Oral ulcers Diagnosis• A-Multiple ulcers:• 1-acute • 2- chronic

• B-recurrent ulcers

• C-single ulcer

Acute multiple ulcers

1 -1ry herpes simplex

Onset: after 6 months ,Peak within 2-3 yearsClinical features:1-Prodrome :1-2 days before appearance of local lesions fever ,headache ,lymphadenopathy, malaise ,vomiting)2-generalized acute marginal gingivitis3-multiple vesicles turn to painful, bilateral ulcers surrounded by erythtematous halo4-mainly keratinized gingiva5-mainly at anterior area of oral cavity

2-Herpangina By coxsackievirus A4Affect children from 3-10 years ,peak from June to October Clinical picture :1-prodrome ,milder than herpes simplex (fever ,anorexia ,malaise)

2-sore throat ,dysphagia

3-ulcers mainly at post .area of oral cavity (soft palate ,fauces ,tonsils ,posterior pharynx)4-ulcers smaller than herpes5 -at post area and more painful.6-no marginal gingivitis7 -mainly in epidemics

3-Hand- foot and mouth disease

Caused by coxsakievirus A16,from 8 months to 33 years ,75%under 4 years.Clinical picture:1-low grade fever2-oral vesicles and ulcers more extensive than herpes(mainly palate ,buccal mucosa)

3-macules and papules on extensor surface of hand and feet.4-examine hands and feet for maculopapular lesions and vesicles if there is acute stomatitis and fever

4-Chicken pox

1ry infection of varicella –zoster virus:Cutaneous lesions:Maculopapular lesion then turn to vesicles on erythematous baseOral lesions ,not diagnostic

5-Herpes zoster (shingles)Clinical picture:1-Prodrome: 2-4 days (shooting pain, paresthesia,burning sensation) along the course of the nerve2-unilateral vesicles on erythematous base ,appears as clusters along the course of the nerve.the most diagnostic manifestation is the unilateral appearance of lesions

6-Erythema multiformeAffects children and young aged

Rare after 50Clinical picture :No prodrome ,systemic and local

lesions appear together, with very rapid onset.

oral lesions 1 - bullae or vesicles on

erythematous base ,then rupture.

2-lesions orally are anywhere but lips are more prominent, and rare gingival involvement most diagnostic), where lips are extensively eroded and large portion are denuded of epithelium.

3-E.M lesions are large, irregular, deep and often bleeds and there are tissue remnants

• Cutaneous lesions:• -Appears on hands and

feet ,extensor surface.• -Macules ,papules ,vesicles, or

bullae• -target lesion or Iris lesion (central

bulla or pale surrounded by edema or erythema)

B-Chronic multiple ulcers

1-Pemphigus vulgaris• 1-Cutaneous lesions:• Thin walled bullae arising on

normal skin and mucosa.• Bullae breaks rapidly leaving

erosions and continuously spread peripherally.

• The mostly diagnostic manifestation:

• A -apply pressure to intact area leads to formation of new lesion (KOEBNER PHENOMENA)

• B -apply pressure to bullae extend peripherally

2-oral lesions:usually presents 4 month before

cutaneous lesions

Clinical manifestations: classical bulla on uninflammed area ,then rapidly breaks leaving irregular erosions and ulcers ,that extend peripherally.

-leaves denuded area

Mainly at buccal mucosa (N.B: E.M : mainly lips)

Differential diagnosis

1- Its chronic appearance differentiate it from (H.S, H.Z and E.M)

2-From R.A.S that its lesions are recurrent and heals rapidly, but pemphigous lesions extends peripherally and takes a period of weeks to months.

3-lesions of pemphigous are not small ,rounded and symmetrical like R.A.S and viral ulcers, and there is detached epithelium at the peripheries.

4-+ve nikolysks sign AND KOEBNER PHENOMENA

5-bullae extend peripherally

2-Mucous membrane pemphigoid

• Age over 50.• Mainly mucosal surfaces( oral

cavity)• Clinical manifestation:• 1-Desquamative gingivitis. • 2-vesicles that rupture leaving

erosions that spread peripherally more slowly and self limited than pemphigus.

• 3- +ve nikolyskis sign• 4- no cutaneous involvement.

C-recurrent oral ulcers

1-Recurrent aphthous stomatitis• Mostly begin during the 2nd

decade• Clinical picture:1-Prodrome :from 2-48 hrs before

ulcer appear burning sensation)2-Localized erythema then small

white papule then ulcerates3-not preceded by vesicles, uniform,

rounded ,painful covered by yellowish membrane and surrounded by erythematous halo about 10mm).

4-no tissue remnants on borders, (there are no vesicles.)

5-mainly on lining mucosa rare on keratinized mucosa

Minor

Major aphthous: (1- 5cm)Appears on keratinized and non

keratinized mucosa.• -Indurated base ,everted edges, very

painful and leave scar. • Takes more than a month to heal.

Herpetiform (least common)• Dozens or hundreds of ulcers about

1-2 mm,very painful surrounded by erythematous halo.

majormajor

herpetiform

2-Behcets disease• Between 20-40• Diagnosis: oral recurrent ulcers (minor

aphthae)at least 3 times within 12 months + 2 of the following

• A-recurrent genital ulcers• B-eye lesions: (uveitis,retinal

vasculitis , corneal inflammation)• C-skin lesions: maculoppapular

lesions,erythema nodosum (reddish ,painful, tender lumps )

• D-+ve pathergy test :cutaneous hyperactivity to intra-cutaneous injection, within 24 hrs) (appearance of small red bump or pustule)

Erythema nodosum

Pathergy test

3-Recurrent herpes simplex 1 -recurrent herpes labialis common

(cold sores, fever blisters(PPt. by

fever ,menstruation ,u.v,emotional stress

Clinical picture:Prodrome, tingling and burning

sensation then edema and clusters of vesicles at mucocutaneous junction and spread to skin ,then coalesce and weep exudate and then rupture and crust

2-recurrent intraoral herpes: vesicles turn to ulcers ,mainly keratinized mucosa (gingiva –hard palate)