Oral ulcers

Common Oral ulcers in dentistry

1. NON-NEOPLASTIC ULCERS OF ORAL CAVITY DR. ALI WAQAR HASAN MDS Resident

2. 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 ARE CALLED ULCERS OR EROSIONS (TERM COMMONLY USED FOR SUPERFICIAL ULCER) THIS MAY EITHER FOLLOW MOLECULAR DEATH OF SURFACE EPITHELIUM OR ITS TRAUMATIC REMOVAL. ULCERATION IS THE MOST COMMON LESION OF ORAL MUCOSA AND IS THE MANIFESTATION FOR MANY LOCAL AND GENETIC DISORDERS.

3. EROSION, EXCORIATION, ULCER EROSION: SUPERFICIAL BREACH OF THE EPITHELIUM WITH LITTLE DAMAGE TO UNDERLYING LAMINA PROPRIA. EXCORIATION : BREECH OF EPITHELIUM THAT IS DEEPER THAN AN EROSION BUT SHALLOWER THAN AN ULCER. ULCER : BREAK IN MUCOUS MEMBRANE WITH LOSS OF SURFACE TISSUE, DISINTEGRATION AND NECROSIS OF EPITHELIAL TISSUE.  Penetration into the epithelial- connective tissue  border, with its base at a deep level in the  submucosa , or even within muscle or  periosteum .

4. THE SURFACE OF AN ULCER IS COVERED BY MASS OF FIBRIN WITH INTERMINGLED, DEAD AND DYING POLYMORPHS WHICH WOULD DRY ON THE SKIN TO FORM A CRUST OR SCAB. A SUPERFICIAL ULCER WITH NO EVIDENCE OF SIGNIFICANT FIBRINOUS EXUDATION ON THE SURFACE OF POLYMORPH EXUDATION SUGGESTS THE POSSIBILITY OF BULLOUS DISORDER . A HEAVY INFLAMMATORY INFILTRATE EXTENDS DEEP INTO THE UNDERLYING CONNECTIVE TISSUE N BLOOD VESSELS MAY SHOW SLIGHT INFLAMMATORY VASCULITIS. GRANULATION TISSUE IS FORMED WITH DILATED BLOOD VESSELS AND HEAVY INFITRATE OF PLASMA CELLS, LYMPHOCYTES AND POLYMORPHS.

5. PARTS OF AN ULCER ULCER CONSISTS OF: EDGE:- THIS IS AN IMPORTANT FINDING OF AN ULCER WHICH BY ITSELF NOT ONLY GIVES CLUE TO DIAGNOSIS ULCER BUT ALSO TO THE CONDITION OF ULCER. FLOOR:- THIS IS THE EXPOSED PART OF AN ULCER. THE COVERING OF FLOOR IS IMPORTANT. BASE (ON WHICH THE ULCER RESTS):- FLOOR IS THE EXPOSED SURFACE OF AN ULCER WHEREAS THE BASE IS ON WHICH THE ULCER RESTS. FLOOR IS SEEN BUT THE BASE IS FELT. MARGIN:- IT’S THE POINT WHERE THE ULCER JOINS THE NORMAL EPITHELIAL TISUE. RED GRANULATION TISSUE HEALTHY AND HEALING PALE AND SMOOTH GRANULATION TISSUE SLOW HEALING ULCER BLACK MASS MALIGNANT MYELOMA

6. CLASSIFICATION CLINICAL PATHOLOGICAL

7. CLINICAL ULCERS TYPES SURROUNDING SKIN ULCER FEATURES OTHER FEATUERS SPREADING INFLAMED NO GRANULATION TISSUE IS SEEN HEALING NOT INFLAMMED GRANULATION TISSUE IS PRESENT IN FLOOR SLIGHT SEROUS DISCHARGE IS SEEN CALLOUS INDURATONS PALE GRANULATION TISSUE IS SEEN AT FLOOR AND INDURATIONS ARE SEENAT BASE AND EDGE NO TENDENCY TOWARDS HEALING

