oralulcers1234567890-098765432123456.pptx

ulcers

1. 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.

2.  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 .

3. 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.

4.  ULCER CONSISTS OF: 1. 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. 2. FLOOR:- THIS IS THE EXPOSED PART OF AN ULCER. THE COVERING OF FLOOR IS IMPORTANT. 3. 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. 4. 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

5. CLINICAL P A THO L OGICA L

6. TYPES SURROUNDING SKIN ULCER FEATURES OTHER FEATUERS SPREADING INFLAMED NO GRANULATION TISSUE IS SEEN HEALING NOT INFLA M MED 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

7.  ULCERATIONS ARE CLASSIFIED ON THE BASIS OF ETIOLOGY. CAUSES OF ORAL ULCERATIONS  TRAU M A  INFECTIVE DISEASES  IMMUNOLOGIC DISEASES

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

9.  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 FITTHE 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.

10.  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.

11.  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 )

12. FACTITIOUS ULCER- CHRONIC ULCERATION OF THE MANDIBULAR ALVEOLAR RIDGE SECONDARY TO SELF-INDUCED TRAUMA

13. 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

14. 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.

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

16. 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

17. HEREDITARY PREDISPOSITION TRAUMA EMOTIONAL STRESS AND PSYCOLOGICAL FACTORS BACTERIAL AND VIRAL INFECTIONS ALLERGIC DISORDERS HAEMATOLOGICAL AND DEFICIENCY DISORDERS GASTROINTESTINAL DISORDERS

18. MINOR MAJOR HERPETIFORM AGE OF ONSET (YEARS) 10-19 10-19 20-29 NUMBER OF ULCERS 1-5 1-10 10-100 PRIN C I P AL SITES LIPS, CHEEKS, TONGUE PALATE, PHARYNX FLOOR OF MOUTH, PALATE, PHARYNX, GINGIVA SIZE OF U L CERS(MM) <10 >10 1-2 BUT OFTEN COALEASE DURATION IN DAYS 7-14 >30 10-30

19. 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

20. 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 .

21. 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

22. 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.

23. 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.

24. 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 .

25. 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 BARBITUR A TE S , S U LF O NA MIDE S A N D ANTISEIZURE MEDICATIONS.

26. 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

27. 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 .

28.  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

29. 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.

30. 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 .

31. 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.

32. 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.

33. 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.

34. THIS IS RARE BUT DESTRUCTIVE, NECROTIC, NONHEALING LESIONS OF NOSE, PALATE AND SINUSES . BIOPSY SHOWS NONSPECIFIC INFLAMMATION DISTINCT FROM WEGENER’S GRANULOMATOSIS M I DLINE GRANU L OM A RE P RESEN T S NK/ T - CELL LYMPHOMA PROGNOSIS IS POOR; DEATH MAY FOLOW WHEN ERODED INTO MAJOR BLOOD VESSELS

35. 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.

36. 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.

37. 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

38. O T HER 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 A CT I NO M Y COSI S 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

39. 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