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Oral Ulcers
acute and chronic
What is an ulcer?
It is a complete loss of epithelium
Edge Margin
Floor
o3
Shines Normal Histology of Oral Mucosa
o
Image: https://www.proteinatlas.org/learn/dictionary/normal/oral+mucosa/detail+1 accessed 19/9/2019
4
What is an ulcer?
It is a complete loss of epithelium
Edge Margin
Floor
Oral Ulcers
Systemic Infections MAcute
Anemia, autoimmune, Behçet’s Causes Viral (herpes), Bacterial (ANUG), necrot
disease, Fungal candidiasis, Histoplasmosis vicera
gnaw
Aphthae Drugs
minor, major, herpitiform NSAIDs, methotrexate
T
herpes Jl y
Malignant Local
Squamous cell carcinoma Physical, chemical, thermal
T
V
trauma
6
means Ulcer
Recurrent Aphthous
Stomatitis (RAS)
if skin lesion Ulcer Not Aphthus
iis.es
kolg I
SoiE o.i
R e c u r r e n t A p h t h o u s S t o m a t i t i s (R A S) 7
20%
confined in epithelium
only
not connectivetissue stress
RAS is Common Mainly affect the Females are more
affecting 20% of the population
non-keratinized mucosa affected than males
s sigoiI w b d
Unknown Etiology NO SKIN LESION Age: less than 50y/o
Heredity is big
2 Stress The most common sites: Ingi
Buccal mucosae
3 Immune mediated I I f
2 Labial mucosae
a Anemia iron
3 Soft palate
Aphthous like Ulcer gingiva hard ad
paleet keratin
tounge
RAS Classifications 8
Based on clinical characteristic
Proceeded by
prodromal symptoms overside b
burning sensation and tingling at the Ulcer formation
site where the lesion will develop
The central necrotic
epithelium begun to slough
O
Up to 24 hrs
Before the lesion
Then, painful red flat
lesion develop
Appears with necrotic center
painfulred flat
Images: Burket's Oral Medicine, 12ed page 75
10
Minor RAS clinical picture
soooo
Single or multiple Small (Less than 1 cm)
Round & Symmetric Red flat borders
I I White -grey necrotic floor argin
Shallow (Similar to viral infection ulcer)
eniaii.im iiioIiItiittioiiseep n
Ulcer formation Recurs as every month or 2-4 times /year
The central necrotic
epithelium begun to slough
Its
5 of 2
herpes
Clinically resemble herpetic stomatitis
f e
Start as multiple pinpoint aphthae
Less than 5mm in size
Em
q
doggy
I s w
Aphthous-like ulcer associated with iron
deficiency anemia
C
Ulcers resolved when iron deficiency anemia
was treated.
9 Is e
I 16
RAS is diagnosed by:
Exclusion
Q U E S T I O N
How can you differentiate
between hepatic ulcer bi Z
I't's
17
RAS is diagnosed by:
Exclusion
R E M E M B E R
Recurrent IMPORTANT
Extraoral lesions?
Skin
No Yes
Naqada
Behçet syndrome
Ulcers in one oral site?
Bullous disease
o Sa I f B Reiter syndrome
No Yes
RAS (minor) RAS (major)
Aphthous-like ulcers
Trauma
Q
(blood, gastrointestinal, immune, skin
diseases)
o
Baking sodatocoverit
Management of RAS: 19
id bp over
Most effective during the prodrome
chlorhexidine prytheareabefone
corticosteroid
andnot to eat for20m
Management of RAS: 20
In Severe cases:
Intra-lesion injection
E sI I I o is
2
r s of
Mac
trimcinolone 10mg (Steroid)
dilated with lidocaine 2%
I
soo
424 2
ti do
co b b
TRAU MATI C U LC E R S Aphthus 21
Treatment:
laser for Major
https://www.youtube.com/watch?v=lyY5bHRGnw4
22
Oral Ulcers
Systemic Infections
Anemia, autoimmune, Behçet’s Causes Viral (herpes), Bacterial (ANUG),
disease, Fungal candidiasis, Histoplasmosis
Aphthae Drugs
minor, major, herpitiform NSAIDs, methotrexate
Malignant Local
Squamous cell carcinoma Physical, chemical, thermal
23
Traumatic Ulcer
Most common
ee
ay Lary
TRAU MATI C U LC E R S 24
9 d
The most common Any location in the Affect males and
oral Ulcer oral cavity females in the same
rate
Due to trauma
The most common sites: Age: any age but
Physical Tongue diFion more in Geriatric
Chemical Labial mucosae Shwaffetooth
Thermal Buccal mucosa
NecroticT R A U M A T I C ULCERS 25
Etiology: Physical/mechanical
Sharp/Broken teeth
To
Notice: the ulcers have no specific shape
no specific size
Images: https://publicdocuments.sth.nhs.uk/TraumaticUlcers.pdf
TRAU MATI C U LC E R S 26
Burn
Etiology: Physical/mechanical
Pizza
JEM
Images: https://publicdocuments.sth.nhs.uk/TraumaticUlcers.pdf
Traumatic ulcer is diagnosed by: TRAU MATI C U LC E R S 27
s
Obvious source of y W l f
Trauma
Traumatic
R E M E M B E R
IMPORTANT
zD DD
Any Sharp Object?
No Yes
virus
RAS herpges Remove the cause
Infection (Viral,TB, Syphilis)
in 2-4 weeks
Malignant (Sq. cell carcinoma)
Aphthous-like ulcers
is
(blood, gastrointestinal, immune, skin Healed no change
diseases)
Treatment:
Treatment:
b fungedf.I
area 3-5Xday
S
Pe
Management: TRAU MATI C U LC E R S 32
In Severe cases:
Intra-lesion injection
H
trimcinolone 10mg (Steroid)
dilated with lidocaine 2%
TRAU MATI C U LC E R S chemical r 33
physical
Traumatic Ulcerative Granuloma with Stromal Eosinophilia (TUGSE)
C
I
White borders
ciretaumatic
Aphthus Reed
is iSo healing EQI JI
7
An uncommon condition similar to traumatic ulcer but Microscopically, it is
characterized by a diffuse eosinophils cell infiltrate Burket's Oral Medicine, 12ed page:88
O
TRAU MATI C U LC E R S 34
Oral Ulcers
Systemic Infections
Anemia, autoimmune, Behçet’s Causes Viral (herpes), Bacterial (ANUG),
disease, Fungal candidiasis, Histoplasmosis
Aphthae Drugs
minor, major, herpitiform NSAIDs, methotrexate
Malignant Local
Squamous cell carcinoma Physical, chemical, thermal
X g
(i) Traumatic ulcer 38
Acute solitary ulcers
(ii) Necrotizing sialometaplasia
Acute ulcers
Size
Location
Numer
Ulcer Borders
Main clinical
feature