8. PATHOLOGICAL ULCERS ULCERATIONS ARE CLASSIFIED ON THE BASIS OF ETIOLOGY. CAUSES OF ORAL ULCERATIONS TRAUMA INFECTIVE DISEASES IMMUNOLOGIC DISEASES

9. TRAUMATIC ULCERATON TRAUMATIC INJURY CAN OCCUR BY THE FOLLOWING MEANS MECHANICAL CHEMICAL THERMAL FACTITIOUS RADIATION EOSINOPHILIC ULCER (TRAUMATIC GRANULOMA)

10. MECHANICAL ULCERATION MECHANICAL TRAUMA OCCURS THROUGH BITING, SHARP CUSPS, OUTSTANDING TEETH OR ILL-FITTING INTRAORAL APPLIANCES SUCH ULCERS DON’T PRESENT A PROBLEM CLINICALLY, BUT 3 CRITERIA MUST BE FOLLOWED. A CAUSE OF TRAUMA MUST BE IDENTIFIED. THE CAUSE MUST FIT THE SIZE, SITE AND SHAPE OF ULCER. ON REMOVAL OF THE CAUSE, THE ULCER MUST SHOW SIGNS OF HEALING WITHIN 10DAYS. CHRONIC TRAUMATIC ULCERS MAY PRESENT FOR SEVERAL WEEKS AND MAY BE DEEP CRATER LIKE LESIONS WITH ROLLED EDGES WHICH ARE INDURATED ON PALPATION BECAUSE OF SURROUNDING FIBROSIS.

11. CHEMICAL ULCERATION A VARIETY OF CHEMICALS MAY CAUSE ORAL ULCERATION HYDROGEN PEROXIDE PHENOL ASPIRIN SILVER NITRATE IT INCLUDES IRRITANTS OR CAUSATIVE AGENTS USED IN DENTAL PRACTICE THE PREPARATIONS USED BY PATIENTS IN SELF TREATMENT OF ORAL COMPLAINTS SUCH AS ANTISEPTIC MOUTHWASHES AND ASPIRIN (MISUSED AS OBTUNDANT FOR TOOTH RELIEF) THE ACTION OF ASPIRIN IS TIME AND DOSE DEPENDENT. THE SEVERITY RANGES FROM ODEMA TO NECROSIS OF THE EPITHELIUM ODEMATOUS EPITHELIUM RESEMBLES LEUKOEDEMA WHEREAS THE NECROTIC EPITHELIUM RESEMBLES SOGGY WHITE PLAQUES WHICH LATER FORMS ULCER.

12. THERMAL & FACTITIOUS TRAUMATIC ULCERS ULCERATION DUE TO THERMAL TRAUMA OCCURS DUE TO VERY HOT FOOD OR DRINKS, CAN OCCUR IN ANY PART OF ORAL MUCOSA BUT MOST COMMONLY SEEN IN PALATE. FACTITIOUS ULCERS MAY BE THE MANIFESTATION OF STRESS, ANXIETY OR EMOTIONAL DISTURBANCES. COMMON CAUSE ARE BITING OR CHEWING OF LIPS, CHEEKS OR TONGUE AND DAMAGE (TO GINGIVA FROM SHARP NAIL BITES )

13. FACTITIOUS ULCER- CHRONIC ULCERATION OF THE MANDIBULAR ALVEOLAR RIDGE SECONDARY TO SELF-INDUCED TRAUMA TRAUMATIC ULCER DUE TO THERMAL BURN

14. RADIATION TRAUMATIC ULCERATION RADIATION INDUCED STOMATITIS SALIVARY GLANDS= XEROSTOMIA= FRICTIONAL DAMAGE ATROPHY OF MUCOSA RADIATION OF BONES= DAMAGE TO VASCULAR BED OSTEORADIONECROSIS THE IMMEDIATE EFFECTS ARE ERYTHEMIA, RADIATION MUCOSITIS AND ULCERATION OEDEMA DUE TO OBSTRUCTION OF REGIONAL LYMPHATICS MAY OCCUR

