Traumatic lesions.Clinic, diagnostics, treatment.

Oral ulcersHow to diagnose?

What is an ulcer?Amouthororal ulcer is an open sore in the mouth, or rarely a break in the mucous membraneor the epithelium on the lips or surrounding themouth.

Epidemiology and frequency

Mouth ulcer is a very common oral lesion. Epidemiological studies show an average prevalence between 15% and 30%. Mouth ulcers tend to be more common in women and those under 45. 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 recurrent aphthous stomatitis

What cause ulcers?Trauma (physical injuries)Chemical injuriesSmoking Infection - viral - bacterial - fungal - protozoansImmunodeficiencyAutoimmunityAllergyDietary

Tools for diagnosis:History ExaminationFurther investigationAdditional diagnostic methods biopsy

Further investigation questions you should ask:How long have you had that ulcer?How many ulcers do you have?Is it painful?Can you relate them to any trauma, hot food or another factors?Is it the first time or you had them before?Where are they located in the mouth?Do they start as ulcer or as vesicle/bulla?Do you get them anywhere else on the body?

Step by step guide to performing an oral cavity examination

Things you need to look for:SiteNumberSizeShapeBaseEdge

Differential diagnostic, based on historyHow long have you had the ulcer?Long time chronicChronic trauma (single, can identify the cause, and should improve after removal) Malignancy (single, painless)TB (single ulcer in the tongue/palate, associated symptoms chronic cough)Mucous membrane pemphigoid (multiple ulcers affect mainly gingiva, blood filled blisters) Primary or tetriary syphilis

Recent acuteAcute trauma (single, can identify the cause, and should improve after removal)Viral infection (multiple, associated symptoms fever)Immune mediated disease (Erythema multiforme, RAS)

How many ulcers do you have?SingleTraumaticPrimary or tetriary syphilisTBMalignancyMultipleViral infectionImmune mediated disease

Is it painful?

YesAcute causes (trauma, viral, immune mediate)NoChronic causes (trauma, TB)

Can you relate them to trauma or hot food?YesConfirm traumatic ulcerRemove the causeReview after 1 weekNoLook for other causes

Do you get them anywhere else on the body?NoThink or oral conditionsYes where?Skin mucocutanous disease (lichen planus, pemphigus)

Traumatic lesionsMechanical trauma (acute or chronic) Chemical injury (acid, alcali)Physical injury (thermal injury, electrical injury)

Mechanical traumaCan be: AcuteChronic

And caused by:A sharp edge of a tooth Accidental bitingSharp, abrasive,or excessivelysaltyfood Poorly fitting dentures Dental braces Trauma from a tooth brush Patients bad habits

Dental braces

Acute traumaSingle, can identify the causeshould improve after removal

Traumatic ulcers:

Clinical featuresof traumatic ulcers:They are clinically diverse, but usually appear as a single, painful ulcer with a smooth red or whitish-yellow surface and a thin erythematous halo.They are usually soft on palpation, and heal without scarring within 610 days, spontaneously or after removal of the cause.However, chronic traumatic ulcers may clinically mimic a carcinoma.The tongue, lip, and buccal mucosa are the sites of predilection.The diagnosis is based on the history and clinical features.However, if an ulcer persists over 1012 days a biopsy must be taken to rule out cancer.

TreatmentRemoving factors, caused traumaGood hygiene of oral cavityAntiseptic for 7-10 daysAnalgetics if it is necessaryTopical steroids may be used for a short time.Biopsy

LeukoplakiaEtiology: -trauma from habitual biting, dental appliances -tobacco use -alcohol consumption -oral sepsis -local irritation -syphilis -vitamin deficiency -endocrine disturbances -dental galvanism -actinic radiation (in the case of lip involvement). Symptoms - painless, fuzzy white patches on the side of the tongue or cheeks.

