SINGLE ULCERS

GOOD MORNIN

G

SEMINAR

YASMIN MOIDIN 2008 BATCH

AL AZHAR DENTAL COLLEGETHODUPUZHA

SINGLE ULCERS

INTRODUCTION

The most common cause of single ulcers on

the oral mucosa is trauma

TYPES

Traumatic ulcer

Eosinophilic ulcer of tongue

Histoplasmosis

Blastomycosis

Mucormycosis

Syphilitic ulcer

TRAUMATIC ULCER

Most common oral mucosal ulcer

Types of trauma

Mechanical

Chemical

Thermal

Radiation

Self-inflicted

Iatrogenic

CLINICAL FEATURES

Tenderness or pain in the area of lesion

Sites : tongue, lips, mucobuccal fold, gingiva and palate

Persist for few days or lasts for weeks

Vary in size and shape

Borders are raised and reddish

Bases are yellowish necrotic surface

Frequently, a painful regional lymphadenitis occur as a result

of contamination of ulcer by oral flora

DIFFERENTIAL DIAGNOSIS

Carcinomatous ulcer

Recurrent aphthous ulcerations

MANAGEMENT

Removal of traumatic factor

Most traumatic ulcer become painless within 3 to 4 days

After the injury producing agent has been eliminated,

most heal with 10 days

Less serious varieties, treat with triamicinolone

acetonide with emolient before bed time and after

meals usually relieves the pain and hastens the

healing

Orabase protects the denuded CT from continued

contamination by oral liquids and cortisone

component tend to arrest the inflammatory cycle

Persistent ulcers are surgically excised

EOSINOPHILIC ULCER OF TONGUE

ETIOLOGYAND

PATHOGENESIS

Inflicting crush injury

on tongue-most

common site

Deep and penetrating

RIGA-FEDE DISEASE

Lesion seen on ventral tongue

Infants

Cause- tongue rasping against newly erupted

primary incisors

CLINICAL MANIFESTATIONS

Bimodal age distribution

1st group- in 1st 2 years of life-lesion

associated with erupting primary dentition

2nd group – adults – 5th and 6th decades

ORAL FINDINGS

Children – anterior ventral or dorsal tongue

associated with erupting mandibular or

maxillary incisors

Adults – posterior and lateral aspect of tongue

Ulcer – not painful & persist for months

History of trauma

Appear cleanly punched out, with surrounding

erythema & whiteness

Size – 0.5cm

Surrounding tissue is indurated5 % - multifocal and recurrences are not

uncommon

In some cases , lesions are ulcerated , mushroom-

shaped , polypoid mass on the lateral tongue


Recurrent aphthous ulcers

Squamous cell carcinoma

T-cell lymphomas

LABORATORY FINDINGS

Biopsy is needed to make diagnosis

MANAGEMENT

Intralesional steroid injections

Wound debridement

Use of nightguard on lower incisor – reduce

nighttime trauma

HISTOPLASMOSIS

ETIOLOGY AND PATHOGENESIS

Caused by fungus Histoplasma capsulatum

Infection results from inhaling dust

contaminated with droppings, from infected

birds or bats


The expression of the disease depends on the quantity

of spores inhaled, the immune status of the host and

the strains of the organism

Asymptomatic and mild flulike illness for 1 to 2 weeks

The inhaled spores are ingested by macrophages

within 24 to 48 hours and specific T lymphocyte

immunity develops in 2 to 3 weeks

TYPES

Acute histoplasmosis

Self –limited pulmonary infection

Acute symptoms are fever, headache, myalgia,

nonproductive cough, anorexia

Patient is ill for 2 weeks

Calcification of hilar lymph nodes

Chronic histoplasmosis

Primarily affects the lungs

Affects older, emphysematous, white men or

immunosuppressed patients

Patients typically exhibit cough, weight loss, fever,

dyspnoea, chest pain, hemoptysis, weakness and

fatigue

Disseminated histoplasmosis Less common

It is characterized by progressive spread of the

infection to extrapulmonary sites

It occurs in older, debilitated, immunosuppressed

patients and patients with AIDS

Tissues that affect include: spleen , adrenal glands,

liver, lymph nodes, GIT, CNS, kidneys and oral mucosa

Common sites – tongue, palate, buccal

mucosa

It appears as a solitary, painful ulceration of

several weeks duration

Some lesions appear erythematous or white

with an irregular surface

Ulcerated lesions have firm, rolled margins

ORAL FINDINGS

Oral lesion begin as an area of erythema ,

becomes papule & forms Painful ,

granulomatous –appearing ulcer

Cervical lymph nodes are enlarged and firm

Patients with HIV has an ulcer with indurated

border, seen on gingiva , palate , tongue


Traumatic ulcerative granuloma

Squamous cell carcinoma

Lymphoma

LABORATORY FINDINGS

Biopsy – stained with PAS OR methanamine

silver – reveal presence of fungi

MANAGEMENT

Immunocompromised patients -IV amphotericin B