15. EOSINOPHILIC ULCER ITS ALSO REFERRED TO AS TRAUMATIC GRANULOMA OR EOSINOPHILIC GRANULOMA OF SOFT TISSUES IT IS PARTICULARLY ASSOCIATED WITH TRAUMA N INJURY TO MUSCLE ALTHOUGH THE PATHOGENESIS IS UNCLEAR IT OCCURS MOST COMMONLY ON THE TONGUE AND PRESENTS CLINICALLY AS CHRONIC, WELL DEMARCATED ULCER WHICH MAY MIMIC A SQ. CELL CARCINOMA.

16. HISTOLOGICAL EXAMINATION SHOWS AN ULCER COVERED BY THICK LAYER OF FIBROUS EXUDATE WITH A DENSE, CHRONIC INFLAMMATORY CELL INFILTRATE IN ITS BASE INVOLVING UNDERLYING DAMAGED MUSCLE THE DEEPER PARTS CONTAIN INFILTRATE RICH IN HISTIOCYTES AND EOSINOPHILS TRUE GRANULOMAS ARE NOT PRESENT.

17. IMMUNOLOGIC DISEASES IDIOPATHIC ULCERS BEHCET’S SYNDROME REITER’S SYNDROME ERTHEMA MULTIFORME DRUG REACTIONS CONTACT ALLERGIES WEGNER’S GRANULOMATOSIS MIDLINE GRANULOMA CHRONIC GRANULOMATOUS DISEASE CYCLIC NEUTROPENIA

18. IDIOPATHIC ULCERS THERE ARE A GROUP OF IDIOPATHIC ULCERS WHOSE ARE CHARACTERISED BY FREQUENT REOCCURANCES SUCH ULCERS ARE TERMED AS RECURRENT APHTHOUS STOMATITIS (RAS) BASED ON PRIMARILY THEIR CLINICAL FEATURES 3 TYPES OF ULCERS ARE RECOGNISED: MINOR APHTHOUS ULCERS MAJOR APHTHOUS ULCES HERPETIFORM ULCERS

19. ETIOLOGY OF RECURRENT APHTHOUS STOMSTITIS HEREDITARY PREDISPOSITION TRAUMA EMOTIONAL STRESS AND PSYCOLOGICAL FACTORS BACTERIAL AND VIRAL INFECTIONS ALLERGIC DISORDERS HAEMATOLOGICAL AND DEFICIENCY DISORDERS GASTROINTESTINAL DISORDERS HORMONAL DISORDERS

20. CLINICAL FEATUERS OF RAS MINOR MAJOR HERPETIFORM AGE OF ONSET (YEARS) 10-19 10-19 20-29 NUMBER OF ULCERS 1-5 1-10 10-100 PRINCIPAL SITES LIPS, CHEEKS, TONGUE PALATE, PHARYNX FLOOR OF MOUTH, PALATE, PHARYNX, GINGIVA SIZE OF ULCERS(MM) <10 >10 1-2 BUT OFTEN COALEASE DURATION IN DAYS 7-14 >30 10-30

21. MINOR APHTHOUS ULCERATION THIS ACCOUNTS FOR 80% OR MORE CASES OF RAS ITS CHARACTERISED BY ROUND OR OVAL ULCERS WHICH AFFECT NON-KERATINISED AREAS OF ORAL MUCOSA AND THEY HAVE GREY/YELLOW BASE WITH ERYTHEMATOUS MARGIN THEY HEAL WITHOUT SCARRING AND TEND TO RECUR AT 1-4 MONTH INTERVALS, WHICH IS VARIABLE

22. MINOR APHTHOUS ULCERATION

23. MAJOR APHTHOUS ULCERATION THEY OCCUR ANYWHERE IN MOUTH INCLUDING THE KERATINISED ORAL MUCOSA BUT THE LIPS, SOFT PALATE, TONSILLAR AREAS AND OROPHARYNX ARE COMMON SITES THEY HEAL WITH SCARRING AND TEND TO RECUR AT LESS MONTHLY INTERVALS AND MAY BE ASSOCIATED WITH SEVERE DISCOMFORT AND WITH DIFFICULTY IN EATING AND SPEAKING THE EXTENSION IS DEEPER AND MAY PRESENT AS CRATER LIKE ULCERS WITH ROLLED MARGINS WHICH ARE INDURATED ON PALPATION BECAUSE OF UNDERLYING FIBROSIS.

