1

Oral Ulcers
acute and chronic

Yagoub Alyami BDS, MDS, OFP Diplomate

 2

Lecture Learning Objectives (ILOs)

To list the differential diagnosis of single and multiple oral ulcers

To diagnose and manage RAS and traumatic ulcers

To differentiate between different types of RAS

To differentiate between RAS ,traumatic ulcers, hepatic ulcers

 3

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

Normal Histology of Oral Mucosa

Viral h
Image: https://www.proteinatlas.org/learn/dictionary/normal/oral+mucosa/detail+1 accessed 19/9/2019
 5

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

Minor Major Herpetiform

(less than 1CM) (More than 1 CM) 10%
80% 10%
ventral
mostcommon surface
Images: https://accessmedicine.mhmedical.com/content.aspx?bookid=685&sectionid=45361081 accessed 19/9/2019
bgW s bl I 68
 dorsom
9
Minor RAS

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

Images: http://www.kidsdentalonline.com/dental-topics/treating-canker-sores-aphthous-ulcers/ accessed 19/9.2019

 11
Major RAS
0
Similar to minor form but solitary and bigger in size with raised red borders

5 of 2

Image: pocketdentistry.com/2-ulceration/ accessed 9/9/2019

 90 12

Minor RAS Major RAS

Common 80% of the cases 10% of the cases

Size Less than 1 cm More than 1 cm

Location vestibule, labial & buccal mucosa any site Keratinized

softpalate I
Numer Single or multiple mostly single

Healing time 10 days Up to 1 month

border redflat redraised

 Mumm
Herpetiform RAS
outs b D 13

herpes
Clinically resemble herpetic stomatitis
f e
Start as multiple pinpoint aphthae
Less than 5mm in size
Em
q
doggy

Image: https://www.semanticscholar.org/paper/Therapeutic-Management-of-Recurrent-Aphthous-A-of-Sabbagh-Felemban/ Images: Burket's Oral Medicine, 12ed page 76

8e7c1fee2ad51204fd4c65ee20afa628936e21e7/figure/6
 apthussiosi.gs o sg io6 wiiwo xoosia ia
14
RAS is diagnosed by:
Many systemic disorder can cause

Exclusion Aphthous-like ulcers 2

Egg 81
e.g. Blood and GIT disorders

I s w
Aphthous-like ulcer associated with iron
deficiency anemia

notice unusual location of ulcer on the

keratinized mucosa of the tongue dorsum

C
Ulcers resolved when iron deficiency anemia
was treated.

unusual location Krakaned

 15
RAS is diagnosed by:
Many systemic disorder can cause

Exclusion Aphthous-like ulcers

e.g. Blood and GIT disorders

Order complete blood picture (CBC) rule out anemia traineewwf

Ask for any similar skin lesion

Look for any source of oral trauma or infection sharpteeth virus7

Ask about the GIT system (Review of GIT system) I 1 Ii s g

e It
Ask for any recent medication that he patient started to take

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

(simplex) and RAS?

wind
Recurrant Aphthusstomatitis

I't's
 17
RAS is diagnosed by:

Exclusion
R E M E M B E R
Recurrent IMPORTANT

Aphthous History of Recurrence

No skin lesion
T
Stomatitis (RAS)
Ask your patient for
history of recurrence and
similar skin lesions
 18
Patient with Recurrent Ulcers

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

Ice Cubes over the ulcer Corticosteroids

II
Patient education
During the prodrome Clobetasol ointment what to do with the lesion
clotbesol
avoid spicy food

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

ill-fitting denture Physical trauma

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

oral History of trauma

No skin lesion

Ulcer Ask your patient for

history of recent trauma
 30 00 TRAU MATI C U LC E R S 28

Diagnosis: clinics picture

Tender in the area of lesion

Borders: Raised and-whitish Enter

Aphthus flatborder ned
Base : Yellowish white necrotic that can be
easily removed

Secondary infection: oral candidiasis on top 6

Apthus notin Apthus A
6 o is
 TRAU MATI C U LC E R S 29
Acute Oral Ulcer

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)

Gto Traumatic ulcer

TUGSE
Biopsy
 carcinoma
aoWfo
gof Fµ TRAU MATI C U LC E R S 30

Treatment:

Remove the cause Topical Steroid

Dental Restoration Dermovate

(Clobetasol ointment)
27Adjusting the occlusion I
apply to the affected area
Fixing the denture
3 3-5Xday
 TRAU MATI C U LC E R S 31

Treatment:

Topical Anaesthetic Topical Anti-fungal?

Orabase Paste contains

benzocaine, a local
c Daktarin IIb I's
anesthetic
2 Miconazole Oral Gel
 B
iMoiwwB9HI.iIH
apply to the affected

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

Etiology: chemical burn

Aspirin Phosphoric acid-etching Alcohol-containing


During dental treatment mouth rinses
 TRAU MATI C U LC E R S 35

Etiology: chemical burn

Aspirin chemical burns
 TRAU MATI C U LC E R S 36

Etiology: Thermal (Burn)

Ulcer from hot ! pizza burn on

the palatal mucosa

Burket's Oral Medicine, 12ed page 87

 37

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

(i) Primary herpetic gingivostomatitis

Acute multiple ulcers
(i) Long-standing traumatic ulcers
(ii) Necrotizing sialometaplasia
(iii) Eosinophilic ulcer
(iv) Ulcerative squamous cell carcinoma
Chronic solitary ulcers (v) Cytomegalovirus-associated ulceration
(vi) Tuberculous ulcer
(vii) Syphilitic ulceration (chancre)
(viii) Deep fungal ulceration
Oral ulcers (Histoplasmosis, Blastomycosis,and
Chronic ulcers Mucormycosis)
Chronic multiple ulcers
(ii) Varicella-Zoster Virus infection
(iii) Herpangina
(iv) Hand-foot-and-mouth disease
(v) Erythema multiforme
(vi) Necrotizing ulcerative gingivitis
(vii) Oral hypersensitivity reactions
(viii) Plasma cell stomatitis
(ix) Chemotherapy-related ulcers
(i) Pemphigus vulgaris
(ii) Mucous membrane pemphigoid
(iii) Bullous pemphigoid
(iv) Lichen planus (LP)
(v) Linear IgA disease

(i) Recurrent aphthous stomatitis

(ii) Recurrent herpes stomatitis
Recurrent ulcers Solitary/multiple ulcers (iii) Herpes-associated erythema multiforme
(iv) Cyclic neutropenia
(v) Beh çet’s disease
 39

Minor RAS Traumatic ulcer

Site

Size

Location

Numer

Ulcer Borders

Main clinical
feature