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Solitary Oral Ulcers
Presented By
Harsh S Shah
Definition
bull Ulcer has been defined as a deeper crater that extends through the entire thickness of surface epithelium and involves the underlying connective tissue
Parts of an ulcer
Margin Margin is the border or transitional zone of skin around an ulcer
EdgeEdge is the mode of union between the floor and the margin of ulcer
FloorFloor of ulcer is the exposed surface of the ulcer we look for
Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]
bull Inflamed margin (red irregular margin with inflamed surrounding skin)
bull Fibrosed margin (thickened white)
Types of edges
bull Sloping edge rarr healing ulcer
bull Punched edge rarr trophic ulcer syphilic
bull Undermined edge rarr tuberculous ulcer
bull Everted edgerarr malignant ulcer
bull Raised edge rarr rodent ulcer
ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle
InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS
Bacterialbull Tuberculosisbull Syphilisbull ANUG
Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Definition
bull Ulcer has been defined as a deeper crater that extends through the entire thickness of surface epithelium and involves the underlying connective tissue
Parts of an ulcer
Margin Margin is the border or transitional zone of skin around an ulcer
EdgeEdge is the mode of union between the floor and the margin of ulcer
FloorFloor of ulcer is the exposed surface of the ulcer we look for
Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]
bull Inflamed margin (red irregular margin with inflamed surrounding skin)
bull Fibrosed margin (thickened white)
Types of edges
bull Sloping edge rarr healing ulcer
bull Punched edge rarr trophic ulcer syphilic
bull Undermined edge rarr tuberculous ulcer
bull Everted edgerarr malignant ulcer
bull Raised edge rarr rodent ulcer
ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle
InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS
Bacterialbull Tuberculosisbull Syphilisbull ANUG
Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Parts of an ulcer
Margin Margin is the border or transitional zone of skin around an ulcer
EdgeEdge is the mode of union between the floor and the margin of ulcer
FloorFloor of ulcer is the exposed surface of the ulcer we look for
Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]
bull Inflamed margin (red irregular margin with inflamed surrounding skin)
bull Fibrosed margin (thickened white)
Types of edges
bull Sloping edge rarr healing ulcer
bull Punched edge rarr trophic ulcer syphilic
bull Undermined edge rarr tuberculous ulcer
bull Everted edgerarr malignant ulcer
bull Raised edge rarr rodent ulcer
ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle
InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS
Bacterialbull Tuberculosisbull Syphilisbull ANUG
Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]
bull Inflamed margin (red irregular margin with inflamed surrounding skin)
bull Fibrosed margin (thickened white)
Types of edges
bull Sloping edge rarr healing ulcer
bull Punched edge rarr trophic ulcer syphilic
bull Undermined edge rarr tuberculous ulcer
bull Everted edgerarr malignant ulcer
bull Raised edge rarr rodent ulcer
ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle
InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS
Bacterialbull Tuberculosisbull Syphilisbull ANUG
Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle
InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS
Bacterialbull Tuberculosisbull Syphilisbull ANUG
Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Bacterialbull Tuberculosisbull Syphilisbull ANUG
Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)
Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma
SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Traumatic Ulcer
bull Most common oral ulcer
bull Caused by Mechanical Chemical amp Thermal
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Etiology
bull Repeated trauma from tooth brushing
bull Drugs ndash Narcotic drugs
bull Denture induced
bull Self-inflicted in decerebrate and comatose patients
bull Placement of fixed acrylic tongue stent
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Features
bull Tender in the area of lesion
bull Borders Raised and reddish
bull Base Yellowish white necrotic that can be easily removed
bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Management
bull Heals in 10 days
bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime
bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle
bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing
bull Chlorhexidine mouthrinse
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
RECURRENT ORAL ULCERS
Recurrent Aphthous Ulcer
RIHS Recurrent intraoral herpes simplex
Major Aphthous ulcer
Herpetiform Aphthae
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Comparison of Clinical Features
RAU RIHS
LocationNonkeratinized mucosa Keratinized Mucosa
Initial Lesion Erythematous macule or papule followed by necrosis and ulceration
Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers
Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo
Shallow ulcer but many in number and border is scalloped
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Recurrent Aphthous Ulcer
Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and
destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens
bull After this the oral mucosa permits additional local factors to come into play
bull Cause of destruction of epithelium increase in leukocyte TNF
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Mononuclear
peripheral
blood cells
Destruction of oral
epithelium (which contains
MHC ndash I and MHC ndash II for
immune response)
This permits entry of local factors
into the oral mucosa
Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Minor RAU
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Management
1 Heals in 7 ndash 10 days
2 Placement of tetracycline solution or a 012
Chlorhexidine solution by cotton applicator to
dried lesion covered by oral banadage
3 Oral Bandage Cyanoacrylate Benzocaine
(Orabase) or hydroxypropyl cellulose (Zilactin)
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent
stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers
bull This may be contracted while working on a patient with the herpetic lesion
bull Lesions of finger are recurrent and may spread to whole hand
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Diagnostic Difficulties
bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Atypical RIHS Lesion
bull RIHS of gingival papilla
bull Persistent infection of gingival papilla
bull Persistent enlarged ulcers
bull RIHS in immuno-incompetence
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Major RAU
bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens
bull Much larger than the minor type upto 2cm
bull Quite deep and very painful and persist for months
bull Heal with formation of scar
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Treatment modalities
bull Excision with primary closure
bull Cryosurgery
bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment
bull Injection of corticosteroid directly into the lesion alone or with prednisolone
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Treatment by Cryosurgery
(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of
intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was
observed after four weeks treatment with levamisole
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Herpetiform Aphthaebull More common in female patients and cause is