24. MAJOR APHTHOUS ULCERS

25. HERPTIFORM ULCERATION ITS CHARACTERISED BY MULTIPLE, SMALL, PIN-HEADED ULCERS THAT CAN OCCUR IN ANY PART OF ORAL MUCOSA WHEN HUNDREDS OF ULCERS ARE CLUSTERED TOGETHER, THEY CONFLUENCE , WHICH RESULTS IN LARGER AREAS OF ULCERATION WITH IRREGULAR OUTLINE THEY HEAL WITHIN 2-3WEEKS WITH SCARRING THE ULCERS TEND TO RECUR AT LESS THAN MONTHLY INTERVEL AND MAY BE ASSOCIATED WITH SEVERE DISCOMFORT

26. HERPTIFORM ULCERS

27. BEHCET SYNDROME IT’S A RARE DISORDER CHARACTERISED BY RECURRENT APHTHOUS STOMATITIS IT MAY BE SEEN AS GENITAL ULCERS, EYE LESIONS, SKIN LESIONS OR RAPID ACUTE INFLAMMATION OF SKIN IN RESPONSE TO MINOR TRAUMA IMMUNE MEDIATED MUCOSAL DAMAGE AND VASCULITIS ASSOCIATED WITH HYPERACTIVITY OF NEUTROPHILS ARE INVOLVED IN PATHOGENESIS OF LESIONS.

28. THERE IS A CONSIDERABLE LOSS OF TISSUE DEPRESSING ULCER WELL BELOW THE SURFACE AND INFLAMMETION EXTENDS DEEPLY INTO SUBCUTANEOUS FAT THE SURFACE IS COVERED BY FIBRINOUS EXUDATE INFILTRATED BY POLYMORPHS FORMING SCAB A LAYER OF GRANULATION TISSUE WITH DILATED CAPILLARIES AND EDEMA IS SEEN SOME BLOOD VESSELS SHOW EXTENSIVE FIBROUS PROLIFERATION OF SUBENDOTHELIAL CONECTIVE TISSUE.

29. REITER’S SYNDROME CLINICAL FEATURES INCLUDE ARTHRITIS, URETHRITIS, CONJUNCTIVITIS OR UVEITIS, ORAL ULCERS. THE CAUSE IS UNKNOWN BUT IT S IMMUNE RESPONSE TO BACTERIAL ANTIGEN WHICH USUALLY FOLLOWS STD OR SHIGELLA DYSENTARY. IT MAY RECUR . THE DURATION IS WEEKS TO MONTHS ORAL LESIONS HAVE BEEN DESCRIBED AS RELATIVELY PAINLESS APHTHOUS ULCERS OCCURING ALMOST ANYWHERE IN THE MOUTH.

30. DIAGNOSIS IS DEPENDENT ON RECOGNITION OF THE VARIOUS SIGNS AND SYMPTOMS ASSOCIATED WITH THE SYNDROME ERYTHROCYTE SEDIMENTATION RATE IS ELEVATED IN THE ACUTE PHASE OF THE DISEASE BUT PERSISTS AFTER ARTHRITIS RESOLVES .