Clinic-located on the tongue, mandibular alveolar ridge and buccal mucosa in ~50%. -palate, maxillary alveolar ridge, lower lip, floor of the mouth and the retromolar regions are somewhat less frequently involved. -may vary from nonpalpable, faintly translucent white areas to thick, fissured, papillomatous, indurated lesions. -surface is often wrinkled or shriveled in appearance and may feel rough on palpation. -color may be white, gray, yellowish-white, or even brownish-gray in patients with heavy tobacco use. Physical: -lesion cannot be wiped away with a gauze

Differential diagnosis:Candidiasis and aspirin burn - can be wiped away with a gauze Erythroplakia (a red plaque that does not rub off), is a dysplastic lesion (or worse) in 90 percent of cases.

TreatmentTreat dental causes such as rough teeth, irregular denture surface, or fillings as soon as possible.Stopping tobacco or/and alcohol.Removal of leukoplakic patches with using a scalpel, a laser or an extremely cold probe that freezes and destroys cancer cells (cryoprobe).

Chemical injures:Chemicals such asaspirinoralcoholthat are held or that come in contact with the oral mucosa may cause tissues to become necrotic and slough off creating an ulcerated surface.

Treatment:Wash a mouth with lot of waterAnalgetics (for 3-5 days )Antiseptics ( for 7 10 days)Keratolytics (after 5-7 days)Keratoplastics (after 7-10 days)

Physical injures:Electric Burns to the Mouth -are most commonly caused when a child bites into a cord, touches the male ends of a "live" but improperly connected cord, or sucks on the female end of an extension cord that is plugged into the wall. The vast majority of the patients is younger than three years.

Treatment:ConservativeAntisepticsAntibioticsAnalgetic2. Surgical (after the healing was completed and after the degree of functional and/or aesthetic deformity was established (usually 6 months post-injury)).

Stomatitis DescriptionStomatitis is an inflammation of the lining of any of the soft-tissue structures of the mouth. Stomatitis is usually a painful condition, associated with redness, swelling, and occasional bleeding from the affected area.Bad breath(halitosis) may also accompany the condition. Stomatitis affects all age groups, from the infant to the elderly.DefinitionInflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth. The inflammation can be caused by conditions in the mouth itself, such as poororal hygiene, poorly fitted dentures, or from mouthburnsfrom hot food or drinks, or by conditions that affect the entire body, such as medications, allergic reactions, or infections.

Herpetic stomatitis

Herpetic stomatitis is a viral infection of the mouth that causes ulcers and inflammation. These mouth ulcers are not the same as canker sores, which are caused by a different virus.

Symptoms:Blisters in the mouth, often on the tongue, cheeks, palate, gums, and a border between the lip (red colored) and the normal skin next to itDecrease in food intake, even if the patient is hungryDifficulty swallowing (dysphagia)DroolingFever (often as high as 104 Fahrenheit) may occur 1 - 2 days before blisters and ulcers appearIrritabilityPain in mouthSwollen gumsUlcers in the mouth, often on the tongue or cheeks -- these form after the blisters pop

Causes

Herpetic stomatitis is a contagious viral illness caused byHerpes virus hominis(also herpes simplex virus, HSV). It is seen mainly in young children. This condition is probably a child's first exposure to the herpes virus.

An adult member of the family may have a cold sore at the time the child develops herpetic stomatitis. More likely, no source for the infection will be discovered.

Differential diagnostics:Streptococcal pharyngitis does not involve the lips or perioral tissues and vesicles do not precede the ulcersErythema multiforme ulcers are larger, usually without a vesicular stage and are less likely to affect the gingiva.Aphthous stomatitis the multiply lesions, palatal and gingival location are indicative to herpesvirus infection. Additionally, aphthae usually localized only on nonceratinized mucoza, such as the floor of the mouth, alveolar mucosa and buccal mucosae.

Treatment:Good oral hygieneAcyclovir family of antiviral medications non later than 48 hours! Analgetic ( or oral topical anesthetic )Diet (no hot or pepper food)Antiseptics

Aphthous UlcersOf all the type of nontraumatic ulcaration that affect oral mucosa that is the most common.

