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ORAL MUCOSAL DISEASES Oral Ulcerative
Diseases
Oral Ulcerations Ulcers are the most common
oral soft tissue lesions. Traumatic ulcers Aphthous stomatitis Behcet’s disease Viral infections of oral mucosa:
Herpes simplex, herpangina, herpes zoster
Erosive lichen planus Bacterial infections: T.B ulcer,
syphilitic ulcerations Vesiculo-bullous diseases Malignant ulcers
Traumatic ulcers Caused by local trauma Either by ill fitted dentures Sharp edges of brocken
tooth Lip or tongue biting after
heavy anesthesia Cheek biting
Traumatic ulceration
Acute traumatic ulcer
Acute ulcer of the floor of mouth (saliva ejector injury)
Anesthesia-associated acute tongue ulcer
Ulcer associated with excessive heat from hydrocolloid impression material
Recurent Aphthae(Aphthous
Stomatitis) Most common oral mucosal lesion
Possible etiological factors: Allergy: food Genetic predisposition: HLA family Nutritional deficiency:B12,folate,Iron Hematological abnormalities Hormonal influences: Female, menstrual
period Infectious agents: AIDS,HSV,VZV Trauma Stress
Of all the types of nontraumatic ulceration that affect oral mucosa, aphthous ulcers (canker sores) are probably the most common.
incidence ranges from 20% to 60%.
Prevalence tends to be higher in professional persons, in those in upper socioeconomic groups, and in those who do not smoke.
Typical features Onset frequently in childhood
but peak in adolescence or early adult life
Attacks at variable but sometimes relatively regular intervals
Most patients are non-smokers Usually self-limiting eventually
Types of Recurrent Aphthae
Three forms of aphthous ulcers have been recognized:
minor, major, and herpetiform
All are believed to be part of the same disease spectrum, and all are believed to have a common etiology. Differences are essentially clinical and correspond to the degree of severity.
Minor Aphthous stomatitisThe most common type
Non-keratinized mucosa affected
Ulcers are shallow, rounded, 5-7mm with erythematous margins and yellowish floor
One or several ulcers may be present
Clinical Features Minor aphthous ulcers usually appears
as a single, painful, oval ulcer that is less than 0.5 cm in diameter, covered by a yellow fibrinous membrane and surrounded by an erythematous halo. Multiple oral aphthae may be seen.
Minor aphthous ulcers generally last 7 to 10 days and heal without scar formation. Recurrences vary from one individual to another. Periods of freedom from disease may range from a matter of weeks to as long as years.
Minor Aphthous Stomatitis
Minor aphthous ulceration Erythematous halo
encircling a yellowish ulceration of the lower labial mucosa
Minor aphthous ulceration. Single ulceration of
the anterior buccal mucosa
Minor aphthous ulcers
Minor aphthous ulcer of the floor of mouth
Minor aphthous ulcers of the lateral tongue
Major Aphthae Uncommon Ulcers frequently several cms
mimic malignant ulcers Ulcers persist for several months Masticatory mucosa, dorsum of
tongue or gingiva may be involved
Scar follow healing
Clinical Features painful recurrent ulcers. prodromal symptoms of tingling or
burning before the appearance of lesions.
The ulcers are not preceded by vesicles and characteristically appear on the vestibular and buccal mucosa, tongue, soft palate, fauces, and floor of mouth.
Only rarely do these lesions occur on the attached gingiva and hard palate, thus providing an important clinical sign for the separation of aphthous ulcers from secondary herpetic ulcers.
Major aphthous ulcer
Major aphthous ulceration . Large, deep, and irregular
ulceration of the posterior buccal mucosa
Major aphthous ulceration. Large. irregular ulcerationof the soft palate.
Major aphthous ulceration. A. large ulceration of the left anterior buccal
mucosa.B. Same lesion after 5 days of therapy with betamethasone syrup used in a
swish-and-swallow method. The patient was free of pain by the second day of
therapy. The ulceration healed completely during the following week.
discomfort, systemic health may be compromised because of difficulty in eating and psychological stress. The predilection for movable oral mucosa is as typical for major aphthous ulcers as it is for minor aphthae.
HIV-positive patients may have aphthous lesions at any intraoral site.
