Ass. Prof.

ORAL PATHOLOGY 8th Semester

Dr: Marwa Abd Al-Salam Oral ulceration 2023-2024

Primary & secondary lesions Primary lesions

The objective sign of disease & diagnosis of many diseases is based upon the recognition of primary lesions.
There is an alteration in the tissue's morphology & changes rapidly to secondary lesions due to trauma or by
mastication or with time passing.
Macule: is a flat circumscribed alteration in tissue that varies from a pinhead to several centimeters may be
circular, polygonal, linear-shaped, red or brown, either Erythematic (petechiae & ecchymosis) or
Pigmentary.
Pigmentation might be- Physiological like in melanosis (melanoplakia), ephelides (freckles) -Pathological
like in Addison disease, Peutz-Jegher's syndrome. Macules may be transitory or permanent.
Papule: is superficial circumscribe elevation, flat conical, or pointed, varies from a pinhead to 5 mm, red,
yellow, white to bluish-red colors. **Both macule & papule produce no symptoms or give burning or itching
sensations or pain. Their surface might be eroded or overlaid with epithelial desquamation.
Nodule: is enlarged papule which is usually deep-seated & involves the submucosa or lower dermis in the
skin. It may also be slightly elevated above mucosa. Example: syphilis, leprosy.
Vesicle: Circumscribed single or grouped elevations of the epithelium of skin or mucosa, beneath or within,
are a collection of fluid (serum, plasma, blood). Example: herpes simplex viral infection.
Bulla: Large vesicle deeply seated & its roof is more resistant to rupture. Example: pemphigoid.
Pustule: A vesicle filled with pus. Example: impetigo.
Tumor: An uncontrolled, abnormal, circumscribed growth of cells. A simple example is the Papilloma; an
epithelial tumor, the surface is warty papillary, keratotic, fissured with a sessile (broad base with no neck) or
pedunculated (narrow base with a neck) base.
Keratosis: Abnormal thickening of surface layers of the epithelium of mucosa or skin. Example: frictional
keratosis.
Secondary lesions
The most common found in the oral cavity include; erosion, fissure, ulcer, pseudomembrane, eschar,
desquamation & crust.
Erosion: is a kind of ulceration or loss of tissue substance produced by trauma or the primary lesion's
sequel. It is superficial circumscribed, punctuate, linear or irregular, and does not leave a scar on healing.
Example: erosive lichen planus.
Fissure: Is cleft or groove in tissue may be superficial or deep, linear, radiating, longitudinal or transverse &
occur on the mucocutaneous junction of mouth, tongue. Example: angular cheilitis, scrotal tongue.
Ulcer: is defect or cut in the surface epithelium or skin deeper than erosion & extend to beneath the
epithelium, circular, ovoid, crescentic, or irregular. Ulcers may result from physical agents like burns, or
chemical, or traumatic like sharp teeth & clasps, or pathological like aphthous. An ulcer may be painless or
severely sensitive (painful).

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Pseudomembrane: There is a loss of epithelium & plasma exudates spread from blood to eroded area &
coagulate, enclosing necrotic epithelium in its fibrous network. Example: diphtheria, Vincent infection
(ANUG).
Eschar: A mass of dead tissues produced by burning or chemical corrosives like: phenol.
Desquamation: is shedding of epithelial elements in scales or sheets as a result of inflammation.
Crust: is a dry product of exudates from lesions on skin or lips, composed of pus, blood, dried serum, or
epithelial debris. It may be yellowish to brown depending on the disease, maybe traumatized, then will crack
& bleed. It is usually formed on the mucocutaneous junction of the lips. Example: angular cheilitis,
carcinomas.
Reactive ulcerative lesions
Most common ---- cause and effect relationship
Traumatic ulcerations (how to diagnose?)
1. A cause of trauma must be identified, 2. fit the site, size, and shape of the ulcer, 3. when removed, the
ulcer must be healed within 10 days.
- Usually in regions trapped between teeth (lower lip, tongue, buccal mucosa)
- Anterior tongue in infants traumatized by natal teeth called Riga-Fede disease (define)

- Ill-fitted dentures with or without denture hyperplasia

- Self-induced ulcer; lip and cheek biting
- Dental procedures; removal of the adherent cotton roll, the negative pressure of saliva ejector accidental
sticking of buccal mucosa

Chemical ulcerations:
Acids, alkalines and irritant allergens, aspirin burn, cavity medications (phenol), itching acid, bleaching
solution, anesthesia ulcer (due to local ischemia after palatal injections).
Necrotizing sialometaplasia is an oral destructive inflammatory condition of minor
salivary glands in the palate, presents as a non-ulcerative swelling associated with pain
and paresthesia; within 2-3 weeks, necrotic tissue slough & leaving a crater-like ulcer of
1-5 cm in diameter. Etiology may be a traumatic injury, dental injection, previous
surgery, and ill-fitting dentures.

