oral ulcerations herpes simplix minor, major and herpitiform

derma presentation

2. MOUTH ULCERS
Presented by
Dr.Mohammed Sultan,M.D.
Lecturer of Dermatology & Andrology, Mansoura Faculty of
Medicine, Mansoura, Egypt
2

3. Causes of Ulcers
Local factors
Recurrent aphthous stomatitis and Behcet syndrome
Primaery oral infections:
‒Viral diseases e.g., HSV, VZV, Herpangina, HFMD
‒Bacterial diseases e.g., syphilitic chancre & guma; tuberculous ulcer.
‒Fungus (rare)
 Systemic conditions
Disorders of uncertain pathogenesis
Malignanat neoplasms

4. Local factors
•Cheek biting
•Self-inflicted (compulsive cheek
chewing).
•Accidental
•Biting an anaesthetized lower lip
or tongue
•Dental structures & devices
(jagged tooth, denture irritation).
•Riga–Fede disease
•Child abuse ..
•Self-mutilation
•Oral sex

•Foods (fish bones, toast).
•Oral hygiene procedures .
•External trauma (fights,
seizures).
•Burns
•Thermal factors (hot fluids or
foods).
•Electric burns.
•Chemical burns
•Aspirin
•Chemicals used in dental therapy
(silver nitrate).
•Irradiation mucositis

5. Systemic causes of oral ulcers

Haematological e.g., leukemia, neutropenia
Gastroenterological :IBD, coeliac
Dermatological:
‒EB
‒EM, SJS
‒Erosive LP
‒PV, Pemphigoid , linear Ig A, DH
‒Paraneoplastic pemphigus (PNP)

6. Systemic causes of oral ulcers

Infective .
Neutrophilic dermatoses (Vasculitis, BD,
SWS)
LE & Reiter syndrome
Iatrogenic :cytotoxic drugs, other drugs, and
radiotherapy

9. Disorders of uncertain pathogenesis

Angina bullosa haemorrhagica
Hypereosinophilic syndrome
Eosinophilic ulcer
Necrotizing sialometaplasia

11. Any patient with a single ulcer lasting > 2–3
weeks ,after exclusion of any PFs, should be
regarded with suspicion and investigated
further, usually by biopsy—it may be a
neoplasm or other serious disorder

13. Angina bullosa haemorrhagica
ABH

Benign , fairly common condition of unknown
pathogenesis
> elderly
No detectable immunological or bleeding disorder .
PFs
‒No PFs
‒Trauma : the most common identifiable PF.
‒Use of corticosteroid inhalers

14. Angina bullosa haemorrhagica
ABH

O/E : oral blood blisters.
‒Subepithelial blisters
‒Lining mucosa (soft palate, buccal,labial)
‒Rupture after few hours →ulcers or superficial
erosion ).
*Ragged , often painless,
*Heal spontaneously within 1 week
*Without scarring.

21. Recurrent Aphthous Stomatitis (RAS)
Recurrent Aphthous Ulcer (RAU)

22. Key features

3 forms : minor, major and herpetiform
Relatively common
Painful
< 5 mm in diameter
Creamy -white with an erythematous halo
The pathomechanism is unknown
Immunologic factors may be involved
Each lasting from 1 to about 4 weeks before healing
Usually controlled through the use of topical corticosteroids

23. Epidemiology
RAS is a common disorder
10–50% of populations (at least 20% of the population).
Male predilection
> second decade.

24. Pathogenesis
Etiology remains obscure
Multifactorial
Genetic predisposition (+ve FH in one third)
Triggering factors
Underlying systemic disorders

25. Genetic & Triggering factors
Immune dysfunction
T lymphocyte-mediated
cytotoxicity

Damage to epithelial cells →
ulceration

26. Abnormal immune response may be triggered or
influenced by
Stress
Trauma
Cessation of tobacco smoking
Hematinic (iron, folate or vitamin B12) deficiencies
(controversial).
Hormonal fluctuations,
Infectious agents,
Food hypersensitivities,
HIV infection.

27. Possible underlying systemic disorder
Behçet’s disease,
Inflammatory bowel disease,
3% of RAS patients have coeliac disease
SLE.,
Reactive arthritis,
Cyclic neutropenia,
PFAPA (periodic fever, aphthous stomatitis,pharyngitis and
adenitis) syndrome,
Certain hereditary periodic fever syndromes .

28. Complex aphthosis
The almost constant presence of more than three oral aphthae
or oral & genital aphthae
Requires the exclusion of systemic disorders
‒Behçet’s disease,
‒Inflammatory bowel disease,
‒Cyclic neutropenia,
‒Vitamin deficiencies (e.g. B12, folate),
‒HIV infection and
‒Others .