Herpetiform Aphthae Uncommon Non-keratinized mucosa affected Ulcers are 1-2 cm Dozens or hundreds may be present May coalesce to form irrigular ulcers Widespread bright erythemous round
ulcers
Herpetiform Aphthous Ulcers. Clinically recurrent crops of small ulcers. movable mucosa is predominantly
affected, palatal and gingival mucosa may
also be involved. Pain may be considerable,
healing generally occurs in 1 to 2 weeks.
Unlike herpes infection, herpetiform aphthous ulcers are not preceded by vesicles and exhibit no virus-infected cells.
Herpetiform aphthous ulcers. The patient also had numerous lesions of the lip and buccal
mucosa.
Herpetiform aphthae of the tongue.
Histopathology the diagnosis of these ulcers is
usually evident clinically, biopsies usually are unnecessary and therefore are rarely performed.
Aphthous ulcers have nonspecific microscopic findings, and no histologic features are diagnostic.
Studies have shown that mononuclear cells are found in submucosa and perivascular tissues in the preulcerative stage. These cells are predominantly CD4 lymphocytes,
Preaphthous ulceration. Intense lymphocytic infiltrate and basilar
epithelial edema seen in preulcerative stage of an aphthous lesion.
Differential Diagnosis. Diagnosis of aphthous ulcers is
generally based on the history and clinical appearance.
Lesions of secondary (recurrent) oral herpes are often confused with ulcers.
A history of vesicles preceding ulcers, location on the attached gingiva and hard palate, and crops of lesions indicate herpetic rather than aphthous ulcers.
Other painful oral ulcerative conditions include trauma, pemphigus vulgaris, mucous membrane pemphigoid, and neutropenia.
Treatment. occasional or few minor
aphthous ulcers, usually no treatment is needed apart from a bland mouth rinse such as sodium bicarbonate in warm water to keep the mouth clean.
patients more severely affected, some forms of treatment can provide significant control (but not necessarily a cure) of this disease.
Behçet’s Syndrome Behçet’s syndrome is a rare multisystem
inflammatory disease (gastrointestinal, cardiovascular, ocular, CNS, articular, pulmonary, dermal) in which recurrent oral aphthae are a consistent feature.
Although the oral manifestations are usually relatively minor, involvement of other sites, especially the eyes and CNS, can be serious.
Behcet’s Disease Disease comprised oral aphthae,
genital ulcerations and ocular diseases and other lesions
Major and minor criteria Affect mostly young adult males
between 20-40y Strong genetic component
Major criteria Recurrent oral aphthae Genital ulceration Eye lesions Skin lesions
Minor criteria Arthralgia or arthritis Gastrointestinal lesions Vascular lesions C.N.S involvement
Behcet’s Disease
Behçet’s syndrome, oral component (aphthous ulcer)
Behçet’s syndrome conjunctivitis
Wegner’s Granulomatosis Clinical features: - Rare disease of middle age - Initial presentation: sinusitis,
rhinorrhea, nasal stuffiness & epistaxis. - Majority of cases, nasal & maxillary
sinus ulceration. - Necrosis & perforation of the nasal
septum or palate are occasionally seen. - Intra-oral lesions consist of red,
hyperplastic, granular lesion on attached Gingiva.
- Classical triad : upper respiratory tract, lung & kidney involvement.
Wegner’s Granulomatosis
Wegner’s Granulomatosis
Allergic Stomatitis Allergic contact stomatitis: many agents
cause reactions in the oral cavity as: numerous food, chewing gums, food additives, mouth washes dental materials, oral anasthesia.
Acute or chronic, female predominance
Appearance, mild redness- bright erythematous lesions or vesicls rapture to form areas of erosions
Allergic contact stomatitis
Allergic Mucosal Reactions to Systemic Drug Adminstration
Anaphylactic stomatitis either alone or in conjunction with urticarial skin lesions.
The affected mucosa show multiple zones of erythema or many aphthous-like ulceration.
Mucosal fixed drug eruptions develop into vesiculo-erosive lesions mostly on the labial mucosa
Most common drugs penicillin, barbiturates and sulfa drugs
Stomatitis Medicamantosa Erythema Multiforme Anaphylactic stomatitis Lichenoid drug reactions Pemphigus-like drug reactions Non-specific vesiculo-ulcerative
lesions
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