Evaluation Of Oral Ulcerations

2. 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

3. 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

4. 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

5. 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

7. 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

8. 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

9. Relation with deeper structures:
› Malignant ulcer – fixed to deeper
tissues
Surrounding skin/mucosa:
› Increased temp. and tenderness –
inflammatory
› Fixity to deeper structures –
malignant ulcer

10. Causes of
Oral Ulcers
Acute
< 3 weeks
Chronic
> 3 weeks
Neoplastic
Non-
neoplastic

11. Acute Ulcer
•Traumatic ulcer
•Acute necrotising ulcerative
gingivitis
•Herpetic ulcer
•Minor aphthous ulcer
•Shingles
•Primary syphilis

12. Chronic
Ulcer
Neoplastic
Non-neoplastic
•Tuberculous ulcer
•Major aphthous ulcer
•Lichen planus
•Secondary & tertiary
syphilis
•Pemphigus
•Cicatricial pemphigoid

13. Acute Ulcers
• Sharp tooth,
badly decayed
tooth
• Roughened
prostheses &
sharp edges
• Chemicals –
aspirin
• Iatrogenic
Etiology
Traumatic Ulcer

15. • 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:

16. • Fusiform bacillus
• Borrelia vincentii
Etiology
Acute Necrotising
Ulcerative Gingivitis
Precipitating factors:
Stres
s
Poor
oral
hygiene
Poor
nutritional
status
Immunosu
ppression

17. • Painful punched out craterlike
lesions – interdental papilla
• Grayish pseudomembrane
covering
• Bleed when touched
• Fetid odour
• Headache , malaise, low-grade
fever
• Metallic taste
• Lymphadenopathy
Clinical Features:

22. Investigation
Smears show
fusiform
bacilli and
spirochetes
with gram
staining

23. Etiology
Herpes
Simplex
Virus 1
• By droplet
spread or
contact of
lesion
Herpetic Ulcer

24. Clinical
Features
Fever, pain
on
swallowing,
regional
lymphadenop
athy
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

26. Primary infection
VZV
Chicken pox
Virus becomes
dormant
Reactivation
Shingles
Varicella Zoster
Virus

27. • 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

30. • 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

31. • Autoimmune response
• B12/Folic acid deficiency
• Psychologic factors - stress
• Allergic factors
• Familial tendency
Etiology
Minor Aphthous
Ulcer

32. • 1-5 shallow, round/oval
ulcer
• 2-10mm gray/yellow base –
erythematous margin
• Heal 7-10 days no scarring
• 1-2 a month – buccal
mucosa, tongue, soft palate
Clinical Features

34. Treponema Pallidum
Primary
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

36. Diagnosis
History of sexual
contact
Lab Diagnosis
• Spirochetes in Dark field
illumination/ Silver stained smears

37. • Mycobacterium tuberculosis
Etiology
• Fever, chills, malaise, cough , loss of weight
• Deep painful ulcer
• Undermined edge
• Watery discharge
• Palpable matted lymph nodes
Clinical Features:
Chronic
Ulcers
Tuberculous
Ulcer

41. Acid fast bacilli
in sputum Chest x-ray
Tuberculin test – 0.1 ml – 5
tuberculin units purified
protein derivative - >10mm
induration
ELISA &
PCR
Investigations

42. • 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

43. Lab Diagnosis:
VDRL test
FTA-Abs test

44. • After 3 years initial infection
• Gumma – focal granulomatous
inflammatory process with central
necrosis
• Nodular mass with yellowish center
• Necrotizes to leave deep painless
ulcer
Clinical Features
Tertiary Syphillis

48. Etiology
Autoantibodies
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

49. • 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

52. Etiology
Autoantibodies
of IgG
Against hemi-
desmosomes
Cicatricial
Pemphigoid
• Bullae are thick-walled –
ruptures 24-48 hours
• Leaves raw eroded bleeding
surface
• Ulceration and scarring
Clinical Features

53. • Desquamative lesions –
common on gingivae
Clinical Features
• Biopsy – subepidermal
vesicles and bullae
• Absence of nikolsky sign
Investigations

55. T lymphocyte-
mediated disorder
Etiology Dental
restorations
– amalgam
Drugs –
NSAIDs Stress
Viral
infection
Lichen Planus

56. Clinical Features:
Atrophic
–
smooth,
red areas
Erosive -
painful,
with a
yellowish
slough
Striae
radiate
from
margins
of
erosions
Common
- buccal
mucosa,
dorsum
of
tongue,
gingiva
Usually
bilateral

59. Etiolog
y
Autoimmune
response
B12/Folic
acid
deficiency
Psychologic
factors -
stress
Allergic
factors
Familial
tendency
Major Aphthous
Stomatitis & Recurrent
Herpetiform Ulcer

60. • 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:

63. Etiology
Tobacco
Alcohol
Infection –
HPV 16 Chronic
irritation
UV radiation
Genetic
predisposition
Neoplastic
Ulcers

64. • Single ulcer – rolled,raised and everted
border
• 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:

67. • 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

68. Ulcer > 3
weeks
Features suggesting
malignancy
- Solitary ulcer
- Proliferative
appearance
Optimise
general 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
- Aphthous
ulcer
Managed in
primary care
if confident of
diagnosis
Widespread
oral ulcer
- Oral lichen
planus
Refer

69. • 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

70. • 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