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

Causes of Oral Ulcers

Acute < 3 weeks

Chronic> 3 weeks

NeoplasticNon-

neoplastic

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:

Investigation

Smears show fusiform

bacilli and spirochetes with gram staining

Etiology

Herpes Simplex Virus 1

• By droplet spread or contact of lesion

Herpetic Ulcer

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

Lab Diagnosis:

VDRL test

FTA-Abs test

• 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