Differential Diagnosis of

Oral Ulcer
 Introduction
Ulcer
✓ A defect in the epithelium; it is a well-
circumscribed depressed lesion over which
the epidermal layer has been lost.

✓OR It is a complete loss of epithelium.

 Introduction
Vesicle:
Small well circumscribed, fluid filled lesion
less than 5 mm in diameter
Bulla:
Well circumscribed fluid filled lesion larger
than 5 mm in diameter
 Differential diagnosis
• Diagnosis of a certain lesion can be reached
via either one, two or all of the following:

History of the lesion

Clinical examination
Laboratory investigations
History of the lesion
 Chief complain
1-Pain
➢Mild e.g. Herpangina

➢Moderate burning sensation e.g.

Herpes Simplex

➢Severe neuralgic pain e.g. Herpes

Zoster
 Chief complain
2- Bleeding
(with or without pain)
ANUG (may be 2ry to leukemia, cyclic
neutropenia or aplastic anemia)
 Chief complain
3- Induration
Carcinoma Major aphthous ulcer

Cancer of the Hard Palate

 Chief complain
4- Burning sensation
aphthous ulcer
Erosive LP.
 History of causative factor
1-Trauma
2-Local application of thermal agent
 History of causative factor
3-Local application of chemical agent

4- Systemic diseases
e.g. leukemia & lymphoma
 Onset of the lesion
Sudden onset Gradual onset
EM ▪ 1ry herpetic
gingivostomatitis
▪ Aphthous ulcers
▪ Herpangina
▪ Recurrent herpes
libialis.
 Duration
➢Few days 5-7 days herpangina
➢1-2 weeks herpes simplix & minor
aphthous ulcer
➢Few weeks Herpes zoster, EM &
major aphthous ulcer
➢Longer duration Squamous cell
carcinom & BMMP
➢Remission & exacerbation LP &
BMMP
 Family History
➢Some ulcers run in families e.g. Aphthous
ulcers.
 History of recurrence
➢EM
➢Aphthous ulcers
➢ Behcet’s syndrome
➢ Recurrent herpes labialis
➢ Recurrent intra-oral herpes
➢Cyclic neutropenia.
 History of stress & strain

➢LP

➢Aphthous ulceration
History of systemic disease

Anemia

leukemia

Syphilis
 History of drug administration
1. Allergy (allergic stomatitis, stomatitis
venenata)

2. Agranuolocytosis phenomenon
(chloramphenicol)
3. Cytotoxic drugs.
Clinical examination
Clinical examination

▪ Intra-oral examination

▪ Extra-oral examination
 Intra-oral examination
1- Site of the ulcer
2- Size of the ulcer
3- Shape of the ulcer
4- Number of ulcers
5- Base of the ulcer
6- Edge of the ulcer
7- Floor of the ulcer
8- The oral mucosa surrounding the ulcer
 Site of the ulcer
Keratinized Non-keratinized
(bound) mucosae (mobile) mucosae

Hard Palate Buccal mucosa

Gingiva Lateral Tongue
Floor of the mouth
Vestibule
 Site of the ulcer
Keratinized oral mucosa
 Site of the ulcer
Keratinized oral mucosa
 Site of the ulcer
Non-keratinized oral mucosa
 Site of the ulcer
Both keratinized & non keratinized oral
mucosa
Site of the ulcer
Tip of the tongue
 Site of the ulcer
Posterolateral aspect of the tongue
Site of the ulcer
Unilateral ulcers
Site of the ulcer
Bilateral ulcers

Erythema multiforme
 Site of the ulcer
Anterior part of the mouth
 Site of the ulcer
Posterior part of the mouth
Size of the ulcer
Size of the ulcer

Herpes simplex
Size of the ulcer
Shape of the ulcer
Number of ulcers
Oral mucosa surrounding the ulcer
Edge of the ulcer
 Undermined edge
It means the rate of destruction of
the subcutaneous tissue is more
rapid than the skin, causing the
edge of ulcer to be undermined.
 Floor of the ulcer
(area seen by the observer)
➢Red granulation tissue healing ulcer
➢Necrotic tissue& slough spreading
ulcer
➢Watery & scanty granulation tissue
tubercular ulcer
➢Floor above surface malignant ulcer
➢Wash leather slough gummatous
ulcer
 Base of the ulcer
• It is part of an ulcer which is palpated.

➢Indurated malignancy
➢Attached to deep structures venous
ulcer
Extra-oral examination
Extra-oral examination
 Extra-oral examination

Oral ulceration may be associated with

cervicofacial lymph-adenopathy
✓1ry herpetic gingivostomatitis
✓Syphilis (1ry & 2ry)
✓Infectious mononeucleosis
✓Lymphocytic leukemia
✓Metastatic carcinoma.
 Extra-oral examination

➢In acute infections LNs tender

Soft
discrete
➢In chronic infections firm
hard
fixed.
 Extra-oral examination

1. Butterfly distribution LE
2. Target or iris lesions EM
3. Photosensitivity SLE
4. Petechiae & ecchymosis leukemia
 Extra-oral examination

Occular, genital, joint lesion as well as

gastrointestinal & CNS affection
Steven Johnson
Behcet’s Syndromes
Reiter’s
 Clinical Features of Acute vs.
Chronic ulceration
Acute Chronic
1. Pain 1. Little or no pain
2. History of trauma 2. History of trauma if
remembered
3. Yellow base with 3. Yellow base with
a red halo. elevated margin.

4. Heals in 7-10 days if 4. Delayed healing.

cause eliminated