF (Contd…)
•Etiology
–Areca nut chewing ( arecholine, tannins)
–Ingestion of chilies
–Genetic and immunologic processes (HLA-A10, HLA-
B7,and HLA-DR3)
–Mutations in the APCgene and low expression of
TP53tumor-suppressor gene product
–Nutritional deficiency (Iron, Vitamin B Complex and
malnutrition )

94. OSMF (Contd…)
•Presentation
–Common in Indian subcontinent, Asia and Pacific
–Progressive trismus
–Oral pain and a burning sensation
–Hearing loss
–Dryness of the mouth
–Nasal voice
–Dysphagia
–Impaired mouth movements

95. Grading of trismus
–Grade I
No mouth opening limitation
Interincisal distance of greater than 35 mm
–Grade II
Interincisal distance of 26-35 mm
–Grade III
Interincisal distance of 15-26 mm
Fibrotic bands on soft palate,
Pterygomandibular raphe and
Anterior pillars of fauces

96. –Grade IVA
Severe trismus
Interincisal distance less than 15 mm
Extensive fibrosis of all the oral mucosa
–Grade VB
Advanced stage with premalignant and malignant
changes throughout the mucosa.
(Khanna et al.,2001)

97. Staging
•Stage 1: Stomatitis
Erythematous mucosa, vesicles, mucosal ulcers, melanotic
mucosal pigmentation, and mucosal petechia.
•Stage 2: Fibrosis
Blanching of the oral mucosa.
Palpable fibrous bands in the buccal mucosa
•Stage 3: Sequelae of OSF
Leukoplakia
Speech and hearing deficits
(Pindborg et al.,1989)

98. Complications
•Oral dysplasias
•Squamous cell carcinomas -7.6% over a 10-year
period
Cox et al., 1996
•Conductive hearing loss: because of functional
stenosis of the eustachian tube opening
Gupta et al., 2000
•Anesthesia of Palate

99. Treatment
–Aimed at improving mouth movements.
–Depends on the degree of clinical involvement
Early stage
–Cessation of the habit sufficient
Moderate OSF
–Intralesionalor topical application of steroids
–Hyaluronidase: improve symptoms more quickly than
steroids
–Steroids + topical hyaluronidase-better long-term
results
–Placental extracts
–IFN-gamma: antifibroticcytokine and interferon is still
evolving

100. •Surgical Treatment
(1) Excision of fibrous bands ,contractured tissue
(2) Split-thickness skin grafting following bilateral temporalis
myotomy or coronoidectomy
Canniff et al., 1986
(3) Nasolabial flaps and lingual pedicle flaps when the tongue is
not involved
Hosein et al., 1994

101. Hairy Leukoplakia
•Etiology
–Epstein–Barr virus
–Associated with HIV and organ
transplantation
•Clinical features
–white asymptomatic, often
elevated and unremovablepatch
–Found bilaterally on the lateral
margins of the tongue
–Corrugated surface with a vertical
orientation.

102. •Laboratory tests
–Histological examination-parakeratosis
–In situ hybridization
–Polymerasechain reaction (PCR)
•Treatment
–Not required
–Aciclovir or valaciclovir

103. Ulcers of oral cavity

104. Causes
•Trauma (physical injury, Chemical injury )
•Infection
-viral
-bacterial
-fungal
-protozoans
•Immunodeficiency
•Autoimmunity
•Allergy
•Dietary

105. Traumatic
•Mechanical trauma (acute or chronic)
•Chemical injury (acid, alkali)
•Physical injury (thermal injury, electrical
injury)

106. Mechanical trauma
1.A sharp edge of a tooth
2.Accidental biting
3.Sharp, abrasive,orexcessivelysaltyfood
4.Poorly fitting dentures
5.Dental braces
6.Trauma from a toothbrush
7.Patients bad habits

107. Denture trauma

108. Chemical injury
•Aspirin
•Alcohol
•Hydrogen peroxide
•Sodium hypochloride
•Mouthwashes

109. Physical injury
•Electrical burn injury

110. Herpes simplex stomatitis
•Viral infection of the mouth that causes ulcers
and inflammation.
•Not the same as canker sores, which are caused
by a different virus
•Blisters in the mouth, often on the tongue,
cheeks, palate, gums, and a border between the
lip and the normal skin next to it
•Ulcers in the mouth, often on the tongue or
cheeks after the blisters rupture

111. Contd…

112. Treatment
•Good oral hygiene
•Acyclovir family of antiviral medications–
non later than 48 hours!
•Analgetic ( or oral topical anesthetic )
•Diet (no hot or pepper food)
•Antiseptics

113. Hand foot and mouth disease
•Group A Coxasackie virus
•Epidemics among school children
•Vesicles on hands, feet and occ. Buttocks
together with intra-oral vesicles and later
ulcers
•Fever/malaise
•Lasts for 1 week

114. Herpangioma
•Common in childeren
•Coxsackie viruses and ECHO viruses
•Similar to H.simplex except the lesions are
more commonly in the oropharynx than
oral cavity
•Sheldom persists beyond one week

