Oral Ulcers

1. Oral Ulcers Adisa A.O

2. Definition • An ulcer is a breach in the epithelium (and includes damage to the lamina propria mucosa[or with exposure of the underlying connective tissue]) • Oral ulcers are common, occur in association with many diseases and by different mechanisms

3. etiology • Trauma • Infection • Neoplastic • Immune-mediated • Drug-induced • Nutritional deficiencies

4. Traumatic ulcer • History of trauma [mechanical, chemical, thermal] • Irregular “jagged” margins • In children - Tearing (and subsequent ulceration) of the upper labial frenum may be a sign of physical [assault] child abuse. The ulceration of the lingual frenum may be a sign of oral sexual abuse

5. Mechanical trauma to the intra-oral minor salivary glands [especially palatal] can result in necrotizing sialometaplasia • Great care has to be taken in the management of necrotizing sialometaplasia since it mimics squamous cell carcinoma both clinically and histologically • If observed carefully the edges of the ulcer begin to ‘heal’ or form granulation tissue in about 15-20 days

6. Infection • Viral • Bacteria • Fungal • Parasitic • Herpes simplex [primary herpetic gingivostomatitis] • Herpes zoster • Mycobacterium tuberculosis • Treponema pallidum • Cryptococcus neoformans • Entamoeba histolytica

7. Viral Ulcers • Usually small, oval and multiple ± confluent • May be preceded by ‘febrile’ presentation • May be preceded by vesicles • Before appearance of vesicles or ulcers, there maybe a tingling or burning sensation of the mucosa • May be restricted to the distribution of nerves

9. Oral Ulcers in Tuberculosis • Oral mucous membranes may become infected through implantation of organisms found in sputum or, less commonly, through hematogenous deposition • The tongue and the palate are favored locations. • The typical lesion is an indurated, non-healing ulcer with raised undermined edges that is usually painful.

10. Oral ulcers in Syphilis • Primary [Chancre] syphilis results in painless indurated ulcer with rolled margins at the site of inoculation • The lesion heals without therapy in 3 to 12 weeks, with little or no scarring • Mucous patches – snail track ulcers

11. Oral ulcers in Fungal infections • Deep fungal infections are characterized by primary involvement of the lungs • Oral infections typically follow implantation of infected sputum in oral mucosa, but may also be hematogenous • Whether single or multiple, lesions are non-healing, indurated, and frequently painful

12. Neoplastic • Typically depicts malignancies [especially carcinomas] • Commonest types – squamous cell carcinomas (OSCC) and salivary gland adenocarcinomas [mucoepidermoid carcinoma, adenoid cystic carcinoma] • OSCC starts as usually as a painless, non-healing ulcer with raised, everted edges, a necrotic floor and an indurated base.

14. Incisional biopsy recommended for any non-healing oral ulcer greater than 3 weeks. • Diagnosis of a malignant lesion and management • Note – late presentation has been discussed in several local studies as the major factor that results in poor prognosis

15. OSCC causative factors • Tobacco use • Alcohol • HPV [Oro-pharyngeal] • Exposure to UV light of certain frequency [lower lip cancer]

16. Aphthous ulcers • Aphthae (i.e., canker sores) [RAS] have plagued mankind throughout recorded history and were first mentioned by Hippocrates (460–370 BC) • a relatively common condition that is characterized by single / multiple recurrent small, round, or ovoid ulcers with circumscribed erythematous margins and yellow or gray floors

17. Several large studies have categorized RAS as the most common inflammatory ulcerative condition of the oral cavity • No singular specific etiology for RAS but several causative factors proposed

19. Local trauma • Microbial • Systemic • Nutritional • Smoking • Bacterial (Streptococci) • Behcets syndrome • MAGIC syndrome • Crohns disease • Stress • Gluten sensitive enteropathy • Iron, Zinc, Vitamin B2 and B6 deficiencies

20. Allergy • Drugs • Food sensitivity • Sodium lauryl sulfate sensitivity • NSAID • B-Blockers

21. There are 3 clinical variants of RAS • Minor • Major • Herpetiform

24. All forms of RAS are painful recurrent ulcers. • bouts of one or several rounded, shallow, painful ulcers at intervals of a few months to a few days. • Patients occasionally have prodromal symptoms of tingling or burning before the appearance of the lesions

25. Treatment - depends on the frequency, size, and number of the ulcers. The best treatment is that which will control ulcers for the longest period with minimal adverse side effects • Topical/ Systemic/ Intralesional corticosteroids [kenalog in ora-base {tiamcinolone acetonide}] • Immunosuppressant • Laser ablation • Tetracycline mouth-rinse • Iron, multivitamins • Oral xylocaine gel

26. Drug Related Oral Ulcers • Oral + Skin presentation • Erythema Multiforme • Lichenoid reaction • Mucositis and ulceration in radiotherapy and cytotoxic chemotherapy

28. Immune-mediated oral ulcers • Pemphigus • Mucous membrane pemphigoid • Lichen planus [erosive or ulcerative] • Reiter's syndrome

29. Oral Contact Allergy • Antigenic stimulation by a vast array of foreign substances, including foods and flavoring agents [cinnamon], preservatives, oral care products, dental materials and cosmetics

31. Thanks for listening