1.OMD 421 ORAL ULCER

2. Macule: flat and well-demarcated lesion of any size, characterized by color change in contrast to the surrounding skin. It is generally caused by alteration of melanin pigment. 3. Papule: elevated, solid and circumscribed lesion, usually 1 cm or less in diameter. 4. Plaque: elevated, flat-topped, firm and superficial lesion, usually greater than 1 cm in diameter; may be coalesced papules. 5. Vesicle: elevated, thin-walled lesion; filled with serous (clear) fluid, less than 1 cm in diameter. 6. Bulla: elevated lesion filled with clear fluid, greater than 1 cm in diameter . 7. Pustule: elevated lesion filled with purulent fluid. The presence of the pustule does not necessarily signify the existence of an infection . 8. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous DiseasesUlceration Without Preceding VesiculationInfective::Infective Primary and recurrent Herpes simplex lesions. Cytomegalovirus associated ulceration Herpes Zoster and Chickenpox Hand-foot-and-mouth disease HerpanginaNon-infective: Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy Some acute specific fevers TB SyphilisNon-infective: Traumatic ulcers Aphthous Stomatitis Behcets disease Reiters syndrome Lichen planus ANUG Some mucosal drug reactions Carcinoma 9. Vesiculo-Bullous Diseases infective: Primary and recurrent Herpes simplex lesions. Herpes Zoster and Chickenpox Hand-foot-and-mouth disease Herpangina 10. Herpes Simplex Virus Infection Herpes simplex type 1: Causes oral and pharyngeal infection, meningeoencephalitis and dermatitis above the waist. Herpes simplex type 2: Causes genital infection and dermatitis below the waist. 11. Primary Herpetic Stomatitis HSV type 1 Transmission by close contact Most primary infections In non-immuneSubclinicalacute vesiculating stomatitis 12. Clinical Picture Prodrome (1-2 days) Early lesion Vesicles (Any part (hard palate & dorsum of the tongue) dome shaped 2-3 mm in diameter) Rupture Ulcers ( round, sharply defined, shallow, yellowish floor, red margins, painful)Gingival Margin Swollen, red, Regional L.N. (swollen, tender)Self limiting (week to 10 days) 13. Primary herpetic gingivostomatitis: multiple ulcers on the tongue. 14. Primary herpetic gingivostomatitis: erythema and multiple ulcers on the gingiva 15. Differential diagnosis Aphthous ulcers (prodrome of fever and malaise, ulcers preceded by vesicles, pinpoint size, involve gingiva and a positive history of contact) Hand-foot-and-mouth disease (by absence of lesions on palms and soles) Herpangina (small vesicles limited to soft palate and oropharynx, while HSV affects anterior palate) 16. Recurrent Herpes Simplex Lesion Recurrent Herpes Libialis Reactivation of latent virus (20-30 %) leading to cold sores. Prodrome (burning sensation Parsesthesia) Erythema 1-2 hrs Vesicles (Clusters at the mucocutaneous junction of the lips can extend) Enlarge, Coalesce & weep exudates 2-3 days Rupture & crust 17. Recurrent herpes labialis 18. Recurrent Herpes Simplex Lesion Recurrent Herpes Libialis Reactivation of latent virus (20-30 %) leading to cold sores.Recurrent Intra Oral Herpes Clusters of small vesicles Break intoProdrome (burning sensation Parsesthesia)Ulcers ( 1-2 mm On keratinized mucosa e.g. gingiva, hard palate)Erythema 1-2 hrs Vesicles (Clusters at the mucocutaneous junction of the lips can extend)Chronic Herpes Simplex Immunocompromised patient Skin & mucosaEnlarge, Coalesce & weep exudates 2-3 days Rupture & crust As recurrent herpes but duration is weeks to months and develop into large ulcers (several Cm) 19. Secondary herpetic stomatitis: small round ulcers on the palate. 