2. Ulcer – is a break in the continuity of the
covering epithelium – skin or mucous
membrane. It may follow molecular death
of surface epithelium or traumatic
removal
3. Margin – junction between normal epithelium
and ulcer
Edge – area between margin and floor of ulcer
Floor – exposed surface of ulcer
Base - where ulcer rests on
4. Shape:
› Oval – generally tuberculous
› Circular to serpiginous - syphilitc
› Irregular - carcinomatous
Number:
› Multiple ulcers – herpetic ulcers
› Usually single – syphilitic & tuberculous ulcers
Position:
› Tuberculous ulcers common in area of
adenopathy
› Carcinomatous can occur anywhere
5. Edge:
› Spreading ulcer –inflamed and edematous
› Healing ulcer – red granulation tissue to blue
zone(growing epit.) to white zone (fibrosis)
› Undermined – tuberculous ulcer
› Punched out – syphilitic ulcer
› Sloping – healing ulcer
› Raised & beaded – rodent ulcer
› Rolled out and everted – squamous cell
carcinoma
32. • 1-5 shallow, round/oval
ulcer
• 2-10mm gray/yellow base –
erythematous margin
• Heal 7-10 days no scarring
• 1-2 a month – buccal
mucosa, tongue, soft palate
Clinical Features
33.
34. Treponema Pallidum
Primary
Syphillis
• Solitary ulcer 3-90 days after contact
• Oral chancre
• Common – lip and anterior part of
tongue
• Painful
• Starts as firm nodule and surface
breaks after a few days
• Rounded ulcer with indurated edges
• Regional lymphadenitis
Clinical Features
41. Acid fast bacilli
in sputum Chest x-ray
Tuberculin test – 0.1 ml – 5
tuberculin units purified
protein derivative - >10mm
induration
ELISA &
PCR
Investigations
42. • Seen after 6 weeks of primary
lesion
• With fever, headache, sore throat,
lymphadenopathy
• Common – palate, tonsils, lateral
border tongue and lip
• Lesions – irregularly linear (snail
track ulcers)Mucous patches –
multiple grayish white plaque
Clinical Features
Secondary
Syphilis
44. • After 3 years initial infection
• Gumma – focal granulomatous
inflammatory process with central
necrosis
• Nodular mass with yellowish center
• Necrotizes to leave deep painless
ulcer
Clinical Features
Tertiary Syphillis
53. • Desquamative lesions –
common on gingivae
Clinical Features
• Biopsy – subepidermal
vesicles and bullae
• Absence of nikolsky sign
Investigations
60. • 1-10 number – large painful
• Yellow necrotic center erythematous halo
• Cheeks, tongue, soft palate – dysphagia
• >10mm – persist >3 weeks and scars
Major Aphthous Ulcer
• Multiple ulcer – 1-100
• 1-2mm at any site and coalesce
• Painful and heals in 2-3 weeks – no scar
Recurrent herpetiform ulcer:
64. • Single ulcer – rolled,raised and everted
border
• Painless usually – non-healing
• Induration on palpation
• Local pain or paresthesia in nerve
involvement
• Referred earache, trismus, dysphagia,
halitosis, enlarged cervical nodes
Clinical Features:
• Symptoms > 3 weeks
• Ulcer without healing 7-10 days – biopsy
• Biopsy – mitotic figures, keratin pearls,
pleomorphism, connective tissue involvement
Diagnosis:
65.
66.
67. • Non-healing ulcer > 3 weeks
• Induration & lack of inflammation surrounding
• Rolled & thickened edge
• Smoking & alcohol
• Male 2:1 & Age > 50 years
• History premalignant lesion in area
• No local factors
Suspicion of Malignancy
• Ulcers – multiple & synchronously
• Clustering ulcer
• Blister formation
• Associated sore and bleeding gums
• Identifiable local cause
• Recurrent ulceration
Reduced Suspicion of Malignancy
68. Ulcer > 3
weeks
Features suggesting
malignancy
- Solitary ulcer
- Proliferative
appearance
Optimise
general health
Refer through 2
week wait route
Features that
do not
suggest
malignancy
Isolated ulcer
- Trauma
Managed in
primary care
if confident
of diagnosis
Recurrent
ulcer
- Aphthous
ulcer
Managed in
primary care
if confident of
diagnosis
Widespread
oral ulcer
- Oral lichen
planus
Refer
69. • Oral ulceration - common and
mostly benign
• Some oral ulcers may be
associated with systemic disease
or particular drugs
• A systematic approach to
examination of the oral cavity
with good lighting and retraction
of mobile tissues is critical
Conclusion
70. • A minority of oral ulcers are malignant
• Ulcer that persists for more than three
weeks should be referred; suspected
malignancy requires urgent referral to a
specialist
• Non-malignant oral ulceration may be
investigated and treated in primary
care or referred
• A benign ulcer is not referred, re-
evaluate the lesion to ensure that
healing has occurred
Conclusion