3. mouth ulcer Latin ulcus and from Greek "ἕλκος" - elkos, "wound"[ American English, canker sore open sore inside the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. Causes: physical abrasion, acidic fruit, infection, other medical conditions, medications, and cancerous and nonspecific processes. Two common types : aphthous ulcers cold sores or fever blisters
4. Epidemiology Epidemiological studies show an average prevalence between 15% and 30%. women > men and < 45 years. >16-25 year olds, and <over 55. The frequency of mouth ulcers varies from fewer than 4 episodes per year (85% of all cases) to more than one episode per month (10% of all cases) including people suffering from continuous RAS
13. Recurrent Aphthous Stomatitis(RAS) Most common ulcerative lesion of oral cavity Recurrent, painful ulcers Confined to soft mucosa Subdivided into three types: Minor aphthae Major aphthae Herpetiformaphthae
14. Recurrent Aphthous Stomatitis(RAS) Minor aphthae: Less than 1 cm Heal completely in 7-10 days without scarring Painful Prodromal stage Shallow and round to oval Gray to yellow membrane Clusters of up to 5 ulcers Steroids
16. Recurrent Aphthous Stomatitis (RAS) Major Aphthae Uncommon Irregular, deep ulcers 1-3 cm in size Raised borders Heal in 4-6 weeks Extensive scarring and distortion BIOPSY!! Steroids
21. Recurrent Aphthous Stomatitis (RAS) Herpetiform Aphthae Uncommon Crops of up to 150 very small (<3mm) ulcers Heal completely in 7-10 days COMPLETELY UNRELATED TO HERPESVIRUS
23. Behcet’s Symptom complex of: Recurrent aphthous ulcers of the mouth Painful genital ulcers Uveitis or conjuctivitis
24. Behcet’s Affects persons of Mediterranean, Middle Eastern, or Japanese decent Easily confused with Stevens-Johnson syndrome or Reiter’s disease Need referral for systemic treatment
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27. Acute Ulcerative Behcet’s Syndrome recurrent oral and genital ulcers arthritis inflammatory disease of eyes and GI tract.
28. Acute Ulcerative Reiter’s Syndrome mainly young men 20 to 30 Classis triad Conjunctivitis Arthritis urethritis. Oral lesions range from erythema to papules to ulcerations involving the buccal mucosa, gingiva, and lips. Lesions on the tongue resemble geographic tongue
30. Herpesvirus Infection Primary Infection Herpetic gingivostomatitis Younger patients Often asymptomatic May be associated with fever, chills, malaise Vesicles-ulcers-crusting Anywhere in the oral cavity
33. Herpesvirus Infection Secondary Infection Reactivation of latent virus Not associated with systemic symptoms Small vesicles Occur only on the hard palate and gingiva Prodromal signs
39. Herpangina NOT caused by Herpesvirus Coxsackie A virus Children < 10 years of age Common in summer and fall Often subclinical presentation Headache/Abdominal pain 48hrs prior to papulovesicular lesions on tonsils & uvula. Sore throat
42. Acute ulcerative Varicella zoster virus- distribution of trigeminal nerve Coxsackie- prodrome, vesicular, pharynx,tonsils, soft palate Recurrent herpes simplex- prodrome present, herpes labialis, limited to keratinized epithelium and can involve the gingiva and hard Viral Infections Herpes simplex- 600,000 new cases annually, prodrome followed by small vesicles that ulcerate, primary infection involves the gingiva, and can involve the entire oral cavity palate
57. Acute ulcerative Histoplasmosis disseminated form, oropharyngeal lesions may present as ulcerative, nodular, or vegetative Biopsy will provide the diagnosis
58. Infection Candida Candida albicans Most common Normal flora Predisposing factors White creamy patches KOH prep Nystatin oral suspension
62. Candidiasis Symptoms: burning, dysgeusia, sensitivity, generalized discomfort Angular cheilitis, coinfection with staph may be present Acutely- atrophic red patches or white curd-like surface colonies Chronic- denture related form confined to area of appliance
64. Leukoedema Diffuse, filmy grayish surface with white streaks, wrinkles, or milky alteration Symmetric, usually involving the buccal mucosa, lesser extent labial mucosa Normal variation present in the majority of black adults, and half of black children At rest, opaque appearance. When stretched dissipates