31. ERYTHEMA MULTIFORME (EM) EM IS A SELF LIMITING HYPERSENSITIVITY REACTION CHARACTERISED BY TARGET SKIN LESIONS AND ORAL ULCERATIVE LESIONS ITS DIVIDED INTO A MINOR FORM USUALLY ASSOCIATED WITH HSV TRIGGER AND A SEVERE FORM TRIGGERED BY CERTAIN SYSTEMIC DRUGS OTHER FACTORS LIKE MALIGNANCY, AUTOIMMUNE DISEASES, RADIOTHERAPY TRIGGER EM DRUGS PRECIPITATING EM ARE BARBITURATES, SULFONAMIDES AND ANTISEIZURE MEDICATIONS.

32. EM IS USUALLY ACUTE, SELF LIMITED PROCESS THAT AFFECTS SKIN OR MUCOUS MEMBRANE AFFECTING MOSTLY YOUNG ADULTS THE TERM ERYTHEMA MULTIFORME WAS COINED TO INDICATE THE MULTIPLE N VARIED CLINICAL APPEARANCES THAT ARE ASSOCIATED WITH CUTANEOUS MANIFESTATIONS THE CLASSIC SKIN LESION CONSISTS OF CONCENTRIC ERYTHEMATOUS RINGS SEPARATED BY RINGS OF NEAR NORMAL COLOR OTHER TYPE OF MANIFESTATIONS INCLUDE MACULES, PAPULES, VESICLES, BULLAE AND URTICARIAL PLAQUES

33. EM PRESENTS AS ULCERATIVE DISEASE VARYING FROM APHTHOUS TYPE LESIONS TO MULTIPLE WIDE SPREAD ULCERS LIPS BUCCAL MUCOSA, PALATE AND TONGUE ARE MOSTLY AFFECTED FROM MILD DISCOMFORT TO SEVERE PAIN IT MAY EVEN LEAD TO HEADACHE, HIGH BODY TEMPERATURE AND LYMPHADENOPATHY STEVENS-JOHNSONS SYNDROME A MAJOR FORM OF EM IS CHARACTERISED BY CRUSTING ULCERATON AT VERMILION BORDER THAT MAY CAUSE IMMENSE PAIN.

34. ORAL ERYTHEMIA MULTIFORME BIOPSY SPECIMEN SHOWING EPITHELIAL EDEMA AND LYMPHOID INFILTRATE THE MICROSCOPIC PATTERN OF EM CONSISTS OF EPITHELIAL HYPERPLASIA AND SPONGIOSIS EPITHELIAL NECROSIS IS SEEN CONNECTIVE TISSUE CHANGES USUALLY APPEAR AS INFILTRATES OF LYMPHOCYTES AND MACROPHAGES IN PERIVASCULAR SPACES AND IN CONNECTIVE TISSUE PAPILLAE.

35. DRUG REACTIONS IT AFFECTS SKIN OR MUCOSA. ERYTHEMIA , WHITE LESIONS, VESICLES OR ULCERS MAY BE SEEN. HISTORY OF DRUG INGESTIONS IS IMPORTANT ALENDRONATE ( BISPHOSPHONATE ) METHOTREXATE ( CHEMOTHERAPY ) NSAIDS ( NICORANDIL ) RECREATIONAL DRUGS ( COCAINE ) THIS IS CAUSED BY POTENTIALLY ANY DRUG VIA STIMULATON OF IMMUNE SYSTEM. REACTIONS SUCH AS ANAPHYLAXIS OR ANGIOEDEMA MAY REQUIRE EMERGENCY CARE; AND HIGHLY VARIABLE CLINICAL PICTURE CAN MAKE DIAGNOSIS DIFFICULT THE PATHOGENESIS OF DRUG REACTIONS MAY BE IMMUNOLOGIC OR NONIMMUNOLOGIC THE IMMUNOLOGIC MECHANISMS ARE TRIGGERED BY AN ANTIGENIC COMPONENT ON DRUG MOLECULE RESULTING IN IMMUNE RESPONSE OR DRUG ALLERGY DRUG REACTIONS THAT ARE NONIMMUNOLOGIC IN NATURE DON’T STIMULATE AN IMMUNE RESPONSE BUT THEY DIRECTLY AFFECT MAST CELLS CAUSING RELEASE OF CHEMICAL MEDIATORS.

