LESI DAN ULKUS DALAM MULUT

 BAKTERI
 VIRUS
 JAMUR
 ALERGI
 TRAUMA
 UNIDENTIFIED
ULCERATIVE , VESICULAR
and BULLOUS LESIONS
( K 12 – ICD WHO )

 Ulceration is the most frequently

 Signs & symptoms of diseases
ranging from the most benign
traumatic of mastication, to the most
rapidly fatal form of malignancy
 careful attention ! ! !
- history
- onset, recurrences, frequency,
severity
- chronic progressive process
- evaluation of lymph nodes
- laboratory
- biopsy
1. Primary Acute Herpetic
Gingivostomatitis
Etiologi : herpes simplex virus (HSV)
 prevalence is not known, increase
in crowded environment
 a prodrome 24 hours or more prior
to the appearance of oral lesion
with malaise, headache ,
adenopathy, gastrointestinal upset
and fever
 pain in food intake
Mucosal vesicle &
ulceration
appear in the
mouth on the
2nd or 3rd day,
on the lips ,
cheeks, tongue,
palate, floor of
the mouth,
gingivae.
 General Gingivitis, lack of necrosis
 Vesicles rupture & form crateriform
ulceration, extremely painful,
surrounded by bright inflammatory red
areolae
Treatment :
 - supportive
 - mouth rinse
 - acyclovir ( if needed)
 2. Recurrent Herpes Labialis .
Etiologi : herpes simplex virus
 a prodome of 12-24 hours marked
by hyperesthesi and burning
sensation of the forming lesion of
the lip
 local edema & erythema of the lip
are initial clinical change  8-24
hours vesicle appears, clear,
friable, odourless fluid, ruptures
easily  ulceration with irregular
 The base is
serohaemorrhagic
---- coagulates
form an adherent
clot. The lesion
disappear in 7-10
days
 recurrences
interval 2-12
months
Treatment
 supportive ( vit
C & Bc )
 Lip lesion
maybe minimize
with acyclovir
cream 5%
applied in the
prodrome
 3. Recurrent Aphthous
Ulceration / stomatitis
 Characterized by the reccurent
appearances of painful ulcers on the
oral mucosa membr.
 A prodome of 1-24 hours, sensation
of burning & tingling in the effected
mucosa
 Initial change : appearance of small
erythematous macules  crateriform
ulcers, extremely painful
 difficulty in eating & speaking
Etiology of RAS
- is not intirely clear
 - a minor degree of immunological
dysregulation underlies aphthae
Praedisposing factors :
* Genetic * stress
* deficiency : Fe, folic acid.
* trauma from biting, dental appliances
* allergies to food
* endocrine fc : menstrual c, contraceptive
pill
* immunological features
The labial & buccal
mucosa are the
most common
site. The tongue,
floor of the mouth,
palate and gingiva
are less frequent.
3 form of RAS :
mayor, minor ,
herpetic form
 Minor aphthous ulcers (80%) are
less than 5 mm in diameter, heal
in 7-14 days (self limiting)
 Mayor aphth. are larger , heal
slowly over weeks or months
with scarring
 Herpetic form ulcers are multiple
pinpoint ulcers, heal within
about a month
Treatment :
 corticosteroid :
locally
systemically
 mouth rinse
 eliminate
etiology factors
4. Herpes Zoster

 Etiologi reactivation
of varicella zoster
virus
( produces varicella
zoster )
 Following resolution,
the virus lies
dormant in the dorsal
root ganglia until
reactivation along
Predisposing
factors
 overwork, fatique
 stress
 malnutrition
 chronic disease
(leukemia,
cancer, hiv)
 radiasi
Sign & Symptom
 An itching sensation and a stabbing
 burning, constant or intermittent pain
 unilateral, along the distribution of a
sensory nerve trunk
 involvement the 2nd & 3rd of the 5th
nerve  result both dermal and oral
manifestation
 vesicle formation surrounded by
erythematous base  ulcers
Treatment

 Supportive
 acyclovir (if needed)
 though the lesion dissapear ----
neuralgia may persist weeks or
months  corticosteroid
5. Erythema Multiforme
 Dermatosis characterized by great
variation in the form, size,
distribution and appearance of the
lesion
 80-90% mouth involvement
 etiologi ??? Herpes virus ?
 Occurs in infant, children, young
adult
 Hypersensitivity reaction
Sign & Symptom
Onset is sudden,
fever, sore throat,
joint pain, acute ill
 skin & mucosal
eruption. Initial
lesion is vesicular
or bullous, found
on the lips,cheeck,
palate, tongue
 lesions are
irregular,
reddish, raised
areas of varying
size
 bloody, crusted
lesion on the
vermillion
border of the
lips, oedem.
Ulcerated moist mucosa
The tongue is extremely painful,
identation marking , lymphadenopathy
Syndromes :
 Steven Johnson : EM +conjunctivitis
 Behcet : dermal, oral, conjunct.
genital
 Reiter : dermal, acute arthritic
D.D: - stomatitis medicamentosa
- recurrent aphthous stomatitis
- pemphigus fulgaris
TREATMENT
 corticosteroid
 antimicrobial agent topically or
parenteral
 mouthwash
 vit Bc & C
 WHITE LESIONS
Devided into 2 main groups :
 A. not associated with hyperkeratosis
 B. associated with hyperkeratosis