Thermal ulcerations:
Pizza burn (hot cheese), impression material (wax, hydrocolloid compounds), radiation
induce a reduction in basal cell renewal resulting in atrophy and ulceration (in
malignancies like SCC & lymphomas). Those 2 need high doses of radiation; the ulcers
remain several weeks in the way of the beam, but disappear without scar after therapy
completion. Diagnosis based on history and clinical appearance.
Allergic reactions:
I. Allergic contact stomatitis: It is extremely diverse. Numerous foods, chewing
gums, candies, dentifrices, mouthwashes, gloves, rubber dam, topical
anesthesia, restorative materials, acrylic, and impression denture materials.
II. Allergic reaction due to systemic administration of drugs:

1. Anaphylactic stomatitis: multiple zones of erythematic or numerous aphthous-like ulceration.

2. Intra-oral fixed drug eruptions: inflammatory ulceration of mucosa and skin that recur at the same site
after drug administration, appears as a localized area of erythema & edema which can develop into vesiculo-
erosive lesion mostly on labial mucosa (e.g., Chlorhexidine, Co-trimoxazole, and Tetracycline).
3. Lichenoid drug eruption: (e.g., Dapsone, Methyldopa, oral contraceptive, and phenothiazine).
4. Lupus erythematosus-like eruptions: (e.g., chlorpromazine and procainamide)
5.Pemphigoid–like eruption: (e.g., Amoxicillin, Ibuprofen, Mefenamic acid, and Salicylic acid).

6. Pemphigus–like eruption: (e.g., ampicillin and cephalexin).

7. Non-specific vesiculo-ulcerative lesions: (e.g., indomethacin and meprobamate).
Recurrent aphthous stomatitis
-Common oral painful lesion (5-20% of people) mostly non-smokers.
-Immunological bases appear to be a primary cause.
Minor aphthous = canker sore

-Has fewest recurrences and shortest duration of 7-14 days.

-Ulcerations may be present from 1-5 lesions during a single episode.
-Located on non-keratinized (mostly buccal and labial) mucosa, 3-10 mm diameter, and heals without
scarring.
-It is preceded by symptoms of burring tingling with the development of erythematous macules, which
develops into an ulcer covered by a yellow-white fibrino-purulent membrane and encircled by a red halo.
-Tends to recur at 1-4 months intervals.
Pathology: Mucosal destruction appears to represent a T cell-mediated immunological reaction. Ulceration
seems to be preceded by leukocytic infiltration of epithelium & underlying corium, & intercellular edema,
leading to the epithelium's disintegration. Ulcers have no specific features.

Major aphthous ulceration

-Larger, more painful, longer duration, and deeper than that of a minor, 1-3cm in
diameter and heals (after 2-6 weeks) with scarring.
-The number of lesions varies from 1-10.

-Any oral surface may be affected, but labial mucosa, soft palate, and tonsillar fauces are frequent sites.
-Extreme pain and L.N enlargement, tension & anxiety.
-Usually, after puberty, recurrent episodes may continue to develop for up to 20 yrs or more.
Herpetiform aphthous ulceration
-Less common, painful, small 1-3 mm in diameter, great in no. (as many as 100
ulcers), resembling herpes simplex infection (but no virus on serological tests).
-Heal in 7-10 days, but the recurrences tend to be closely spaced. Any oral
surface may be affected, with a female predominance.

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Notes:: Patients with Crohn's disease have, in addition to oral aphthae, mucosal fissures & nodules mostly
in the buccal mucosa, vestibule, and lips producing a 'cobblestone effect.'

Predisposing factors for aphthous: "different things in different people."