29. Immunological mechanisms
CMI mechanisms appear to be involved .
Epithelial damage may result from antibody-dependent cellular
cytotoxicity reaction
There is no evidence that RAS is an autoimmune disease

31. Clinical features
There are three categories of simple aphthae
1.Minor aphthae: 80 % of all RAS,
2.Major aphthae : 10% of patients, and
3.Herpetiform aphthae: 10 % of cases.

32. Clinical features
Sites
Mostly non-keratinized mucosa: any RAU
‒Buccal and labial mucosa
‒Ventral tongue,
‒Floor of mouth,
‒Soft palate
‒Oropharyngeal mucosa
Rarely occurs on keratinized mucosa : major RAU
‒Hard palate and attached gingiva (mucosa overlying bone)
‒Dorsal tongue

33. Minor aphthae
Round to ovoid, shallow
Painful .
< 5 mm in diameter.
Covered by a creamy-white pseudomembrane
Sharply defined border
Erythematous rim or halo. .

34. Minor aphthae
The most common form,
Typically limited to the non-keratinized oral mucosa.
Heal without scarring within 1–2 weeks.
Infrequent recurrences in majority
Some may have almost continuous lesional activity.

38. Major aphthae (Sutton’s ulcers).
Larger ulcerations
Typically >1 cm - ? 3 cm.
Usually deeper
Persist for up to 6 weeks
Recur frequently
May heal with scarring.
Considerable oral pain
Sometimes accompanied by fever and malaise.
On keratinized or nonkeratinized mucosa including the dorsum of the
tongue or palate.

41. Herpetiform aphthae
Multiple minute (2 mm), discrete ulcers
Up to 100 ulcers are possible at one time.
Resemble primary HSV infection.
DDx from primary HSV by
‒Typically confined to non-keratinized mucosa
‒Recurrent.

44. Herpetiform aphthae
Extremely painful
Very frequent recurrences (? virtually continuous).
Increase in size and coalesce → large ragged ulcers
Heal in 10 days or longer

45. Minor aphthae Major aphthae Herpetiform ulcers
Age Childhood or
adolescence
Childhood or
adolescence
Young or old
Size 2–4 mm May be 10 mm or
larger
Initially tiny but
ulcers coalesce
Number Up to about 6 Up to about 6 10–100
Site Mainly confined to
non-keratinized
mucosa
; rarely dorsum
of tongue, gingiva or
palate
Any site Typically confined
to non-keratinized
mucosa , but may
occur on other sites
Duration of each
ulcer
Up to 10 days Up 6 weeks Up to 1 month
Other comments Most common May heal with
scarring
females
most painful

46. Complex aphthosis
Recurrent oral and genital aphthous ulcers or almost constant,
multiple (≥3) oral aphthae
Without manifestations of systemic disease
Resemble minor aphthous ulcers except that there is a greater
number of lesions
Major and/or herpetiform aphthae may occur

48. Prognosis
Resolve or decrease spontaneously with increasing
age.
Suspect an underlying predisposing cause if RAS
commences or worsens in adult life
Assist patients to understand & cope better with their
problem (to reduce stress).

49. Pathology

Nonspecific .
Early : perivascular neutrophilic submucosal infiltrate.
Diagnosis usually clinical.

50. 1- All of the followings are local
causes of mouth ulcers except:
A-Cheek biting
B-Irradiation mucositis
 C-Riga–Fede disease
D-Aspirin
E-Antithyroid drugs

51. 2- The hematological disease
causing mouth ulcer is :
A- Anemia
B- Bleeding disorders
C- thrombocytosis
D- leukemia
E- lymphocytosis

52. 3- All of the following drugs causing
oral ulceration except:
A- Calcium channel blockers
B- Systemic cotricosteroids
C- Antithyroid drugs
D- Cytotoxic drugs
E- B & C

53. 4- Any patient with single ulcer lasting
more than 3 weeks should be:
A- assured
B- do CBC
C- do smear and culture
D- do biopsy
E- all of the above

54. 5- The most common cause of
angina bullosa haemorrhagica is:
A- hematological
B- cytotoxic drugs
C- trauma
D- malignancy
E- all of the above

55. 6- All of the following is ture about
angina bullosa haemorrhagica except:
A- ragged
B- painful
C- heal without scar
D- painless
E- affect soft palate

56. 7- Which of the following is true about
recurrent aphthous stomatitis:
A- ragged
B- painful
C- start as blister filled with blood
D- painless
E- non immunlogic

57. 8- Recurrent aphthous stomatitis
mediated by :
A- T cytotoxic
B- B Lymphocyte
C- T helper
D- Natural killer cells
E- b & c

58. 9- Recurrent aphthous stomatitis
triggered by all of the followings except
:
A- trauma
B- tobacco smoking
C- stress
D- HIV
E- food hypersenstivity

59. 10- Complex aphthosis means:
A- more than one oral ulcer
B- more than two oral ulcers
C- more than two genital ulcers
D- more than three oral ulcers
E- none of the above