A. Not associated with hyperkeratosis

a. - traumatic lesions of the lips &
cheeks
- thermal burns ----- foods
- medicaments ------ aspirin
Cheek biting
b. Moniliasis
-the common form is thrush
-etiology : Monilia ( candida)
Predisposing factors :
1. Marked change in the oral flora
- administration of AB
- excessive use of antibacterial
mouth wash
- xerostomia
2. Chronic local iritation
- denture
- heavy smoking
3. Corticosteroid
- topical , systemic
4. Radiation to head & neck
5. Age : - infancy, old age
6. Hospitalization
7. Systemic diseases :
- diabetes, leukemia, lymphomas, HIV
 The lesion of thrush in infants
( premature, malnourish )
 -white or bluish-
white adherent
patch on the oral
mucosa
 -non painful
 Remove with
difficulty, leaving
a raw, painful,
bleeding surface
 The lesions of candidiasis in adult
 -inflamation,
erythema, painful
eroded areas
 Diagnosis : made
by microscopis
examination 
scraping
Treatment :
nystatin drop / susp
3-5x/day 1-2
weeks
 B. White lesions associated with
Hyperkeratosis
1. LICHEN PLANUS
- an immunologically mediated
mucocutaneous disorder
- can affect stratified squamous
epithelia the skin, oral mucosa ,
genitalia
- frequent occurrence on the oral
mucosa
precede skin eruption
- stress has been widely held to be an
important aetiological factor
a.Non erosive form
slightly raised, diffusely
outline,bluish-white areas which
have linear, reticular configuration
- typically bilateral
-on the buccal mucosa (mostly), the pa
late ,tongue, floor of the mouth,
gingiva, vermillion portion of lower lip
Diagnosis is clinical supported by
biopsy
Treatment :
- Topical vit A
b. Erosive form ( Bullous )
 more frequently
 pain, interference when eating
 cheek mucosa, tongue, attched
gingiva, palate
 pre-maglinant potential
Treatment : - anaesthetic
- mouthwash
- steroid - topical
- systemic
2. LEUKOPLAKIA
 is used as a clinical descriptive term
 potentially precancerous
 the most serious lesion in the oral
mucosa

Etiology :
 multiple etiologic factors, local &

systemic
1. Systemic
a. Possible constitutional
characteristic

b. Possible nutritional factors :

1. Vit. A hyponutrition
2. Vit Bc complex hyponutrition
c. Possible endocrine factors
d. Possible relation to systemic
disease:
syphilis
2. Local (chronic irritation)
a. Trauma
- sharp edges of teeth
- iritation malposed teeth,
prosthetic appliances
b. Chemical and thermal
c. Bacterial : - poor O.H
- periodontal disease
 Sign and symptom
 Lesion may vary from a
small to an extensive
hyperkeratotic of large
area
 Lack of painful
symptoms, if the lesion
becomes eroded---
painful --- maglinancy
 The yellowish-white
area with loss of
flexibility, well defined
 Find on the
cheek mucosa,
tongue (lack of
papillae) floor of
the mouth, palate,
dentulous ridge
 “Smoker patch”: a
white plaque on
the vermellion
border of lip
Treatment
Biopsy
----- non dyskeratotic lesions:
- eliminate all traumatic microbial &
other sources of iritation
- vit Bc & C
- vit A
- should be followed
------ hyperkeratosis with dyskeratosis
- malignant ----- surgical
 Leukoplakia

