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Ulcer – is a break in the continuity of the
covering epithelium – skin or mucous
membrane. It may follow molecular death
of surface epithelium or traumatic
removal
Margin – junction between normal epithelium and ulcer
Edge – area between margin and floor of ulcer
Floor – exposed surface of ulcer
Base - where ulcer rests on
Shape:› Oval – generally tuberculous
› Circular to serpiginous - syphilitc
› Irregular - carcinomatous
Number:› Multiple ulcers – herpetic ulcers
› Usually single – syphilitic & tuberculous ulcers
Position:› Tuberculous ulcers common in area of
adenopathy
› Carcinomatous can occur anywhere
Edge:
› Spreading ulcer –inflamed and edematous
› Healing ulcer – red granulation tissue to blue
zone(growing epit.) to white zone (fibrosis)
› Undermined – tuberculous ulcer
› Punched out – syphilitic ulcer
› Sloping – healing ulcer
› Raised & beaded – rodent ulcer
› Rolled out and everted – squamous cell
carcinoma
Floor:
› Slough – stage of extension
› Red granulation tissue - healing ulcer
› Smooth pale granulation – stage of healing
› Watery granulation tissue - tubercular ulcer
› Floor above surface – malignant ulcer
› Wash leather slough – gummatous ulcer
Discharge :
› Purulent – bacterial infection
› Watery – tuberculous
› Bloody – malignancy
Tenderness:
› Exquisitely tender - acute
› Slightly tender - chronic
› Never tender – neoplastic
Base:
› Using thumb and index finger – attempt to
pick up ulcer
› Slight induration – chronic ulcer
› Marked induration – malignancy
Relation with deeper structures:
› Malignant ulcer – fixed to deeper
tissues
Surrounding skin/mucosa:
› Increased temp. and tenderness –
inflammatory
› Fixity to deeper structures –
malignant ulcer
Acute Ulcer
•Traumatic ulcer
•Acute necrotising ulcerative
gingivitis
•Herpetic ulcer
•Minor aphthous ulcer
•Shingles
•Primary syphilis
Chronic
Ulcer
Neoplastic
Non-neoplastic
•Tuberculous ulcer
•Major aphthous ulcer
•Lichen planus
•Secondary & tertiary
syphilis
•Pemphigus
•Cicatricial pemphigoid
Acute Ulcers
• Sharp tooth, badly decayed tooth
• Roughened prostheses & sharp edges
• Chemicals –aspirin
• Iatrogenic
Etiology
Traumatic Ulcer
• Pain, inflammation
• Acute - covered with yellow whitish fibrinous exudate surrounded by erythematous halo
• Chronic – yellow membrane –raised margins
• Whitish surrounding mucosa
Clinical Features
• History and examination
• Chronic – 2 week examination – biopsy
Diagnosis:
• Solitary ulcer – bacterial origin – suppurative
• Chancre – indurated
• TB ulcer – systemic ulcer
Differential diagnosis:
• Fusiform bacillus
• Borrelia vincentiiEtiology
Acute Necrotising
Ulcerative Gingivitis
Precipitating factors:
Stress
Poor oral
hygiene
Poor nutritional
status
Immunosuppression
• Painful punched out craterlike lesions – interdental papilla
• Grayish pseudomembranecovering
• Bleed when touched
• Fetid odour
• Headache , malaise, low-grade fever
• Metallic taste
• Lymphadenopathy
Clinical Features:
Clinical Features
Fever, pain on
swallowing, regional
lymphadenopathy
Yellowish fluid filled vesicles –ragged and well
delineated
Along sensory nerve
distribution
Ruptures and covered by
gray membrane
and erythematous
halo
Common – lips, tongue, palate, buccal mucosa
Heals within
7-10 days
Recurrent in
immuno-comprom
ised
Primary infection VZV
Chicken pox
Virus becomes dormant
Reactivation
Shingles
Varicella Zoster
Virus
• Acute ulcers along division trigeminal nerve
• V1 – upper eyelid, forehead, scalp
• V2 – midface & upper lip
• V3 – lower face & lower lip
Clinical Features
• V2 – prodrome of pain, burning – palate
• Unilateral distribution
• 1-5 mm clustered ulcers – painful
• Coalesce form larger
• Heal -10-14 days
Ulcers
• Ramsay hunt syndrome - bells palsy, loss of taste sensation in anterior 2/3rd and vesicles of external ear
Complication
• Smear – no difference HSV, VZV
• Fluorescent antibody tests
• PCR
Investigations
• Autoimmune response
• B12/Folic acid deficiency
• Psychologic factors - stress
• Allergic factors
• Familial tendency
Etiology
Minor Aphthous
Ulcer
• 1-5 shallow, round/oval ulcer
• 2-10mm gray/yellow base –erythematous margin
• Heal 7-10 days no scarring
• 1-2 a month – buccalmucosa, tongue, soft palate
Clinical Features
Treponema PallidumPrimary
Syphillis
• Solitary ulcer 3-90 days after contact
• Oral chancre
• Common – lip and anterior part of tongue
• Painful
• Starts as firm nodule and surface breaks after a few days
• Rounded ulcer with indurated edges
• Regional lymphadenitis
Clinical Features
Diagnosis
History of sexual contact
Lab Diagnosis