1-Iron, foliate, or vit. B12 deficiencies. 2-Stress.
3-Food allergies & some drugs. 4-HSV and VZV infection.
5-Relationship with the luteal phase of menstruation. 6-Genetic Predisposition.
RAU lesions may be associated with a systemic condition called Behçet
syndrome (define); this disorder is a combination of chronic ocular inflammation, and
orogenital ulcerations that appear to be an immunological defect (immune
dysfunction) in which vasculitis has a part, it may affect, mouth, skin, genitals, joints
(causing morning stiffness), eyes and C.N.S. Oral lesions are similar to aphthous that
involves soft palate and oropharynx, which are infrequent sites for routine aphthous. Diagnosis: Recurrent
oral ulceration, plus 2 of the following: *recurrent genital ulceration, **eye lesions, ***skin lesions, and
****positive pathergy test in which a sterile pustule develops at the site of injection of inert material (e.g.,
sterile saline) during 1-2 days after skin injection.
Erythema multiforme
EM Recurrent attacks for 10-14 days, once or twice a year, blistering ulcerative mucocutaneous,
probably an immunologically mediated etiology, it is self-limiting. In about 50% of cases, one can identify
either: *Preceding infection as herpes simplex, or TB. **Exposure to a variety of drugs (antibiotics or
analgesics), sulfonamides, and barbiturates.
Clinical features of EM minor: Young adults mostly male, 50% of cases develop skin
lesions, that appear flat, round, and dusky red macules on extremities, these become
slightly elevated and may evolve into bulla with a necrotic center, some skin lesions
present as concentric circular erythematous rings resembling a target or bull's eye or iris
lesion (target lesion). The oral lesion begins as erythematous patches that undergo
epithelial necrosis and evolve into erosion and ulcer with irregular borders mostly on
the labial, buccal mucosa, tongue, and floor of the mouth, crusting (hemorrhagic
lesion) of the vermilion zone of lips are common.
Pathology: Degeneration of spinous cells & widespread
intercellular edema leading to intraepithelial vesiculation
or extensive vacuolar change leading to subepithelial
vesiculation. Rupture of vesicles leaves erosions. There is
a mononuclear inflammatory infiltrate subepithelially.
Erythema multiforme major=Stevens Johnson Syndrome
A more severe form of EM is usually triggered by a drug rather than an infection. For a diagnosis to
be made, the ocular & genital mucosae should be affected in conjunction with the oral and skin lesions,
Pneumonia, arthritis myocarditis, heals with a scar.
Pemphigus Vulgaris

• Chronic autoimmune skin & mucous membrane disease, intradermal bulla

formation (why?) ,
• Jewish mostly affected over 35 yrs age. If not treated, it's lethal.
• Caused by antibodies against epithelial desmosomes leading to acantholysis &
suprabasal clefting
• Oral lesions may appear before skin; bulla break rapidly (why?), leaving irregular ulcers on buccal
mucosa, palate & gingiva
 • Characteristic skin sign is +ve Nikolsky sign (= pressure on the normal area will result in a new
lesion).
Pathology: IgG is initiating the release of intracellular lysosomes and proteolytic enzymes, causing the
squamous cells to separate from each other (acantholysis), forming suprabasal clefts, and then intraepithelial
bullae. Basal cells adhere to one another & underlying c.t. to form the floor of vesicles but they eventually
separate after rupturing of vesicles to leave ulcers with chronic inflammatory cells infiltration. Prickle cells
after acantholysis become round & float off in vesicle fluid & are seen in smears (Tzanck cells).
Diagnosis: history, biopsy (suprabasal epithelial separation), +ve Tzank cytological smear,
immunofluorescent antibody test (fishnet pattern).
Mucous membrane pemphigoid

• Chronic blistering, mucocutaneous autoimmune disease, antibody directed

against hemidesmosomes.
• Affect old adults over 50 yrs with a female predilection
• May affect another mucosa----genitalia, nose, esophagus, larynx & trachea.
• Orally; vesicles & bullae are tense, long-lived (why?), involve the palate,
cheek more localized than pemphigus & it's not lethal.
• Ulcers may persist for weeks or months if not treated
• On gingiva causes desquamative gingivitis as in pemphigus & erosive lichen
planus (occurs in 90% of cases)
Pathology: subepithelial bulla is separating full thickness of epithelium from lamina propria, no
acantholysis, mixed chronic inflammatory cells infiltration.

Diagnosis: history, biopsy, immunofluorescent test (linear pattern, along with basement membrane zone).
Epidermolysis bullosa
Is a set of hereditary diseases that result in defective components of collagen and other proteins of
the basement membrane zone.

The five recognized types are:

◼ epidermolysis bullosa simplex,
◼ epidermolysis bullosa simplex with muscular dystrophy,
◼ epidermolysis bullosa atrophicans generalisata graves,
◼ epidermolysis bullosa dominant dystrophic/hypertrophic form,
◼ scarring epidermolysis bullosa with dermolytic vesicles.
Pathology: They are all characterized by subepithelial bullae, which initially show little inflammation.
Precise diagnosis requires electron microscopy and immunofluorescence mapping.