Iritan + Iritan -

Hilangkan iritan
Biopsi

Respons + Respons -
Displasia - Displasia +

Observasi Tx kanker

Skema Manajemen Leukoplakia

Allergy
- similar to cutaneous allergy, except
that the mucous has mucous
glands for lubrication & protection,
and no hair follicles
 The oral lesion resulting from the
absorption of drugs ----- stomatitis
medicamentosa. Resulting from
contact -------- stomatitis venenata
 1. Stomatitis medicamentosa
 Lesion are produced by
certain of drugs
 due absorption via the
gastrointestinal tract ,
respiratory tract or skin
 occur in any area of the body
 the lesions are multiple,
amorphous, eroded or fungoid
appearance
 vary from marked erythema to
vesicle, an erosive , an
ulcerative or gangraen lesion
2. Stomatitis Venenata =
Contact Allergi Stomatitis
 contact of the causative agent with
the tissues
 include two different processes :
a. stomatitis due to physical agents
or irritants
b. stomatitis due to sensitizing
substances
 the symptoms are local
 In the early stages : red color and
smooth wax-like appearance
 in mild reaction : small shallow
ulcerations
 in severe reactions : actual
necrosis of the mucosal tissues
 the lesion develop soon after
contact with the causative agent
Treatment
 a. elimination of the causative agents
 b. local symptomatic care :
 - anti allergy
 - anaesthetic troche
Deteksi Dini Kanker Rongga
Mulut
 -kanker rongga mulut cenderung
meningkat
 -di AS > 35.000 penderita kanker mulut
& faring / th., menyebabkan 8000
kematian/th.
 -data R.S dr. Sutomo, 1987-1992, 994 ca
mulut dari 2193 kasus tumor rongga
mulut ( 45,3% )
 Depkes 1998 : ca mulut 4,6 orang/100rb
penduduk
Pentingnya Deteksi Dini :
Makin dini terdeteksi, makin baik
prognosisnya
 Komplikasi akibat pengobatan
keganasan ini makin kecil
 Metastase ke bagian lain juga makin
kecil
 ↓ morbiditas dan mortalitas
 Etiologi
Belum jelas, beberapa faktor dikaitkan :
 - zat karsinogen : tembakau, alkohol dll.
 - sinar matahari ---- kanker bibir
 - infeksi : sifilis, kandidiasis, virus
 - kelainan mukosa mulut : leukoplakia,
lichen planus, eritroplakia
 - genetik ; ↓imunologik ; polusi lingk
 - defisiensi nutrisi ; obat-obatan
 - faktor lokal: OH jelek ; Iritasi kronik
Gambaran klinis
 - sering dimulai dari lesi
prakanker
(precancerous lesion)
 - tidak semua lesi prakanker jadi
kanker
 - tidak semua kanker berasal
dari lesi pra kanker
WHO membagi prakanker menjadi 2:

a. Lesi prakanker (precancerous lesion)

 ialah perub. morfologi jaringan ---
kanker mudah terjadi dibanding normal :
leukoplakia, erytroplakia
b. Keadaan prakanker
 ialah keadaan umum dimana kondisi
risiko untuk dapat terjadi kanker >
normal
contoh : sifilis, lupus eritematosus
 Bentuk Awal Kanker Mulut
1. Lesi kemerahan ( eritroplakia )
- adalah daerah/bercak sangat merah,
berbatas tegas, secara klinis/patologis
bukan kelompok kelainan/penyakit ,
warna merah krn atropi epitel &
inflamasi
- permukaan halus (beludru), kadang ada
bercak putih diatasnya
 Permukaan rata
atau sedikit diba -
wah permukaan
 warna merah tak
selalu eritroplakia ,
dpt krn trauma
fisik, kimia atau
inflamasi
 Apabila
penyebab tidak
diketahui atau
lesi merah dlm 1
bulan tidak
sembuh ---
curiga
erytroplakia
 2. Lesi Putih (leukoplakia)
 -lesi putih dalam mulut
dapat krn iritasi
setempat, lichen
planus, leukoplakia dll.
 -kanker mulut bentuk
lesi putih, insiden kecil
 -lesi putih dg ulcerasi
/celah-celah atau
dg lesi merah segera
biopsi
 3. Ulkus
 Tidak khas bentuk
kanker , dapat
ulkus stomatitis
aftosa, ulkus
dekubitis dll.
 -penting riwayat
peny.: sakit/tidak,
sembuh/tidak,
kambuh/tidak
 Iritasi/trauma
krn karies,
tambalan atau
protesa yang
tajam
4. Lesi Eksofilik
 dpt krn reaksi jar.
berlebihan krn iri -
tasi --- contoh
hiperplasi krn gigi
palsu.
 Iritasi dihilangkan
 tidak sembuh 
biopsi
GEJALA OBYEKTIF
1. Indurasi
2. Ulserasi
3. Eksofilik
4. Peninggian permukaan
5. Fiksasi
6. Gigi goyang tanpa sebab
7. Lidah  fungsi bicara dan menelan↓
8. Pembesaran kel.sub mandibula
 Lesi khronis

Ulkus tunggal
Indurasi+
Tanda Trauma lokal
keganasan +
Risiko+ Hilang penyebab Hilang penyebab
Lesi hilang Lesi tetap >2mg

KSS Ulkus dekubitus biopsi

KSS

Skema Manajemen Lesi Prakanker Berupa Ulkus

 Leukoplakia

Iritan + Iritan -

Hilangkan iritan
Biopsi

Respons + Respons -
Displasia - Displasia +

Observasi Tx kanker

Skema Manajemen Lesi Prakanker Berupa Leukoplakia

SELAMAT
BELAJAR