Course 341 MDS Dr Asma’a Faden Faden

Course 341 MDS

Dr Asma’a FadenDr Asma’a Fadenhttp://faculty.ksu.edu.sa/Asmaa Faden

Ulcerative lesionsUlcerative lesions

Main causes of oral ulcerationMain causes of oral ulceration

1. Local Causes

2. Recurrent Aphthous Stomatitis

3. Infections

4. Drugs

5. Malignant disease

6. Systemic disease


4) Drugs4) Drugs

- A wide range of drugs can give rise to ulcers of the oral mucosa.

- Drugs may induce ulcers by producing a local burn, or by a variety of

mechanisms such as the induction of lichenoid lesions.

- A drug history is essential to elicit such uncommon reactions, and then

the offending drug should be avoided.


4) Drugs4) Drugs

Common drugs causing oral ulcerations:Common drugs causing oral ulcerations:

i) Drug-induced neutropenia/anaemia (cytotoxics, e.g, Chemotherapy)

ii) Lichenoid drug reactions (e.g. β-blockers, NSAIDs)

iii) Drug-induced mucositis (cyclophosphamide, e.g, Chemotherapy)


4) Drugs4) Drugs

Clinically:

- The mucosal reactions vary according to the causative agent, including localized

stomatitis, or generalized in case of systemic drugs. Diagnosis rely on medical

history, clinical examination and drugs used.

Differential diagnosis:

- Lichen planus, Stevens–Johnson syndrome, pemphigus vulgaris, severe and

extensive burns.

Management:

- Elimination of any local cause, topical steroids and supportive therapy

Oral mucositis after chemotherapy (CT) and radiotherapy (RT)

Drug reaction oral ulceration



1. Local Causes


3. Infections

4. Drugs


6. Systemic disease

5- Malignant diseases5- Malignant diseases


i) Oral squamous cell carcinoma

ii) Kaposi’s sarcoma

iii) Non-Hodgkin’s lymphoma




- Squamous-cell carcinoma represents about 90% of oral cancers, and

accounts for 3–5% of all cancers.

- The cause is multifactorial. The most important predisposing factors are

tobacco smoke, alcohol, sun exposure, poor oral hygiene, dietary

deficiencies, iron deficiency, liver cirrhosis, Candida infection, oncogenic

viruses (e.g, HPV).




- Oral squamous-cell carcinoma occurs more frequently in men than in

women (ratio 2 : 1), and usually in those over 40 years of age.

- It has a varied clinical presentation, and may mimic several diseases.

- Early carcinoma may appear as a white lesion, a red lesion, or both, or

even as an exophytic mass. However, the most common clinical

presentation is an erosion or an ulcer.




- Clinically: a carcinomatous ulcer has an irregular papillary surface,

elevated borders, and a hard base on palpation.

- The lesions are almost always chronic and indurated. The lateral border,

the ventral surface of the tongue, and the lips are the most commonly

affected areas followed by the floor of the mouth, the gingiva, the alveolar

mucosa, the buccal mucosa, and the palate.

- The prognosis depends on the tumor stage and the histopathological

pattern.




- Laboratory tests Histopathological examination.

- Differential diagnosis Traumatic ulcer, tuberculosis, syphilis, eosinophilic

ulcer, minor salivary gland carcinomas.

- Treatment Surgical excision, radiotherapy, or both, and chemotherapy.

Squamous Cell Carcinoma



ii) Kaposi’s sarcoma

(Discussed in viruses part)




- Non-Hodgkin lymphoma (also known as non-Hodgkin's lymphoma, NHL,

or sometimes just lymphoma) is a cancer that starts in cells of the lymph

system, which is part of the body's immune system.

- Non-Hodgkin lymphoma may develop in any organ associated with the

lymphatic system (e.g. spleen, lymph nodes, or tonsils). Most cases start

with infiltration of lymph nodes, but some subtypes may be restricted to

other lymphatic organs.

http://en.wikipedia.org/wiki/Spleen

http://en.wikipedia.org/wiki/Lymph_node

http://en.wikipedia.org/wiki/Tonsils




- Clinically: NHL may manifest as a solitary area of necrotic ulcers typically

affecting the gingiva, palate and fauces.

- Laboratory tests Histopathological and immunohistochemical

examination.

- Differential diagnosis Eosinophilic ulcer, necrotizing sialadenometaplasia,

tuberculosis, squamous cell carcinoma.

- Treatment Radiotherapy and chemotherapy

Non-Hodgkin lymphoma: large ulcer on the soft palate



1. Local Causes


3. Infections

4. Drugs


6. Systemic disease

6- Oral ulcers related to systemic diseases6- Oral ulcers related to systemic diseases


i) Mucocutaneous.

ii) Haematological.

iii) Gastroentrological.

Oral ulcers related to systemic diseasesOral ulcers related to systemic diseases


i) Mucocutaneous:

1- Behcet’s syndrome

2- Lichen Planus.

3- Vesiculobullous diseases



i) Mucocutaneous:


- Behçet disease is a chronic multisystemic inflammatory disorder.

-The exact cause is unclear, although an immunogenetic basis is suggested.

- It is more common in males (5–10 times), and the onset is usually in the 20–

30 years age group.



i) Mucocutaneous:


Clinical features

- The major clinical diagnostic criteria for the disease are:

(a) recurrent oral ulcerations (aphthae)

(b) recurrent genital ulcerations

(c) ocular lesions (conjunctivitis, reduced visual acuity

(d) skin lesions (papules, pustules,ulcers)



i) Mucocutaneous:


Clinical features

- Minor clinical features may also be present, e. g., arthritis, arthralgia, vein

thrombosis, arterial occlusion and aneurysms, central nervous system

involvement, pulmonary, renal, and gastrointestinal manifestations.

