Oral Ulcerations: Causes and Treatment Options<br>

1. ORAL ULCERSPart 2 D / D of ULCERS

2. DRUG -INDUCED

3. CHEMOTHERAPY INDUCED ULCERATION Cytotoxicity induced ulcers: these have a non-specific appearance,but are widespread and very painful

4. Ulcer producing Cytotoxic agents – methotrexate Agents producing lichen-planus-like (lichenoid) lesions- NSAIDs, some antihypertensives,antidiabetics, antimalarials Agents causing local chemical burns- (aspirin held in the mouth) Agents causing erythema multiforme- (sulphonamides and barbiturates)

5. Patients receiving chemotherapy, with or without radiotherapy: Prevention of Mucositis: allopurinol for patients treated with 5-FU cryotherapy for patients treated with 5- FU Treatment of Mucositis symptoms  topical dyclonine or lignocaine

6. INFECTIONS

7. BACTERIAL

8. TUBERCULOSIS In HIV-infected people with active tuberculosis (TB), levels of HIV in the bloodstream --- five- to 160-fold Isoniazidand Rifampicin Lupus vulgaris

9. SYPHILIS “ PRIMARY SECONDRY TERTIARY CONGENITAL ACQUIRED SMALL RED-BROWN MACULES PAPULES CONDYLOMA LATA

10. patchy alopecia  VDRL Test Snail-track” Procaine penicillin 1.2 mega unit IM qd x 10 days

11. GONNORRHEA • Neisseria gonorrhoeae • Attaches to oral or urogenital mucosa by fimbriae • Females may be asymptomatic; males have painful urination and pus discharge • Treatment with antibiotics • Untreated may result in • Endocarditis • Meningitis • Arthritis

12. V I R A L

13. VIRAL Acute onset Multiple lesions Systemic manifestations (malaise, fever, diarrhea, lymphadenpathy, lymphocytosis) often present Vesicle stage present in all

14. HERPES Herpesvirus Infection: þ Primary Infection þ Vesicles- ulcers- crusting þ Anywhere in the oral cavity COLD SORES small, grouped vesicles on erythematous bases, which then become pustules, umbilicate, and later crust larger and deeper – immunocompromised

15. HERPES NEONATAL SECONDARY þ Secondary Infection þ Reactivation of latent virus þ Small vesicles þ Occur only on the hard palate and gingiva þ Prodromal signs acyclovir 60 mg/kg/day I.V. divided 8h for 21 days.

17. VERICELLA ZOSTER Hodgkin's disease or non-Hodgkin's lymphoma Acyclovir, 10 to 12 mg/kg every 8 hours for 7 days

18. HIV RELATED Erythematous candidiasis Pseudomembranous candidiasis Angular Cheilitis • Candidiasis (Thrush) • Periodontal Problems • Oral Ulcerations NUP RAU HSV

19. CANDIDIASIS Candida þ Candida albicans þ Most common þ Predisposing factors Þ White creamy patches Erythematous candidiasis Pseudomembranous candidiasis Angular Cheilitis Denture stomatitis

20. ANGULAR CHEILITIS

21. CANDIDIASIS

22. CANDIDIASIS

23. Topical antifungals: Nystatin Swish and swallow Systematic therapies: ketoconazole, Itraconazole or fluconazole

24. A U T O I M M U N E D I S E A S E S

25. AUTOIMMUNE DISEASES • Characterized by: • Blisters and painful ulcers of slow onset • Persistent and chronic • Do not heal in a predictable period • Lymphadenopathy typically not present

26. LICHEN PLANUS Erythemathous mucosal lesions usually with areas of ulceration • Hyperkaratosis • Saw-tooth rete ridges, • Liquefactive degeneration • of the basal cell layer • Band-like subepithelial • inflammatory infiltrate, • Civatte bodies

27. EM Ulcers and lip swelling • Usually accompanied by skin lesions - "iris," lesion • Strong association between HSV and erythema multiforme, • especially recurrent erythema multiforme Stevens-Johnson syndrome- combination of oral, ocular and genital lesions

28. SLE Malar rashes Ulceration and crusting of the lips, nose and oral cavity Shallow oral ulcers and gingivitis

29. PEMPHIGUS VULGARIS • Thin-walled intraepithelial bullae on • cutaneous and mucosal surface • Oral involvement can be the first sign of lesions • (desquamative gingivitis) • Positive Nikolsky sign • Rounded, acantholytic epithelial cells in • exfoliative cytology • TT: Mild – short duration therapy • Severe - 1 -2 mg/kg/d Prednisone • +/- Azathioprim or Cyclophosphamide • Taper dose when relief occurs

30. MMP • Auto-immune disease • Affects40 to 50 year old aged women • Hemorrhagic and may heal with scarring (cicatricial pemphigoid) • Cleavage occurs in the subepithelial zone • Autoantibodies are produced against various Ags

31. RECURRENT APHTHOUS ULCER Canker sores Appears as a painful white or yellow sore (ulcer) surrounded by a bright red area • early onsetbetween the ages of • 10 and 40 • dietary deficiencies • menstrual periods • hormonal changes • recurrent ulcers usually lasting • 1 week to 1 month

32. Recurrent small • Round or ovoid ulcers • Circumscribed margins • Erythematous haloes • Yellow or grey floors • Associated with other disease • Extremly painful • Minor • Major • Herpetiform

33. Aetiology: Unclear Typically early onset with recurrent ulcers usually lasting 1 week or 1 month Three distinct clinical patterns: . Minor– small ulcers (<4 mm) on mobile mucosae, healing within 14 days, no scarring . Major– large ulcers (may be >1 cm), any site including dorsum of tongue and hard palate, healing within 1–3 months, with scarring . Herpetiform ulcers–multiple minute ulcers that coalesce to produce ragged ulcers

34. MINOR • 80% - minor form – 2-4 mm • Non-keratinized sites (mobile mucosae) • Either single or in crops of four or five

36. Sutton's disease MAJOR • 10% of patients • more severe • any site of the oral mucosa including keratinized sites • scarring

37. MAJOR

38. HERPETIFORM

39. Management: Diagnosed from history and clinical features No diagnostic test A blood picture is useful to exclude possible deficiencies and coeliac disease Treat any underlying predisposing factors

40. Symptomatic treatment with topical anaesthetic or NSAID ( topical diclofenac) Treat aphthae with chlorhexidine aqueous mouthwash or topical corticosteroids Vitamin supplementation – B-complex with zinc

41. BEHCET’S DISEASE Hulusi Behçet1937 • Mediterranean region, Middle East • Male-to-female ratio was 24:1 • Third decade of life • Recurrent mucosal membrane ulcerations 6 months to 5 yrs • Heal in days to weeks with scarring • Vasculitis with triad of oral and genital ulcers and uveitis or iritis