ORAL MUCOSAL DISEASES Oral Ulcerative

Diseases

Oral Ulcerations Ulcers are the most common

oral soft tissue lesions. Traumatic ulcers Aphthous stomatitis Behcet’s disease Viral infections of oral mucosa:

Herpes simplex, herpangina, herpes zoster

Erosive lichen planus Bacterial infections: T.B ulcer,

syphilitic ulcerations Vesiculo-bullous diseases Malignant ulcers

Traumatic ulcers Caused by local trauma Either by ill fitted dentures Sharp edges of brocken

tooth Lip or tongue biting after

heavy anesthesia Cheek biting

Traumatic ulceration

Acute traumatic ulcer

Acute ulcer of the floor of mouth (saliva ejector injury)

Anesthesia-associated acute tongue ulcer

Ulcer associated with excessive heat from hydrocolloid impression material

Recurent Aphthae(Aphthous

Stomatitis) Most common oral mucosal lesion

Possible etiological factors: Allergy: food Genetic predisposition: HLA family Nutritional deficiency:B12,folate,Iron Hematological abnormalities Hormonal influences: Female, menstrual

period Infectious agents: AIDS,HSV,VZV Trauma Stress

Of all the types of nontraumatic ulceration that affect oral mucosa, aphthous ulcers (canker sores) are probably the most common.

incidence ranges from 20% to 60%.

Prevalence tends to be higher in professional persons, in those in upper socioeconomic groups, and in those who do not smoke.

Typical features Onset frequently in childhood

but peak in adolescence or early adult life

Attacks at variable but sometimes relatively regular intervals

Most patients are non-smokers Usually self-limiting eventually

Types of Recurrent Aphthae

Three forms of aphthous ulcers have been recognized:

minor, major, and herpetiform

All are believed to be part of the same disease spectrum, and all are believed to have a common etiology. Differences are essentially clinical and correspond to the degree of severity.

Minor Aphthous stomatitisThe most common type

Non-keratinized mucosa affected

Ulcers are shallow, rounded, 5-7mm with erythematous margins and yellowish floor

One or several ulcers may be present

Clinical Features Minor aphthous ulcers usually appears

as a single, painful, oval ulcer that is less than 0.5 cm in diameter, covered by a yellow fibrinous membrane and surrounded by an erythematous halo. Multiple oral aphthae may be seen.

Minor aphthous ulcers generally last 7 to 10 days and heal without scar formation. Recurrences vary from one individual to another. Periods of freedom from disease may range from a matter of weeks to as long as years.

Minor Aphthous Stomatitis

Minor aphthous ulceration Erythematous halo

encircling a yellowish ulceration of the lower labial mucosa

Minor aphthous ulceration. Single ulceration of

the anterior buccal mucosa

Minor aphthous ulcers

Minor aphthous ulcer of the floor of mouth

Minor aphthous ulcers of the lateral tongue

Major Aphthae Uncommon Ulcers frequently several cms

mimic malignant ulcers Ulcers persist for several months Masticatory mucosa, dorsum of

tongue or gingiva may be involved

Scar follow healing

Clinical Features painful recurrent ulcers. prodromal symptoms of tingling or

burning before the appearance of lesions.

The ulcers are not preceded by vesicles and characteristically appear on the vestibular and buccal mucosa, tongue, soft palate, fauces, and floor of mouth.

Only rarely do these lesions occur on the attached gingiva and hard palate, thus providing an important clinical sign for the separation of aphthous ulcers from secondary herpetic ulcers.

Major aphthous ulcer

Major aphthous ulceration . Large, deep, and irregular

ulceration of the posterior buccal mucosa

Major aphthous ulceration. Large. irregular ulcerationof the soft palate.

Major aphthous ulceration. A. large ulceration of the left anterior buccal

mucosa.B. Same lesion after 5 days of therapy with betamethasone syrup used in a

swish-and-swallow method. The patient was free of pain by the second day of

therapy. The ulceration healed completely during the following week.

discomfort, systemic health may be compromised because of difficulty in eating and psychological stress. The predilection for movable oral mucosa is as typical for major aphthous ulcers as it is for minor aphthae.

HIV-positive patients may have aphthous lesions at any intraoral site.