- The diagnosis is mainly made on clinical grounds. For accurate diagnosis,

recurrent oral ulcerations plus two of the other four major criteria must be

present.




- Differential diagnosis Recurrent aphthous ulcers, erythema multiforme,

Stevens–Johnson syndrome.

-Treatment Topical steroids in mild cases. Systemic steroids in severe

cases.

Behcets Disease


Behçet Disease

http://en.wikipedia.org/wiki/Image:Canker_sore.jpg



ii) Haematological:

1- Anemia.

2- Leukemia.



ii) Haematological:

1- Anemia

-Pernicious anemia, iron deficiency anemia usually affect the oral mucosa.

Clinical features: The oral manifestations are early and common, and are

characterized by an atrophic, smooth and red tongue. A burning sensation, taste loss,

angular cheilitis may be present.

Differential diagnosis includes atrophic lichen planus and malnutrition disorders.

-The diagnosis is based on hematological laboratory tests.

- Management: treat the cause by supplements or good nutrition.

Pernicious anemia: red and smooth dorsum of the tongue with areas of ulcerations.



ii) Haematological:

2- Leukemia

- Leukemias are a group of malignant disorders of the blood-forming tissues,

characterized by defects in the maturation and proliferation of leukocytes.

Etiology These conditions are probably caused by a combination of genetic and

environmental factors (viruses, chemicals, radiation).

- Leukemias are classified as acute and chronic, depending on the clinical course, and

myeloid or lymphocytic, according to the histogenetic origin.



ii) Haematological:

2- Leukemia

Clinical features: All forms of leukemia can have oral manifestations.

-The most common oral lesions are ulcerations, spontaneous gingival hemorrhage,

petechiae, ecchymoses, tooth loosening, and delayed wound healing. Gingival

enlargement is a characteristic pattern, frequently seen in patients with myelomonocytic

leukemia.

- Candidiasis and herpetic infections are relatively common oral complications of

leukemia.



ii) Haematological:

2- Leukemia

Laboratory tests Peripheral blood counts, bone-marrow examination.

Differential diagnosis Agranulocytosis, cyclic neutropenia, thrombocytopenic

purpura, acute necrotizing ulcerative gingivitis, gingival overgrowth due to drugs.

Treatment Chemotherapy, bone-marrow transplantation, supportive therapy.

Chronic lymphocytic leukemia: ulcer on the palate

Chronic lymphocytic leukemia: severe gingival enlargement and ulcerations



iii) Gastroentrological diseases:

1- Coeliac diseases (Gluten-sensitive entropathy)

2- Crohn’s disease.



1 -Coeliac Disease

-Also known as gluten-sensitive enteropathy, celiac disease occurs in people who

have a susceptibility to gluten intolerance.

-Celiac disease results in damage to the villi. Without villi, the inner surface of the

small intestine becomes less like a plush carpet and more like a tile floor, and the

body is unable to absorb nutrients necessary for health and growth.

- Instead, nutrients such as fat, protein, vitamins and minerals are eliminated with your

stool.

-The exact cause of celiac disease is unknown, but it’s often inherited



1 -Coeliac Disease

-Clinical features: Typical cases of CD present at the age of 6-24 months with

symptoms of intestinal malabsorption, impaired growth, abnormal stools, abdominal

distension, muscle wasting, hypotonia, poor appetite or unhappy behaviour.

- In adults, the symptoms of CD may be highly varied and range from severe weight

loss and diarrhoea with bulky offensive stools, to subtle complaints of cramps,

abdominal bloating, flatulence and even constipation.

- These individuals are often mistakenly diagnosed as having an irritable bowel

syndrome.



1 -Coeliac Disease

- Differential diagnosis: Recurrent oral aphthous ulcers-like are common and

should arouse suspicion of the condition.

--There are a range of blood tests that have been introduced internationally over the

past few years that can be used to support the diagnosis of CD .

- Management: The first line of treatment is the complete removal of gluten from the

diet. This usually entails life-long avoidance of all cereals containing gluten, including

wheat, oats, rye and barley.

Aphthous ulcer-like in Gluten entropathy patient


2- Crohn’s Disease

Definition Crohn’s disease or regional ileitis is a chronic inflammatory disease that

primarily affects the ileum and other parts of the gastrointestinal tract.

- The disease usually affects young individual

Etiology Unknown; probably immunologically mediated.




Clinical features:

-Presents clinically with abdominal pain, nausea, diarrhea, weight loss, low-

grade fever, and rectal bleeding.

- Extra-abdominal involvement includes arthritis,uveitis, and oral lesions.




Clinical features:

Oral lesions occur in 10–20% of patients and are characterized by nodular

swelling, which may be ulcerated.

-Diffuse raised nodules resulting in a cobblestone appearance of the mucosa

or mucosal tag lesions may occur.

- Granulomatous lip swelling, angular cheilitis, gingival swelling, and atypical

ulcerations may be seen.




Laboratory tests: Histopathological examination.

Differential diagnosis Orofacial granulomatosis, epulis fissuratum, pyogenic

granuloma.

Treatment Topical steroids, systemic steroids, sulfasalazine


Crohn’s disease

Crohn’s disease: cobblestone appearance of the buccal mucosa

Irregular superficial ulcers on ventral surface of tongue in Crohn’s disease

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Course 341 MDS Dr Asma’a Faden Faden