Oral ulcers

Oral ulcers

1. Oral Ulcers Marwa M ahamoud Khalifa Faculty of Medicine Alexandria University

2. Oral ulceration is one of the most common complaints of patients who attend their GPs with an oral problem and the differential diagnosis is extensive . Although the cause of ulceration is often local, the oral mucosa is an important site of manifestation of many systemic conditions and oral ulceration may be the initial presentation in such cases. Ulcers may arise de novo (primary ulcers) or secondary to breakdown of vesicles or bullae (secondary ulcers) and may be recurrent or persistent.

3. Common causes of oral ulceration A) Primary ulcers 1- Recurrent aphthous stomatitis minor, major and herpetiform variants associated with haematinic deficiencies, GIT disease ( Crohn’s disease, ulcerative colitis and coeliac disease), congenital and acquired immunodeficiency and blood dyscrasias consider Behçet’s , MAGIC, and Sweet’s and PFAPA syndromes

4. 2- Trauma usually accidental, or trauma from overextended dentures or sharp teeth; rarely, burns, stomatitis artefacta or trauma to exophytic lesion 3- Dermatoses erosive and atrophic lichen planus , discoid and systemic lupus erythematosus , erythema multiforme , linear IgA disease

5. 4- Malignancy squamous cell carcinoma usually presents as a persistent primary ulcer 5- Infections TB, syphilis, Reiter’s syndrome and acute necrotising ulcerative gingivitis; atypical lesions and ‘exotic’ infections in HIV disease, including deep mycoses

6. 6- Orofacial granulomatosis linear or serpiginous ulcers, particularly in the buccal sulci; associations with gastrointestinal diseases and allergies 7- Neutropenic ulcers congenital and acquired immunodeficiencies ; ulcers lack an inflammatory erythematous halo; may be drug related; atypical viral fungal and bacterial lesions

7. 8- Drugs aspirin and other caustic burns; cytotoxic drugs often cause mucositis and ulceration; fixed and lichenoid drug eruptions, nicorandil and bisphosphonate ulceration

8. B) Secondary ulcers 1- Viral diseases mostly herpes virus group and enterovirus group enanthemata 2- Dermatoses pemphigus (and variants), pemphigoid (and variants), congenital and acquired epidermolysis bullosa , dermatitis herpetiformis and bullous lichen planus 3- Angina bullosa haemorrhagica idiopathic blood blisters, usually on the soft palate

9. Diagnosis of oral ulcers Because of the rich innervation of the oral mucosa, most ulcers are painful. An important exception to this rule is early squamous cell carcinoma until it involves the periosteum , bone or deep mucosal tissues It typically presents as an ulcer with a rolled everted edge and sloughing or granular base. The exophytic form, verrucous carcinoma, is uncommon but has a better prognosis .

10. Persistent, painless ulcers that are found on routine examination, particularly in the elderly, should thus not be ignored, especially in those who smoke or drink alcohol regularly , or where there is evidence of erythroplakia or leucoplakia . The incidence of oral cancer is increasing.

11. Recurrent aphthous stomatitis common and may affect 10 % of the population at some time One in 15 patients have an underlying cause three variants – minor, major and herpetiform The pathogenesis is immunologically mediated respond to simple treatments such as topical steroids, eg 0.1 per cent triamcinolone acetonide a nd antimicrobial mouthwashes, eg chlorhexidine , povidone -iodine or benzydamine . In adults, herpetiform aphthous stomatitis usually responds to tetracycline mouthrinse and swallow

12. Nicorandil ulceration. The ulceration is persistent, painful, deep, punched out , with little inflammatory halo and no induration.

13. squamous cell carcinoma; the ulcer is persistent, often relatively painless, with raised,rolled edges, necrotic base and indurated on palpation

14. Recurrent aphthous ulceration (minor type ). painful, with a yellow-white sloughing base and inflammatory erythematous halo; not indurated and heal spontaneously within two weeks

15. Lichenoid eruption (to a beta-blocker). There is central ulceration, but peripherally reticular ( strial ) white lesions are present; the ulceration is persistent and painful , but will resolve completely with cessation of the offending drug

16. Erythema multiforme acute onset, painful, superficial and irregular; often the entire oral mucosa is involved and there is bloody crusting of the lips