115. Tuberculosis
•Affects the oral cavity with sputum positive
pulmonary TB and give rise to multiple
superficial and painful ulcers on tongue
and elsewhere in the oral cavity

116. Aphthous ulcers

117. Pathogenesis/predisposing
factors
•Heredity
–42% of patients have +ve family history.
–90 of likelihood of developing lesions when
both parents affected.
•Psychologic factors
–Stress and anxiety been implicated in
development of aphthous ulcers.
•Mechanical trauma

118. •Dietary deficiencies
–Iron, folate or vit B12 , zinc deficiency
(replacement therapy often improves the
condition).
•Allergy
–Patients with known allergy benefit from
avoiding the allergen.
-Common kinds of foods that are potential
allergens: milk, cheese, nuts, flour,
tomatoes, citrus fruits, shellfish.
-Sodium lauryl sulfatepresent in toothpaste.

120. Presentation
–Painful open sores inside the mouth caused by
a break in the mucuous membrane
–Typically white color / erythematous around
lesion.

121. Recurrent aphthous ulceration
(RAU)
•3 types
–Minor aphthous ulcers(80%)
–Major aphthous ulcers(10%)
–Herpetiform aphthous ulcers(10%)

122. Minor aphthous ulcers
–Occur in childhood / adolescence
–Exclusively on non-keratinized mucosa (floor
of mouth, buccal mucosa, soft palate)
–Usually yellow-grey in color with erythematous
halo less than 10 mm around it

123. Major aphthous ulcers
–Typically up to 10 mm in size
–Painful and typically leave a scar
–Take up to 1 month to heal

124. Herpetiform aphthous ulcers
–Occurs frequently in females
–Onset usually in adulthood
–Small numerous lesions of 1 –3 mm in clusters

125. Histopathology aphthous ulcer

126. Diagnosis
•Usually based on clinical signs and symptoms.
There are tests which may be ordered to rule out
other ulcer etiologies:
r/o nutritional deficiency of vit B12, folate, iron
r/o herpeticstomatitis with cytology smear (-) for
cytopathic effects, (-) viral culture/
immunofluoresence
r/o HIVfor large, slow-healing ulcers

127. Diagnosis (contd…)
•r/o cancerfor non-healing ulcer with biopsy
•r/o Crohndisease with biopsy (+) for
characteristic granulomatous inflammation
•r/o Behçetsyndrome-presence of anogenital or
ocular lesions, arthralgia, skin, vascular or
neurological involvement
•r/o cyclic neutropeniawith CBC
•r/o possible drug reaction due to cytopathic drug
therapies

128. Differential diagnosis
•Infection: HSV, CMV, HIV, Coxsackie virus,
syphilis, histoplasmosis
•Autoimmune: Behcet’s disease, SLE, Crohn’s
disease, bullous pemphigoid, pemphigous
vulgaris, cicatricial pemphigoid, erythema
multiforme.
•Neoplasms: squamous cell carcinoma.
•Medications: methotrexate, chemotherapy.
•Poor nutrition: including vitamin deficiencies.

129. Treatment
•As cause unknown treatment consists of
therapeutic measures to suppress its
symptoms rather than bringing about a
definitive cure

130. Treatment (contd…)
1.Early treatment/avoidance of triggers:
•Data support that early treatment promotes
more rapid healing
•Topical anesthetics including triamcinolone
in orabase, fluocinonidegel in orabase.
•Identify and avoid triggers (physical trauma,
emotional stress, food hypersensitivity like
chocolate, sodium laurylsulfate, menstrual
cycle association).

131. 2.Supportive Care
•Symptomatic relief
–Anesthetics
•OTC Benzocaine
•Compound anesthetics
•Viscous lidocaine
–Covering agents/Compound agents
•Kaolin and Pectin
•5% amlexanox
•1:1:1 solution of Milk of Magnesia + Benadryl +
Viscous lidocaine
•Systemic corticosteroids, dapsone,colchicine,thalidomide,
pentoxifylline, low-dose interferon-α, and levamisole

132. Field EA, Longman LP. Tyldesley’s Oral Medicine, 5th edn.
Oxford: Oxford University Press, 2003.

133. •5% Amlexanox
–Anti inflammatory , anti allergic
–Only drug approved by US –FDA for RAS
–As oral tablet or paste
–Reduce size of ulcer as well as pain
Wenxia et al.,2009

134. Thank You !!

137. Classification of diseases of oral cavity
•Congenital conditions
–Mucosal lesions
•Dyskeratosis congenita
•Fordyces spots
•White sponge nevus/Cannon’s disease
•Hereditory hemorrhagic telangiectasia
–Lesions of tongue
•Macroglossia
•Ankyloglossia
•Median rhomboid glossitis
–Cleft lip and palate

138. Congenital lesions (contd…)
–Swellings
•Hemangioma
•Lymphangioma
•Lingual thyroid
•Hereditory angio-edema
•Gorlin –Goltz syndrome
–Ulcer
•Epidermolysis bullosa

139. Classification (contd…)
•Acquired lesions
–Blisters
–Pigmented lesions
–Red lesions
–Swellings
–Oral soreness or pain
–White lesions
–Ulcers