36. ORAL MANIFESTATIONS MAY BE ERYTHEMATOUS, VESICULAR OR ULCERATIVE. THEY MAY ALSO MIMIC LICHEN PLANUS SO, THEY ARE KNOWN AS LICHENOID DRUG REACTIONS. THE NONSPECIFIC FEATURES INCLUDE SPONGIOSIS, APOPTOTIC KERATINOCYTES, LYMPHOID INFILTRATES, EOSINOPHILS AND ULCERATION.

37. CONTACT ALLERGIES LESIONS ARE CAUSED BY DIRECT CONTACT WITH FOREIGN ANTIGEN; ERYTHEMA, VESICLES AND ULCERS MAY BE SEEN ITS CAUSED BY POTENTIALLY ANY FOREIGN ANTIGEN THAT CONTACTS SKIN OR MUCOSA; CINNAMON IS FREQUENTLY CITED IN ORAL CONTACT STOMATITIS THE IMMNUNE RESPONSE IS PREDOMINANTLY T-CELL MEDIATED PATCH TESTIN G MAY BE HELPUL FOR DIAGNOSIS; HISTORY IS IMPORTANT.

38. CONTACT ALLERGY IS FREQUENTLY SEEN ON SKIN AND ITS UNCOMMON INTRAORALLY. MATERIALS CAUSING INTRAORAL ALLERGY ARE TOOTHPASTE, MOUTHWASH, CANDY, TOPICAL ANTIMICROBIALS, TOPICAL STEROIDS, IODINE, DENTURE BASE MATERIAL ETC THIS CONDITION PRIMARILY AFFECTS ATTACHED GINGIVA AS BRIGHT BILATERAL BAND MICROSCOPICALLY, EPITHELIUM AND CONNACTIVE TISSUE SHOW INFLAMMATORY CHANGES BLOOD VESSELS MAY BE DILATED AND EOSINOPHILS MAY BE SEEN.

39. WEGENER’ GRANULOMATOSIS CLINICAL FEATURES INCLUDE INFLAMMATORY LESIONS OF LUNG, KIDNEY AND UPPER AIRWAY; MAY AFFECT GINGIVA WHEN INTRAORAL. THE HEAD AND NECK MANIFESTATIONS ARE SINUSITIS, RHINORRHEA, NASAL STIFFNESS AND EPITAXIS. INTRAORAL LESONS CONSIST OF RED, HYPERPLASTIC, GRANULAR LESONS OF ATTACHED GINGIVA. KIDNEY INVOLVEMENT CONSISTS OF FOCAL NECROTIZING GLOMERULITIS AND THE FINAL OUTCOME IS RENAL FAILURE. THIS IS A RARE DISEASE OF MIDDLE AGE. THE CAUSE IS POSSIBLY IMMUNE DEFECT OR INFECTION. IT MAY BECOME LIFE THREATING AS A RESULT OF TISSUE DESTRUCTION IN ANY OF 3 INVOLVED SITES.

40. THE BASIC PATHOLOGIC PROCESS IS GRANULOMATOUS WITH CHARACTERISTIC NECROTIZING VASCULITIS NECROSIS AND MULTINUCLEATED GIANT CELLS MAY BE SEEN IN THE GRANULOMATOUS AREAS DIAGNOSIS MAY BE MADE BY EXCLUSION OF OTHER DISEASES PARTICULARLY MIDLINE GRANULOMA.