20. Recurrent intraoral herpes 21. Herpetic Whitlow 22. Varicella Zoster Infection Primary Varicella Zoster infection Chicken poxReactivation of the latent virus Herpes Zoster of the Trigeminal areaHerpes Zoster of the Geniculate ganglionHerpes Zoster (reactivation of virus adults)Ramsay Hunt Syndrome 23. Chicken Pox Mild systemic symptoms Maculopapular lesions (Generalized Puritic) Rapidly develop into Vesicles (on erythematous base) Rupture Ulcers 24. Oral lesions not diagnostic 25. Herpes Zoster of the Trigeminal area Pain Vesicles (rash) StomatitisIn the related dermatome 26. Trigeminal Nerve Ophthalmic division (Corneal scarring Blindness) Maxillary (2nd) & Mandibular (3rd) divisions (Oral lesions) 27. Herpes Zoster Prodrome (2-4 days) Sharp shooting pain, Parsesthesia, burning and tenderness along the course of the affected dermatomeVesicles Unilateral often confluent L.N. enlarged and tenderPain continues until lesion crust over and heals 28. Herpes zoster: clusters of vesicles on the palate. 29. Secondary Infection Suppuration and scarring of skin Malaise and fever Herpes sine eruption Pain without rash or oral eruptions Post herpetic neuralgia 30. Differential DiagnosisHerpes simplex (Unilateral distribution in HZ while HSV is bilateral) 31. Ramsay Hunt Syndrome Herpes Zoster of the Geniculate GanglionAffects Facial nerve (motor and sensory fibers) 32. Prodrome (Facial pain may radiate to jaws and misdiagnosed as toothache)Bells Palsy Herpetic Oticus (unilateral vesicles on the external ear)Oral mucosa (unilateral vesicles (Chorda Tympaniulcers on erythematous base) ant. 2/3 of tongue & soft palate)Complications (Permanent facial paralysis) 33. Hand Foot and Mouth Syndrome Coxsackie A Virus Epidemic among school children Incubation period 3-10 days Causes oral ulcers and rash on the extremities. Highly infectious 34. Oral Ulcers Small, scattered with little pain Affect Ant. Part of oral cavity Gingivitis is not a feature Systemic upset Mild or absent 35. Hand-foot-and-mouth disease: shallow ulcers on the buccal mucosa 36. Rash on the extremities Vesicles (occasionally bullae) Mainly around the base of fingers and toes, But can affect any part of the limbs. 37. Differential diagnosis Aphthous ulcers Herpes simplex infection Herpangina (by presence of lesions on soles and palms) 38. Herpangina Coxsackie A Virus Epidemic Children 3-10 years Incubation period 2-10 days 39. Prodrome: Fever, chills, sore throat, anorexia, dysphagia On soft palate, tonsils and pharynx (posterior part of the mouth) Papules & vesicles Ulcers (1-2 mm) Heals within 7 days. 40. Herpangina: numerous shallow ulcers on the soft palate 41. Differential diagnosis Herpetiform ulcers - Aphthous ulcers (Prodrome of systemic illness) Primary herpes simplex infection (small vesicles limited to soft palate and oropharynx, while HSV affects anterior palate) Hand-foot-and-mouth disease. (by presence of lesions on soles and palms) 42. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous DiseasesUlceration Without Preceding VesiculationInfective::Infective Primary and recurrent Herpes simplex lesions. Cytomegalovirus associated ulceration Herpes Zoster and Chickenpox Hand-foot-and-mouth disease HerpanginaNon-infective: Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy Some acute specific fevers TB SyphilisNon-infective: Traumatic ulcers Aphthous Stomatitis Behcets disease Reiters syndrome Lichen planus ANUG Some mucosal drug reactions Carcinoma 43. Ulceration Without Preceding Vesiculation :Infective Cytomegalovirus associated ulceration Some acute specific fevers TB Syphilis 44. T.B Ulcer on mid dorsum or tip of tongue. Less common on lips and other parts Angular or stellate over-hanging edges & pale floor. Indurated base Painless in early stages. 45. Syphilis (Primary syphilis (Chancre 3-4 weeks after infection with Triponema Pallidum. Affects lips and tip of the tongue. Firm nodule (1 cm) within few days surface breaks Round ulcer with raised indurated edges, painless. LNs enlarged and rubbery. Within 8-9 weeks healing with no scar. 46. Secondary syphilis 1-4 month after infection. Mild fever, malaise, headache, sore throat & generalized lymphadenopathy Followed by rash & stomatitis Rash starts at trunk, asymptomatic pinkish macules, symmetrical distribution, few hours to weeks. Stomatitis lateral borders of the tongue, tonsils and lips. ulcers are flat, covered with grayish membrane, snail tract, may coalesce and form well defined round ulcer. 