Oral Medicine, Oral Diagnosis & Periodontology Department

ORAL ULCERS

Part 4
 Etiological classification

Microbial
agents

Immunologic Gastrointestinal
reactions disease

Neoplasm

Reactive
Blood disorders
ulcers

Drugs
Immunologic
Reactions
 How to Diagnose Oral Ulcerative Lesions?
Contributing Factors

Onset and Duration

I-History History of pain or

associated symptoms

History of similar lesions

N. of lesions present/ if
II-Clinical preceded by vesicles/bulla

Examination skin lesion

III-
Laboratory
How to describe an ulcer?!!
Site/ Extension

Size

Shape

Surrounding Mucosa

Margin

Edge

Floor

Base

Depth

Number 5:02 AM
 Chronic Acute Recurrent
Multiple ulcers Multiple ulcer Ulcers

Erythema Multiform
1- Aphthous Ulcers
2- Behcet’s Syndrome
1- Pemphigus Vulgaris 3- Reiter’s Syndrome
2- Bullous pemphegoid
3- Benign Mucous membrane Pemphegoid
 ??
Mucocutaneous ocular syndromes
These diseases include:

Behcet’s disease (syndrome)

Reiter’s disease (syndrome)

Stevens Johnson syndrome

Ready to meet your patients?!!
I- History Patient (1)

A 16 years old patient presented to our clinic suffering from

sudden fever headache since 2 days followed by extensive
painful ulcerations after 24 hours all over the mouth and his
skin showed reddish papules and his eye is red. He gave history
of recent intake of cephalosporin and diclofenac injection
subsequently he developed blisters which later transformed to
irregular ulcers when extended on lip it become bloody and
crusted
 II-Clinical Patient (1)
Examination Always Remember the history

(Eye lesion)
Conjunctivitis with corneal ulceration

(Maculopapular lesion) (Dull red – flat or slightly raised)

were seen on hands feet elbows face and neck and
genitalia other lesions appear as concentric erythematous
rings with purpuric central spots (Target iris)
 II-Clinical
Examination Patient (1)
Always Remember the history

•Lips are extensivly eroded and denuded of epithelium

(Bloody crusted lip) - +ve Nickolesky’s sign
•Large irregular deep ulcer on buccal mucosa with bleeding with
ill defined margins with hemorrhagic irregular red hallow
Key for Diagnosis
 Erythema Multiform
I-History
1. Fever, headache, malaise, anorexia of sudden onset.
2. Acute Multiple/Vesiculo- bullous lesions of sudden onset.
3. History of recurrence (33% of cases).
Etiology and possible contributing factors:
 Infections, particularly herpetic can be triggering factors.
 Drugs, particularly Sulphonamides and Barbiturates,
NSAIDs
 In most patients no precipitating cause can be found.

 Erythema multiform is an acute, inflammatory,

self-limiting disease with multiple skin and oral
lesions.
 Types Of Erythema Multiform

Herpes
Major Minor Chronic Associated
65%

Toxic
Steven
epidermal
Johnson’s
necrolysis
syndrome
(TEN).
 Stevens-Johnson Syndrome
I-History
 Age: infants, children and young
adults.
 Sex: Affects both sexes equally.
 Onset: Sudden onset.
 Prodrom of fever, headache, malaise,
anorexia
 Severe Vesiculo-bullous lesions within
24 - 48 hours. Affect skin, oral, eye,
genitalia
 The patient appears toxic, dehydrated
and actually ill.
 Central zone of Middle zone of
erythema edema (pale)

Outer ring
of erythema
(well
defined)

Typical target- or iris-like lesions of the skin.

Skin Lesions
Koebner phenomenon
Vesiculobullous lesion+ Eye lesion
 Oral Lesions

Large, deep, irregular and hemorrhagic surrounded

by erythema + Bloody crusted lip

Healing with no scar formation occurs within 2-3 weeks

 Toxic Epidermal Necrolysis (TEN)
“Lyell’s syndrome”
I-History

 Site: Skin and mucous

membrane of the mouth,
throat, nose, trachea and
conjunctiva.

 Mucous membrane Represents the MOST

involvement may precede SEVERE form of erythema
skin lesion by 1-2 weeks. multiforme
 II-Clinical
Examination
 Severe erythema, followed by
Vesiculo-bullous lesions and
detachment of epidermis
resembling scalding (burn
with hot steam).

Death
??!!!
Management:
 Early diagnosis and treatment is important as the
reaction can be lethal
Treatment
The disease is self-limiting.

In mild cases:

1. Topical steroids.
2. Topical anesthesia to control pain.
3. Topical tetracycline mouth washes to control secondary infection.

In severe cases:

1. Systemic steroids.
2. Systemic antibiotics to control secondary infection.
3. Systemic analgesic to control pain.
4. Hospital admission to control fluid and electrolyte imbalance.
 Patient (2)

I-History
A 28 female patient in a good heath complaining of multiple
painful intraoral lesions interfere with eating and speaking from
1 week ago, the patient reported short periods of relieve and the
lesion usually recure, upon asking the patient of any prodromal
symptoms she only reported some tingling and burning
sensation before lesion appear.
 II-Clinical
Examination Patient (2)
Always Remember the history

Tiny pinhead sized 1-2 mm and other ulcers of

larger size as the coalesced forming irregular
large ulcers on non keratinized mucosa
Key for Diagnosis
Oral Medicine, Oral Diagnosis & Periodontology Department

ORAL ULCERS

Part 4
Immunologic
Reactions
 Chronic Acute Recurrent
Multiple ulcers Multiple ulcer Ulcers

Erythema Multiform
1- Aphthous Ulcers
2- Behcet’s Syndrome
1- Pemphigus Vulgaris 3- Reiter’s Syndrome
2- Bullous pemphegoid
3- Benign Mucous membrane Pemphegoid
 RECURRENT APHTHOUS
STOMATITIS
I-History

 Onset → In childhood Ask About:

➢Stress ???
 Peak →
And contributing factors
Adolescence ➢Family History ???