41. MIDLINE GRANULOMA THIS IS RARE BUT DESTRUCTIVE, NECROTIC, NONHEALING LESIONS OF NOSE, PALATE AND SINUSES. BIOPSY SHOWS NONSPECIFIC INFLAMMATION DISTINCT FROM WEGENER’S GRANULOMATOSIS MIDLINE GRANULOMA REPRESENTS NK/T-CELL LYMPHOMA PROGNOSIS IS POOR; DEATH MAY FOLOW WHEN ERODED INTO MAJOR BLOOD VESSELS

42. MIDLINE GRANULOMA IS A UNIFOCAL DESTRUCTIVE DISEASE IN THE MIDLINE OF ORONASAL REGION. OTHER DISEASES THAT PRODUCE THIS KIND OF LESIONS ARE WEGENER’S GRANULOMATOSIS, INFETIOUS DISEASE AND CARCINOMA. MICROSCOPICALLY THIS PROCESS APPEARS AS ACUTE AND CHRONIC INFLAMMATION IN PARTIALLY NECROTIC TISSUE WITH ANGIOCENTRIC INFLAMMATION AS COMMON FINDING.

43. CHRONIC GRANULOMATOUS DISEASE THIS DISEASE IS RARE AND PRESENTS AS RECURRENT INFECTIONS IN VARIOUS ORGANS. MOSTLY OCCCURS IN MALES IT’S A GENETIC DISEASE (X-LINKED) THIS IS CAUSED BY THE DEFECT IN NICOTINAMIDE ADENINE DINUCLEOTIDE PHOSPHATE OXIDASE COMPLEX THAT RESULTS IN ALTERED NEUTROPHIL AND MACROPHAGE FUNCTION RESULTING IN INABILITY TO KILL BACERIA AND FUNGI MANIFESTATIONS APPEAR DURING CHILDHOOD DUE TO MORE FREQUENT X-LINKED INHERITANCE PATTERN.

44. CYCLIC NEUTROPENIA THE CLINICAL FEATURES INCLUDE ORAL ULCERS WITH PERIODICITY; INFECTIONS, ADENOPATHY; PERIODONTAL DISEASE THIS IS CAUSED BY MUTATIONS IN NEUTROPHIL ELASTASE GENE CYCLIC NEUTROPENIA RESULTS IN RARE BLOOD DYSCRASIA FEVER, MALAISE, ORAL ULCERS, CERVICAL LYMPHADENOPATHY AND INFECTIONS CAN OCCUR

45. INFECTIVE ORAL ULCERATIONS

46. BACTERIAL - SYPHILIS THIS IS SEXUALLY TRANSMITTED BY A SPIROCHETE-TREPONEMA CLASSIFICATION: PRIMARY ( CHANCRE)- SINGLE, INDURATED NONPAINFUL ULCER AT THE SITE OF SRIROCHETE ENTRY, SPONTANEOUSLY HEALS IN 4-6 WEEKS SECONDARY- MACULOPAPULAR RASH ON SKIN , ORAL ULCERS COVERED BY MEMBRANE(MUCOUS PATCHES) TERTIARY - GUMMAS, CARDIOVASCULAR AND CNS LESIONS CONGENITA L- HUTCHINSON TRIAD(DEAFNESS, INTESTINAL KERATITIS, DENTAL ANOMALIES)

47. SYPHILIS PRIMARY AND SECONDARY FORMS ARE HIGHLY INFECTIOUS. SECONDARY FORM DEVELOPS IN 2-10 WEEKS. LATENCY PERIODS ARE SEEN BETWEEN PRIMARY AND SECONDARY STAGES AND BETWEEN SECONDARY AND TERTIARY STAGES.