unknown
bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters
bull Management by mouthrinse only
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Behcetrsquos Syndrome
bull Oral ulcers
bull Recurrent ulcers of genital region
bull Ocular lesions including conjunctvitis retinitis and uveitis
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus
draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured
bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Sloughing Pseudomembranous ulcers
bull Crushing type of traumatic ulcers
bull Acute necrotizing ulcerative gingivitis (Interdental papillae)
bull Candidiasis
bull Gangrenous Stomatitis
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Squamous Cell Carcinoma
bull Most common persistent ulcer in the oral cavity or on the lips
bull Patient is usually unaware as the ulcer is painless
bull Craterlike lesion having a velvety base and a rolled indurated border
bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Syphilitic Ulcer
bull Veneral disease caused by motile spirochete Treponema Pallidum
bull Primary Lesion ndash Chancre (solitary)
bull Secondary lesions ndash numerous macules papules condylomas or combinations
bull Tertiary lesions ndash Gumma and interstitial glossitis
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Chancrebull Develop 3 weeks after inoculation and may
persist upto 2 months
bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center
bull Chancre is extremely contagious
bull Management Systemic Penicillin from the early days
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Gumma
bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters
bull Necrosis commences within the nodules and produces ulceration in the surface epithelium
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Ulcer secondary to systemic disease
bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia
Neuropenia sickle cell anemia)
bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material
bull A painful regional cervical lymphadenitis is almost invariably present
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi
bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)
bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution
of underlying uremia and lowering of blood urea nitrogen (BUN) levels
bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria
producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment
may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents
against microbial or fungal infections
Uremic Stomatitis
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Some Chronic oral ulcerDiagnosis Clinical features
Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments
Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments
Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo
Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)
Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding
Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis
Tuberculosis
Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Erosive Lichen Planus Mucous membrane pemphigoid
Tuberculous ulcer Pemphigus Vulgaris
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Management of pemphigus vulgaris1 High doses of systemic corticosteroids
(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are
immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy
3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab
Paraneoplastic pemphigus PNPP - multiorgan disease with
underlying neoplasmCastleman disease and Waldenstrom
macroglobulinemia are associated with PNPP
Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that
manifests on skin and often oral mucosa
bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)
bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions
bull Ulceration and crusting is common in lip and ulcers on oral mucosa
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Histoplasmosis
bull Most common fungal disease caused by organism Histoplasma Capsulatum
bull Three forms
bull Acute Histoplasmosis
bull Chronic Histoplasmosis
bull Disseminated Histoplasmosis
bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull Solitary variably painful ulcerations of several weeks duration
bull Margins Firm rolled margins
bull Clinically it may be confused with malignancy
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Drug induced ulcers
bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments
bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin
bull NSAIDs are popular drugs that are well-known to induce oral ulcerations
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Leukemic ulcer
1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)
acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions
may be the presenting feature of acute leukemias and are therefore important
diagnostic indicators of the disease
2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells
with leukemic cells
3 Oral cavity usually is involved as part of a widespread disease however oral ulcers
can be the first presentation of the disease which can lead physicians to make exact
diagnosis
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Differential Diagnosis
bull Short Term Ulcers (Shallow and not raised)
bull Persistent Ulcers (Extensive borders and bases)
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Differential list of Short term Ulcers
Differential list of Short term Ulcers
Traumatic Ulcer
RAU RIHS and herpetiform ulcers
Ulcer as a result of odontogenic infection
Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease
Ulcer secondary to noninfectious systemic disease
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Differential List of Persistent UlcerDifferential List of Persistent Ulcer
Traumatic ulcer
Ulcer from odontogenic infection
Major aphthous ulcer
Squamous cell carcinoma
Ulcer secondary to systemic disease
Ulcer in HIV disease
Traumatized tumour that does not ulcerate
Low grade mucoepidermoid tumor
Metastatic tumor
Keratoacanthoma
Necrotizing sialometaplasia
Systemic mycosis
Chancre
Gumma
Other rarities
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Necrotizing Sialometaplasia Keratoacanthoma
Mycosis HIV Ulcer
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Management
bull Amphotericin B is indicated ( More potent )
bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
RARITIESbull Actinomycosisbull Adenoid squamous cell
carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth
disease bull Fungal infections
bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the
newborn bull Hand-foot-and-mouth disease
bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-
ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims
macroglobulinemiabull Warty dyskeratoma
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Conclusion
bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient
bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages
bull Proper clinicopathological investigation may help in avoiding these lethal diseases
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources
Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and
fissures Textbook of Differential Diagnosis in oral medicie and Radiology
bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu
bull Siegel RD Granich R Letter to editor Oral Surgery 764061993
bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159
doi 1041030972-124X60230 PMCID PMC2848788 Oral
histoplasmosis Karthikeya Patil V G Mahima and R M
Prathibha Rani
bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano
bull Web Sources