47. (Tertiary syphilis (gumma 3 or more years after infection. Insidious onset. Affects palate, tongue, tonsils. Swelling with yellowish center (several inches) Necrosis painless deep ulcer Ulcer is rounded, soft, punched out edges, floor is depressed and pale. Heals with sever scarring distort tongue and soft palate, destroy uvula, perforate hard palate. 48. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous DiseasesUlceration Without Preceding VesiculationInfective::Infective Primary and recurrent Herpes simplex lesions. Cytomegalovirus associated ulceration Herpes Zoster and Chickenpox Hand-foot-and-mouth disease HerpanginaNon-infective: Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy Some acute specific fevers TB SyphilisNon-infective: Traumatic ulcers Aphthous Stomatitis Behcets disease Reiters syndrome Lichen planus ANUG Some mucosal drug reactions Carcinoma 49. Ulceration Without Preceding Vesiculation Non-Infective: Traumatic ulcers Aphthous Stomatitis Behcets disease Reiters syndrome Lichen planus Some mucosal drug reactions Carcinoma 50. Traumatic ulcers Obvious cause as sharp edge of denture or a broken tooth cause traumatic ulcer on tongue and/or buccal mucosa. Single Acute onset and Short duration No systemic features Painful, yellowish floor, red margins Removal of the cause healing within 7-10 days If not Biopsy 51. Recurrent Aphthous Stomatitis Onset In childhood Peak Adolescence Recurrent In healthy patient Prodrome: Burning sensation 2-48 hrs with localized erythema 52. Minor Most common type Non keratinized mucosa Shallow, rounded, 5-7 mm with red margins and yellowish floor Can be one or many Healing with no scar formation in 7-14 daysMajorHerpetiformUncommonUncommonKeratinized & non keratinized mucosaNon keratinized mucosaSeveral centimeters, deep and sometimes with indurated base & everted edges1-2 mmPersistent for several month Healing with scar formationDozens or hundreds (may cluster Large ulcers). Wide spread bright erythema around the ulcers. 53. Minor Aphthous ulcer 54. Major Aphthous ulcer 55. Herpetiform Aphthous ulcer 56. Differential diagnosis Pemphigus and mm pemphigoid by absence of vesicles and healing in 7-14 days, and the well defined appearance, absence of epithelial tags. Erythema Multiforme As above + uniform appearance and size, also no lip crusting. Atrophic candidiasis predisposing factors in candidiasis, most cases pass through white necrotic phase or have a minor keratotic component. 57. Primary herpetic gingivostomatitis Prodrome of fever and malaise, ulcers preceded by vesicles, pinpoint size, involve gingiva and a positive history of contact.Recurrent Intra oral herpes Involve keratinized mucosa, while RAU involves non keratinized mucosa. 58. Behcets disease Triad of Oral ulcers Genital ulcers Uveitis Oral & genital ulcers (aphthous like ulcer) Eye lesion (conjunctivitis, Uveitis) Skin lesion (erythema nodosum, acneiform eruptions) +ve pathergy test 59. It has Four patterns 1. Mucocutaneous (oral & genital ulcers) 2. Arthritic (joint involvement with or without 1) 3. Neurological (with or without 1 & 2) 4. Ocular (with or without 1,2 & 3) 60. Eye lesion 61. Oral ulcers (aphthous like ulcer) 62. Skin lesion (erythema nodosum) 63. Pathergy test +ve pathergy test: when needle puncture Cause pustule formation after 48h 64. Differential diagnosis StevensJohnson syndrome Erythema Multiform Reiter syndrome Recurrent aphthous ulcers 65. Reiters Syndrome Triad of uritheritis, arthritis, conjunctivitis Oral manifestations Painless white lesions which may ulcerate Aphthous like ulcer Geographic tongue like lesion Purpuric rash on palate Self limiting 66. Geographic tongueCharacteristically, the lesions persist for a short time in one area, then disappear completely and reappear in another area. The condition is usually asymptomatic 67. Purpuric rash on palate 68. Squamous cell carcinoma Deep & large Indurated base Raised everted edge Necrotic fetid floor Painless unless invade nerve Metastatic L.N: Large Painless Hard Fixed to underlying tissues 69. A.N.U.G Painful gingivitis Redness Swelling Gingival bleeding Punched