• Spirochetes in Dark field illumination/ Silver stained smears
• Mycobacterium tuberculosis
Etiology
• Fever, chills, malaise, cough , loss of weight
• Deep painful ulcer
• Undermined edge
• Watery discharge
• Palpable matted lymph nodes
Clinical Features:
Chronic
UlcersTuberculous
Ulcer
Acid fast bacilli in sputum Chest x-ray
Tuberculin test – 0.1 ml – 5 tuberculin units purified
protein derivative - >10mm induration
ELISA & PCR
Investigations
• Seen after 6 weeks of primary lesion
• With fever, headache, sore throat, lymphadenopathy
• Common – palate, tonsils, lateral border tongue and lip
• Lesions – irregularly linear (snail track ulcers)Mucous patches –multiple grayish white plaque
Clinical Features
Secondary
Syphilis
• After 3 years initial infection
• Gumma – focal granulomatousinflammatory process with central necrosis
• Nodular mass with yellowish center
• Necrotizes to leave deep painless ulcer
Clinical Features
Tertiary Syphillis
EtiologyAutoantibodies
DSG 3 -desmosomes
Weakens intercellular connection
Pemphigus
• Pressure to apparently normal area – forms new lesion
• Nikolsky sign – peeling of upper layer of epithelium
Clinical Features
• Bulla breaks – shallow irregular ulcer
• Edges extends peripherally over time
• Start – buccal mucosa – along areas of trauma in occlusal plane
• Painful – difficult to eat or drink
Clinical Features
• Positive nikolsky sign
• Biopsy – suprabasilar acantholysis – stratum spinosum
• Direct immunofluorescence – IgG presence
Investigation
Etiology
Autoantibodiesof IgG
Against hemi-desmosomes
Cicatricial
Pemphigoid
• Bullae are thick-walled –ruptures 24-48 hours
• Leaves raw eroded bleeding surface
• Ulceration and scarring
Clinical Features
• Desquamative lesions –common on gingivae
Clinical Features
• Biopsy – subepidermal vesicles and bullae
• Absence of nikolsky sign
Investigations
T lymphocyte-mediated disorder
EtiologyDental
restorations – amalgam
Drugs –NSAIDs Stress
Viral infection
Lichen Planus
Clinical Features:
Atrophic –
smooth, red areas
Erosive -painful, with a
yellowish slough
Striaeradiate from
margins of
erosions
Common - buccalmucosa, dorsum
of tongue, gingiva
Usually bilateral
Etiology
Autoimmune response
B12/Folic acid
deficiency
Psychologic
factors -stress
Allergic factors
Familial tendency
Major Aphthous
Stomatitis & Recurrent
Herpetiform Ulcer
• 1-10 number – large painful
• Yellow necrotic center erythematous halo
• Cheeks, tongue, soft palate – dysphagia
• >10mm – persist >3 weeks and scars
Major Aphthous Ulcer
• Multiple ulcer – 1-100
• 1-2mm at any site and coalesce
• Painful and heals in 2-3 weeks – no scar
Recurrent herpetiform ulcer:
Etiology
Tobacco
Alcohol
Infection –HPV 16 Chronic
irritation
UV radiation
Genetic predisposition
Neoplastic
Ulcers
• Single ulcer – rolled,raised and evertedborder
• Painless usually – non-healing
• Induration on palpation
• Local pain or paresthesia in nerve involvement
• Referred earache, trismus, dysphagia, halitosis, enlarged cervical nodes
Clinical Features:
• Symptoms > 3 weeks
• Ulcer without healing 7-10 days – biopsy
• Biopsy – mitotic figures, keratin pearls, pleomorphism, connective tissue involvement
Diagnosis:
• Non-healing ulcer > 3 weeks
• Induration & lack of inflammation surrounding
• Rolled & thickened edge
• Smoking & alcohol
• Male 2:1 & Age > 50 years
• History premalignant lesion in area
• No local factors
Suspicion of Malignancy
• Ulcers – multiple & synchronously
• Clustering ulcer
• Blister formation
• Associated sore and bleeding gums
• Identifiable local cause
• Recurrent ulceration
Reduced Suspicion of Malignancy
Ulcer > 3 weeks
Features suggesting malignancy
- Solitary ulcer
- Proliferative appearance
Optimisegeneral health
Refer through 2 week wait route
Features that do not
suggest malignancy
Isolated ulcer
- Trauma
Managed in primary care if confident of diagnosis
Recurrent ulcer
- Aphthousulcer
Managed in primary care
if confident of diagnosis
Widespread oral ulcer
- Oral lichen planus
Refer
• Oral ulceration - common and mostly benign
• Some oral ulcers may be associated with systemic disease or particular drugs
• A systematic approach to examination of the oral cavity with good lighting and retraction of mobile tissues is critical
Conclusion
• A minority of oral ulcers are malignant
• Ulcer that persists for more than three weeks should be referred; suspected malignancy requires urgent referral to a specialist
• Non-malignant oral ulceration may be investigated and treated in primary care or referred
• A benign ulcer is not referred, re-evaluate the lesion to ensure that healing has occurred
Conclusion
Recommended