Herpetiform Aphthae Uncommon Non-keratinized mucosa affected Ulcers are 1-2 cm Dozens or hundreds may be present May coalesce to form irrigular ulcers Widespread bright erythemous round

ulcers

Herpetiform Aphthous Ulcers. Clinically recurrent crops of small ulcers. movable mucosa is predominantly

affected, palatal and gingival mucosa may

also be involved. Pain may be considerable,

healing generally occurs in 1 to 2 weeks.

Unlike herpes infection, herpetiform aphthous ulcers are not preceded by vesicles and exhibit no virus-infected cells.

Herpetiform aphthous ulcers. The patient also had numerous lesions of the lip and buccal

mucosa.

Herpetiform aphthae of the tongue.

Histopathology the diagnosis of these ulcers is

usually evident clinically, biopsies usually are unnecessary and therefore are rarely performed.

Aphthous ulcers have nonspecific microscopic findings, and no histologic features are diagnostic.

Studies have shown that mononuclear cells are found in submucosa and perivascular tissues in the preulcerative stage. These cells are predominantly CD4 lymphocytes,

Preaphthous ulceration. Intense lymphocytic infiltrate and basilar

epithelial edema seen in preulcerative stage of an aphthous lesion.

Differential Diagnosis. Diagnosis of aphthous ulcers is

generally based on the history and clinical appearance.

Lesions of secondary (recurrent) oral herpes are often confused with ulcers.

A history of vesicles preceding ulcers, location on the attached gingiva and hard palate, and crops of lesions indicate herpetic rather than aphthous ulcers.

Other painful oral ulcerative conditions include trauma, pemphigus vulgaris, mucous membrane pemphigoid, and neutropenia.

Treatment. occasional or few minor

aphthous ulcers, usually no treatment is needed apart from a bland mouth rinse such as sodium bicarbonate in warm water to keep the mouth clean.

patients more severely affected, some forms of treatment can provide significant control (but not necessarily a cure) of this disease.

Behçet’s Syndrome Behçet’s syndrome is a rare multisystem

inflammatory disease (gastrointestinal, cardiovascular, ocular, CNS, articular, pulmonary, dermal) in which recurrent oral aphthae are a consistent feature.

Although the oral manifestations are usually relatively minor, involvement of other sites, especially the eyes and CNS, can be serious.

Behcet’s Disease Disease comprised oral aphthae,

genital ulcerations and ocular diseases and other lesions

Major and minor criteria Affect mostly young adult males

between 20-40y Strong genetic component

Major criteria Recurrent oral aphthae Genital ulceration Eye lesions Skin lesions

Minor criteria Arthralgia or arthritis Gastrointestinal lesions Vascular lesions C.N.S involvement

Behcet’s Disease

Behçet’s syndrome, oral component (aphthous ulcer)

Behçet’s syndrome conjunctivitis

Wegner’s Granulomatosis Clinical features: - Rare disease of middle age - Initial presentation: sinusitis,

rhinorrhea, nasal stuffiness & epistaxis. - Majority of cases, nasal & maxillary

sinus ulceration. - Necrosis & perforation of the nasal

septum or palate are occasionally seen. - Intra-oral lesions consist of red,

hyperplastic, granular lesion on attached Gingiva.

- Classical triad : upper respiratory tract, lung & kidney involvement.

Wegner’s Granulomatosis

Wegner’s Granulomatosis

Allergic Stomatitis Allergic contact stomatitis: many agents

cause reactions in the oral cavity as: numerous food, chewing gums, food additives, mouth washes dental materials, oral anasthesia.

Acute or chronic, female predominance

Appearance, mild redness- bright erythematous lesions or vesicls rapture to form areas of erosions

Allergic contact stomatitis

Allergic Mucosal Reactions to Systemic Drug Adminstration

Anaphylactic stomatitis either alone or in conjunction with urticarial skin lesions.

The affected mucosa show multiple zones of erythema or many aphthous-like ulceration.

Mucosal fixed drug eruptions develop into vesiculo-erosive lesions mostly on the labial mucosa

Most common drugs penicillin, barbiturates and sulfa drugs

Stomatitis Medicamantosa Erythema Multiforme Anaphylactic stomatitis Lichenoid drug reactions Pemphigus-like drug reactions Non-specific vesiculo-ulcerative

lesions

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