Aphthous ulcers are also known as canker sores. They are painful, temporary sores that may occur anywhere in the mouth. Usually, they show up in several places:

On the inside of the lipsInside the cheeksOn the tongueAt the base of the gums

Canker sores on tongue:

Etiology:

Immune system disorders Other conditions cause similar sores:Blood and immune system diseases, including HIVVitamin and mineral deficienciesAllergiesTraumaCrohn's diseaseLupus

Clinical features:

Three forms of aphthous ulcers have been recognized: minor, major and herpetiform.

Major Ulcerations(> 0,5cm)10% of lesionsoextremely painful (odynophagia)... typically heal with scar formationoAppearance- deeply cratered ulcersoDuration-> 1 month for healing.oLocation- posterior oral cavity.0 Number 1- 10oNOTE- THINK OF HIV DISEASE PROGRESSION OR IMMUNOSUPPRESIONMinor Ulceration(1-5 mm)85% of lesionsopainful heal without scar formationoDuration- 7-10 daysoLocation- anterior oral cavity0 Number 1-5 Herpetiform Ulceration(1-3mm lesions that form clusters)5% of lesions.oSxs- as above (but more severe)0 Number 10-100oLocational any intraoral site

Minor ulcers:Are the most commonly encountered formSingle, painful oval ulcer less than 0,6 mm, covered by a yellow fibrinous membraneLast 7 to 10 daysPeriods of freedom from disease 2-3 weeks to year

Major ulcers:Lesions are larger: more than 10 mmMore painfulPersist longer that minor aphthaeOne ulcer disappears, another one startsHealing generally occurs in 6 weeks and longerChronic stress, common disease can cause

Herpetiform ulcers

Recurrent crops of small ulcersHealing generally occurs in 1 to 2 weeksNot preceded by vesicle and exhibit no virus-infected cells

Treatment:Oral hygieneAvoiding spicy foodOral rising with sodium bicarbonateAnalgesicsAntisepticsAnti inflammatory agentsAntimicrobial and corticosteroids

Noma also known ascancrum orisorgangrenous stomatitis, is agangrenousdiseaseleading totissuedestruction of the face, especially the mouthandcheek. Noma (derived from the Greek "nomein" meaning "to devour") is a devastating gangrenous disease which attacks children, quickly destroying their mouth, nose, and face, and which can prove fatal after just a few weeks. Noma, also known as cancrum oris, seems to start on the gum and extends outwards to the cheeks and lips.

NOMA FACTS

NOMA FACTS Mainly attacks children 2-14 years old. Africa accounts for the majority of the cases. The World Health Organization estimates that 100,000 children contract noma every year. Without treatment, the mortality rate is 70-90%. Most victims starve to death because their jaw muscles are literally eaten away and they cannot chew; others die as the infection spreads.

key players in the process :Fusobacterium necrophorum Prevotella intermedia Borrelia vincentii Porphyromonas gingivalis Tannerella forsynthesis Treponema denticola Staphylococcus aureus

The reported predisposing factors include:The reported predisposing factors include:Malnutrition or dehydrationPoor oral hygienePoor sanitationUnsafe drinking waterProximity to unkempt livestockRecent illnessMalignancyAn immunodeficiency disorder, includingAIDS

Symptoms:The early features of noma include soreness of the mouth, a swollen tender cheek, a foul-smelling purulent oral discharge, fetid odor in the mouth of the affected child, swelling of the regional lymph nodes, anorexia, grayish-black discoloration of the skin in the affected area. The long-term effects of Noma depend largely on the anatomic sites of the lesion, the extent and severity of tissue destruction and the stage of development of the dentition and facial skeleton prior to onset of the disease.

Treatment:The progression of the disease can be halted with the use of antibiotics and improved nutrition; however, its physical effects are permanent and may require reconstructive plastic surgery to repair. Reconstruction is usually very challenging and it should be delayed until full recovery (usually about one year following initial intervention)