66. Oral Leukoplakia Clinically defined white patch or plaque that has been excluded from other disease entities Presence of dysplasia, carcinoma in situ, and invasive carcinoma from all sites 17-25% (Bouqot and Gorlin 1986) Etiology associated with tobacco (smoking, smokeless tobacco), areca nut/betel preparations
69. Oral Leukoplakia May be macular, slightly elevated, ulcerative, erosive, speckled, nodular, or verrucous Clinical shift in appearance from homogenous to heterogenous, speckled, or nodular, a rebiopsy is mandatory Correlation between increasing levels of dysplasia and increases in regional heterogeneity or speckled quality
70. Proliferative Verrucous Leukoplakia Uncommon variant of leukoplakia Multifocal, occurring more in women, and in those without the usual risk factors Evolution from a thin, flat white patch to leathery, then papillary to verrucous Development of squamous cell CA in over 70% of cases
72. Site of Leukoplakia Risk of dysplasia/carcinoma higher with floor of mouth, ventrolateral tongue, retromolar trigone, soft palate than with other oral sites
76. Oral hairy leukoplakia Asymptomatic, seen with systemic immunosuppression EBV Lateral tongue bilaterally; subtle white keratotic vertical streaks to thick corrugated ridges Diagnosis by microscopy and in situ hybridization Management includes establishing diagnosis and treating immunosuppression
77. Neoplasm Squamous cell carcinoma (SCC) Most common Irregular ulcers with raised margins May be exophytic, infiltrative or verrucoid Mimic benign lesions grossly
84. Generalized: broad classification encompassing a wide variety of causative agents or conditions Contact stomatitis Radiation mucositis Cancer chemotherapy
86. Dermatologic Disorders Erythema multiforme Rapidly progressive Antigen-antibody complex deposition in vessels of the dermis Target lesions of the skin Diffuse ulceration, crusting of lips, tongue, buccal mucosa Self-limited, heal without scarring
87. Acute ulcerative Erythema multiforme Mucocutaneous hypersensitivity reaction Etiology infectious (strong association with HHV-1, viral, mycoplasma) drugs (antiseizure medications, sulfonamides) Clinically target lesions develop over the skin with erythematous periphery central area that can develop bullae, vesicles.
90. Erythema Multiforme Clinically Oral mucosa and lips demonstrate aphthous like ulcers and occasionally vesicles or bullae may be present. Gingiva rarely involved; common sites include labial mucosa, palate, tongue, and buccalmucosa Mucosal ulcers are irregular in size and shape, tender and covered with fibrinousexudate. Sialorrhea, pain, odynophagia, dysathria. Severe EM are associated with involvement of other mucosal sites- eyes, genitalia, and less common esophagus and lungs
91. Erythema Multiforme Histopathology] Intense lymphocytic infiltration in a perivascular distribution and edema from submucosa into the lamina propria, epithelium lack antibodies, blood vessels contain fibrin, C3, IgM Treatment- with oral involvement only can treat symptomatically/short course of corticosteroids
92. Dermatologic Disorders Lichen planus Chronic disease of skin and mucous membranes Destruction of basal cell layer by activated lymphocytes Reticular: fine, lacy appearance on buccal mucosa (Wickman’s striae) Hypertrophic: resembles leukoplakia Atrophic or erosive: painful
94. Oral lichen planus 0.2%- 2% population affected Usually asymptomatic, reticular from, white striaform symmetric lesions in the buccal mucosa T-cell lymphocytic reaction to antigenic components in the surface epithelial layer Other variants: plaque, atrophic/erythematous, erosive
96. Oral lichen planus Small risk of squamous cell carcinoma, more likely seen in the atrophic or erosive types Studies show that dysplasia with lichenoid features have significant degree of alleic loss. Recommendation is to remove these lesions/follow patient closely
99. Dermatologic Disorders Benign mucous membrane pemphigoid Tense subepithelial bullae of skin and mucous membranes Rupture, large erosions, heal without scarring Sloughing (Nikolsky sign) Bullous pemphigoid Cutaneous lesions more common Both show subepithelial clefting with dissolution of the basement membrane IgG in basement membrane