out lesion on interdental papillae M.m covered with greyish necrotic membrane Bad breath(foetid oris) Bad taste lymphadenopathy 70. Important Causes of Oral Mucosal Ulcers Vesiculo-Bullous DiseasesUlceration Without Preceding VesiculationInfective::Infective Primary and recurrent Herpes simplex lesions. Cytomegalovirus associated ulceration Herpes Zoster and Chickenpox Hand-foot-and-mouth disease HerpanginaNon-infective: Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy Some acute specific fevers TB SyphilisNon-infective: Traumatic ulcers Aphthous Stomatitis Behcets disease Reiters syndrome Lichen planus ANUG Some mucosal drug reactions Carcinoma 71. Vesiculo-Bullous Diseases : Non-infective Pemphigus vulgaris Mucous membrane pemphigoid Erythema multiform Contact allergy 72. Erythema multiform Acute Inflammatory Mucocutaneous disease Oral lesions (most prominent or the only one seen) 73. E.M. Minor )(80% of cases Skin lesions Maculopapular lesion (dull red flat or slightly raised) Remains small or reach 1-3 cm within 48 hrs Often involve the hands selectively Kobner phenomenon Target (iris) lesions: Typical: Less than 3 cm in diameter. Consist of 3 zones. Atypical: Consist of only 2 zones. 74. Central zone of erythemaMiddle zone of edema (paler)Outer ring of erythema (well defined) Typical target- or iris-like lesions of the skin. 75. Koebner phenomenon 76. Oral manifestations of EM Mucous membrane Extensive bullae formation Followed by Erosions and a grayish white membrane. Lips Show characteristic hemorrhagic crusting. 77. EM Major ((Steven Johnson Syndrome Onset :sudden, may be preceded by a prodrome 1-13 days. Organs involved Mouth (100%) Eye Bullae formation may occur corneal ulceration is frequent these changes often regress completely, rarely cause blindness. Skin variable typical maculopapular lesion bullous lesions rarely pustular. Male genitalia Anal MM Bronchitis. 78. StevensJohnson syndrome: severe erosions on the lips, tongue, and nose in an 8-year-old boy 79. Differential diagnosis Primary herpetic gingivostomatitis. Involve gingiva Aphthous ulcers. By absence of vesicles and healing in 7-14 days, and the well defined appearance, uniform appearance and size, also no lip crusting. Pemphigus vulgaris. Ulcers lacking erythema, Positive Nikolskys sign, flaccid bullae. 80. Pemphigus Vulgaris Uncommon 40-60 y Autoimmune disease Causing vesicles or bullae on skin and mucous membrane Fatal if untreated 81. Oral manifestations Appears first in mouthspread to skin.Vesicles (fragile) Erosions (superficial, ragged, painful, tender) Peeling off of oral epithelium due to lateral movement. Desquamative gingivitis Positive Nikolskys sign 82. Desquamative gingivitis 83. Skin Lesions Vesicles or flaccid bullae RupturesErosions (painful, ragged) Positive Nikolskys sign Death due to electrolyte imbalance and secondary infection. 84. Pemphigus vulgaris: severe lesions of the skin of the face. 85. :Diagnosis confirmed by Smear taken from base of vesicle (tzank smear) show tzank cells (acantholytic cells) High titre of circulating antibodies(IGg4) against intracellular cementing substance Direct immunoflouresence 86. Direct immunoflouresence Show binding of antibodies to intercellular substance 87. Differential diagnosis Cicatricial pemphigoid & Viral diseases o Bullae in pemphigus is smaller than mm pemphigoid and considerably larger than viral diseases such as herpes and hand-foot-and-mouth disease. o By immunoflorescence Erythema Multiforme. Aphthous ulcers. 88. ImmunofluorescencePVMMP 89. (b.m.m.pemphigoid (autoimmune Old age Oral lesion: Non keratinized mucosa Desquamative gingivitis vesicles that rupture leaving erosions that spread peripherally more slowly and self limited than pemphigus. Skin lesion: Large tense bullae Stay long time rupture leaving eroded area Nikolskys sign is +ve 90. erosions on the buccal mucosa 91. Desquamative gingivitis 92. Eye lesion: Conjunctival erosion Corneal ulcers may heal by scarring symblepharon 93. conjunctivitis 94. :Diagnosis confirmed by Biopsy Direct immunoflourescence 95. Thank you