AIDS – itraconazole & maintenance therapy

Immunocompetent – itraconazole or ketoconazole for 6

to 12 months

BLASTOMYCOSIS


Caused by Blastomyces dermatitidis

Infection results from inhalation and is found

in agricultural and construction workers


It is acquired by inhalation of spores , particularly after

rain

The spores reach the alveoli of lungs, where they begin

to grow as yeasts

The infection is halted and contained in the lungs

The sites of dissemination include skin, bone, prostate,

meninges, oropharyngeal mucosa and abdominal organs

Types

Acute blastomycosis

Resembles pneumonia, characterised by high

fever, chest pain, malaise, night sweats and

productive cough with mucopurulent sputum

Rarely, the infection may precipitate life-

threatening adult respiratory distress syndrome

Chronic blastomycosis

More common

Characterisezd by low grade fever, night sweats, weight

loss and productive cough

Chest radiographs shows diffuse infiltrates or pulmonary

or hilar masses

Calcification is not typically present

Lesion begins as erythematous nodules that enlarge ,

becoming verrucous or ulcerated

ORAL FINDINGS

It may result from either extrapulmonary

dissemination or local inoculation with the

organism

Lesions have an irregular, erythematous or white

intact surface

Appear as ulcerations with irregular rolled borders

and varying degree of pain

LABORATORY FINDINGS

Diagnosis by biopsy and culture demonstrates presence

of multinucleated yeast cells with dark cytoplasm &

colorless cell walls with characteristic of B.dematitidis

TREATMENT

Disseminated or progressive – ketoconazole ,

fluconazole , itraconazole for mild to moderate

Amphotericin B – sever disease

MUCORMYCOSIS

ZYGOMYCOSIS/ PHYCOMYCOSIS


Caused by saprophytic fungi

Occurs in soil or as a mold on decaying food

Fungus is nonpathogenic


Rhinocerebral zygomycosis

Patient experiences nasal obstruction, bloody nasal

discharge, facial pain or headache, facial swelling or

cellulitis and visual disturbances with concurrent proptosis

With progression of disease into the cranial vault,

blindness, lethargy and seizures may develop followed by

death

If maxillary sinus is involved, the initial

presentation may seen as intraoral swelling

of maxillary alveolar process & palate

If the condition is untreated, palatal

ulceration, appears as black and necrotic and

massive destruction

ORAL FINDINGS

Ulceration of the palate

Lesion is large & deep, causing denudation of

underlying bone

Other sites- gingiva, lip , alveolar ridge

Initial manifestation confused with dental pain or

bacterial maxillary sinusitis caused by invasion of

maxillary sinus

LABORATORY FINDINGS

Biopsy is split into culture & histopathology

Histopathologic findings- necrosis &

nonseptate hyphae

Necrosis & occlusion of vessels is present

MANAGEMENT

Combination of surgical debridement of the

infected area

Amphotericin B for 3 months

Observed for renal toxicity

Posaconazole , antifungal agent is used for patients

unable to tolerate toxicity of amphotericin

SYPHILITIC ULCER

Syphilis is a sexually transmitted disease ,

caused by Treponema pallidumCHANCRESeen in genital region Other sites- lips , tongue, palate, tonsillar regionsIn initial stage- papule seen which subsequently

erodesTypical syphilitic ulcer is punched-out, non tender,

indurated and associated with yellowish discharge

Associated nodes are firm & non tender on palpation

Self-limiting & last for 2 weeksHeal with minimum scar formation MUCOUS PATCHESAppears after a latency period of 6 months Patient complains of fever, headache, bodyache & sore

throatCutaneous maculopapular rashes associated with

lymphadenopathy

Oral lesions are characterised by appearance of oval red macules (palate) or papules (buccal mucosa & commissures) and mucous patches

Mucous patches are seen as raised erosive areas covered by a grayish white pseudomembraneous and surrpunded by an erythematous halo

Measure about 1 cm in diameterSmall lesions join together to give rise to snail

track ulcers severe & generalised form – lues maligna, also

termed ulceronodular disease

Oral mucosa reveals shallow crater like ulcers

Common sites – palate , buccal mucosa, tongue, lower lip, and gingiva

GUMMAIt is a highly destructive lesion It occurs 8 to 10 years after initial infectionCommon sites – hard palate , tongue

MANAGEMENT

Parenteral pencillin G

Allergic to pencillin, treated with

doxycycline , tetracycline , erythromycin

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