 Recurrent
 In healthy patient
 Prodrome: Burning
sensation 2-48 hrs with
localized erythema
stress
➢Systemic conditions ???
➢Blood Disease ???
➢Nutritional Deficiency ???
➢Extraoral Lesions: Eye/
Genital/ Joints/ Skin ????
Three Clinical forms of Aphthous Ulcers

Minor Major Herpetiform

 Minor Major Herpetiform

Most common type Uncommon 10% Uncommon 10%

80%
Keratinized & non Non keratinized
Non keratinized keratinized mucosa mucosa
mucosa
Several centimeters, 1-2 mm
Shallow, rounded, deep and sometimes Wide spread bright
or oval 5-7 mm with with indurated base erythema around
red margins and & everted edges the ulcers.
yellowish floor
Dozens or hundreds
One or two (may cluster →
Can be one or many Large ulcers).
Persistent for several Overlap
Healing with no scar month (6-8w) Heal in 14 days with
formation in 7-10 no scar
Healing with scar
days
formation
 III-
Laboratory
Investigations
History
Examination Diagnosed by
No Special investigations Exclusion
Used only to exclude underlying conditions

 In cases with underlying systemic disease :

 Educate the patient
 Give Palliative treatment
 Treat the cause
In mild and moderate cases:
 Protective topical treatment as
orabase
 Topical anesthetic
 Non-steroidal anti-inflammatory
Benzydamine hydrochloride MW.
 Tetracycline mouth bath
 Topical Steroids
In Severe cases:
 Systemic and intralesional steroids
 ??
Mucocutaneous ocular syndromes
These diseases include:

Behcet’s disease (syndrome)

Reiter’s disease (syndrome)

Stevens Johnson syndrome

 Behcet’s Syndrome
I-History
- Age: mainly affect young

adults.

- Sex: males > females.

- Oral aphthous
Behcet’s ulcers.
syndrome is a multisystem
inflammatory disorder of unknown etiology
- Genital ulceration.
characterized by recurrent oral ulcers, genital
ulcers and eye lesions.
- Eye lesions
Skin Lesions
 a) Erythema nodosum: tender red nodules.
 b) Acneform lesions: papules or pustules.
 c) Large pustular lesions
+ve Pathergy test
Oral Lesions = Genital Lesion
 Aphthous Ulcers
Eye Lesions
 Conjunctivitis and keratitis
 Treatment
 Systemic prednisone 40 - 60 mg/day.
 Combination of steroid and immunosuppressive agent as
azathioprine, in chronic lesions.
 Topical corticosteroids for management of oral lesion.
 Topical anaesthesia to relief discomfort of oral lesions.
 Reiter’s Syndrome
Skin manifestations:
- Red
Age:or
30yellow keratotic
- 40 years of age.
- macules
Sex: mostly affects white
or papules on males.
palm and soles which
desquamates

Oral manifestations:
 Aphthous-like ulcers (Painless)
 Geographic tongue.
 Purpuric rash on the palate.
 Oral lesions are self limiting
(Few months)
 Patient (3)

I-History
A 45 years old male complaining from a painful recurrent oral
ulcers. upon asking the patient of any other lesions in his body, he
reported a similar genital ulcer, and history of red eye and pustular
skin eruptions.
 II-Clinical
Patient (3)
Examination
Always Remember the history

Upon clinical examination large ulcer appear in inner

side of cheek near corner of mouth,
Skin lesions manifest as large pustules and papules on
limbs and trunk and apparent red eye also revealed.
Thank you
Key for Diagnosis
Ready for Problem solving??
A middle aged male patient having recurrent oral
lesion, genital ulcers , and eye lesion

 The most possible diagnosis.

 Describe the oral lesion
 Name of the skin lesions?
 Other criteria associated
with disease?
 Confirmatory test.
 A 19 years old male reported history of herpes
infection and represented with this sudden oral and
skin lesions.
 Name of the disease?
 Describe the oral lesion
 Name of the skin lesion
 A patient with multiple intraoral lesions came to your clinic
which interfere with eating from week ago the patient
reported short periods of remission.
 D.DDiagnosis
 Describe the lesion
 Treatment
A 35 patient with painful lesion on lips he
reported it one weak ago

 Describe the lesion

 Diagnosis
 D.D
 Treatment
A patient came to your clinic complaining of
extremely painful lesion 2 weeks ago that interfere
with eating and speaking after examination
submandibular lymph nodes were palpable.

 Describe the lesion

 Diagnosis
 D.D
 treatment
 A patient came to the dental clinic with oral lesions and an
eye lesion and complained of painful joints
 What could be the diagnosis of the disease?
 Describe oral lesions?
 Name of the eye lesion?