48. OTHER INFEC-TIONS CLINICAL FEATURE CAUSE SIGNIFICANCE GONORRHEA GENITAL LESIONS WITH RARE ORAL MANIFESTATIONS; ERYTHEMA OR ULCERS N.gonorrhea MAY BE CONFUSED WITH OTHER ULCERATIVE DISEASES TUBERCULOSIS INDURATED, CHRONIC ULCER THAT MAY BEPAINFUL- ON ANY MUCOSAL SURFACE M.tuberculosis INFECTIOUS ORAL LESIONS ARE ALWAYS RESULT OF LUNG LESIONS LEPROSY SKIN DISEASE WITH RARE NODULES OR ULCERS M.leprae COMMON IN SOUTHEAST ASIA, INDIA, SOUTHAMERICA ACTINOMYCOSIS TYPICALLY SEEN IN MANDINLE, WOOD HARD NODULE WITH SULFUR GRANULES A.israelii INFECTION FOLLOWS ENTRY THROUGH SURGICAL SITE, PERIODONTAL DISEASE OR OPEN ROOT CANAL NOMA NECROTIC, NONHEALING ULCER OF GINGIVA OR BUCCAL MUCOSA; RARE; AFFECTS CHILDREN ANAEROBES IN PATIENT WHOSE SYSTEMIC HEALTH IS COMPROMISED OFTEN ASSOCIATED WITH MALNUTRITION; MAY RESULT IN TISSUE DESTRUCTION

49. DEEP FUNGAL INFECTIONS DEEP FUNGAL INFECTIONS ARE CHARACTERISED BY PRIMARY INVOLVEMENT OF THE LUNGS. ORAL INFECTIONS FOLLOW IMPLANTATION OF INFECTED SPUTUM IN ORAL MUCOSA. ORAL LESIONS ARE USUALLY PRECEDED BY PULMONARY INFECTION. PRIMARY INVOLVEMENT OF ORAL MUCOUS MEMBRANE IS UNLIKELY MODE OF INFECTION.

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51. THE BASIC INFLAMMATORY RESPONSE IN A DEEP FUNGAL INFECTION IS GRANULOMATOUS. MACROPHAGES AND MULTINUCLEATED GIANT CELLS DOMINATE THE HISTOLOGIC PICTURE PECULIAR TO BLASTOMYCOSIS IS PSEUDOEPITHELIO-MATOUS HYPERPLASIA ASSOCIATED WITH SUPERFICIAL INFECTION

52. SUBCUTANANEOUS FUNGAL INFECTIONS - SPOROTRICHOSIS THIS IS CAUSED BY SPOROTHIX SCHENCKII AND RESULTS FROM INOCULATION OF SKIN OR MUCOSA BY CONTAMINATE SOIL OR THRONY PLANTS. LESIONS APPEAR AT SITE OF INOCULATION AND SPREAD ALONG LYMPHATIC CHANNELS. THE INFLAMMATORY RESPONSE IS GRANULOMATOUS. CENTRAL ABSCESSES MAY BE FOUND IN SOME OF GRANULOMAS AND OVERLING EPITHELIUM EXHIBITS PSEUDOEPITHELIOMATOUS HYPERPLASIA.

53. OPPURTUNISTIC FUNGAL INFECTIONS: PHYCOMYCOSIS AND ASPERGILLOSIS PHYCOMYCOSIS (MUCORMYCOSIS) IS CAUSED BY GENERA MUCOR AND RHIZOPUS.ASPERGILLOUS IS UBIQUITOUS IN THE ENVIRONMENT THE ROUTE OF INFECTION IS THROUGH GASTROINTESTINAL TRACT OR RESPIRATORY TRACT. IN HEAD AND NECK, LESIONS ARE MOST LIKELY TO OCCUR IN NASAL CAVITY, PARANASAL SINUSES AND OROPHARYNX.

54. ACUTE AND CHRONIC INFLAMMATORY INFILTRATE IS SEEN IN RESPONSE TO FUNGUS CHARACTERISTIC NECROTIC WALLS CONTAINING THROMBI AND FUNGI MAY BE EVIDENT THE FUNGUS CONSISTS OF LARGE PALE STAINING NON -SEPTATE HYPHAE THAT TEND TO BRANCH AT 90 DEGREES.

55. TREATMENT TREATMENT IS CAUSE RELATED SYMPTOMATIC IF UNDERLYING CAUSE IS UNKNOWN OR NOT CORRECTABLE MOST ULCERS WILL HEAL COMPLETELY WITHOUT ANY INTERVENTION REMOVAL OF LOCAL IRRITATING CAUSE ADDRESSING UNDERLYING FACTORS, DRY MOUTH

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