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Clinical and Experimental Dermatology
Oral ulcers: clinical aspects. A tool for dermatologists. Part II. Chronic
ulcers
M. Mun˜oz-Corcuera, G. Esparza-Go´mez, M. A. Gonza´lez-Moles* and A. Bascones-Martı´nez*Stomatology epartment, ental Sc!ool, Complutense "n#$ers#ty o% Madr#d, Madr#d, Spa#n& and *epartment o% 'ral Med#c#ne and
(er#odont#cs, Complutense "n#$ers#ty o% Madr#d, Madr#d, Spa#n
do#)+../0-11+.1++2.+12.3
Summary Oral ulcers are generally painful lesions that are related to various conditions developing ithin the oralcavity. !hey can "e classified as acute or chronic according to their presentation and
progression. Acute oral ulcers are "e associated ith conditions such as trauma# recurrent
aphthous stomatitis# $ehc%et&s disease# "acterial and viral infections# allergic reactions or adverse drug reactions. Chronic oral ulcers are associated ith conditions such as oral
lichen planus# pemphigus vulgaris# mucosal pemphigoid# lupus erythematosus# mycosis
and some "acterial and parasitic diseases. !he correct differential diagnosis is necessary to
esta"lish the appropriate treatment# ta'ing into account all the possi"le causes of ulcers in
the oral cavity. In this second part of this to(part revie# chronic oral ulcers are revieed.
1++2 4!e Aut!or5s6
70/ 8ournal comp#lat#on 1++2 Br#t#s! Assoc#at#on o% ermatolog#sts ) Cl#n#cal and E3per#mental ermatology, 7, 70/97/
Cl#n#cal dermatology ) :e$#e; art#cle
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4a@le Chronic oral ulcers.
#agnos#s Cl#n#cal %eatures
rug-#nduced ulcers S#ngle, #solated ulcers, located on t!e s#de o% t!e tongue, surrounded @y aneryt!ematous !alo and res#stant to usual treatments
Eros#$e l#c!en planus Areas o% atrop!y, eros#ons or pa#n%ul ulcers, generally res#stant to con$ent#onaltreatments
(emp!#gus $ulgar#s Bullae appear #n oral ca$#ty 5poster#or reg#on6, %orm#ng pa#n%ul ulcers ;#t! necrot#c%undus and eryt!ematous !alo
Mucous mem@rane pemp!#go#d Spontaneous onset o% @ullae t!at read#ly rupture, g#$#ng r#se to a !#g!ly pa#n%ul ulceratedarea
5most common areas are palate and g#ng#$a6
upus eryt!ematosus Eryt!ema and oral ulcers, ;#t!out #ndurat#on and accompan#ed @y ;!#t#s! str#ae and atendency to @leed#ng
:e#terDs syndrome Art!r#t#s, uret!r#t#s, conunct#$#t#s and oral ulcers s#m#lar to t!ose o% recurrent ap!tousstomat#t#s
4u@erculos#s (r#mary tu@erculos#s) deep, #rregular, pers#stent and pa#n%ul ulcer on t!e tongue, ;#t!rolled @order and granulat#on t#ssue #n t!e %undus
Secondary tu@erculos#s) c!ron#c ulcer, pa#n%ul and #ndurated
Mycos#s Mycoses g#$e r#se to c!ron#c ulcers on t!e oral mucosa, most commonly #n#mmunocomprom#sed pat#ents
't!er @acter#al and paras#t#cd#seases
le@s#ella and e#s!man#a spp. can produce c!ron#c oral ulcers #n F
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Oral ulcers: clinical aspects ) ?. ?unBo+(Corcuera et al.
>#gure 1 ?ucous mem"rane pemphigoid: ulcer on the soft palate.
reveals the presence of Ig or Ig? and complement
fragments in intercellular spaces.,3#,4
Mucous mem@rane pemp!#go#d
!his group of immunological diseases mainly affects
mucosae# ith su"epithelial "ullae and deposits of
immunoglo"ulin # immunoglo"ulin A or complement
fraction C throughout the "asal mem"rane. ??P
occasionally involves the s'in# oral and ocular mucosa#
oesophagus# nasopharynx and larynx. Patients ith
??P produce anti"odies that attac' several autoantigens
of the mucosal or epidermal "asal mem"rane. !he most
common autoantigens are laminin(3# type I< collagen#
laminin(4# su"unit "/ of integrin# uncein# and "ullous
pemphigoid antigens , and -.,5
??P develops in the oral mucosa ith thespontaneous onset of "ullae that readily rupture# giving
rise to a very painful ulcerated area. !he most commonly
involved areas are the palate 0>ig. -1 and gingiva#
commonly in the form of chronic des@uamative
gingivitis.,5
upus eryt!ematosus
=upus erythematosus 0=E1 is an autoimmune disease of
the connective tissue that appears in to forms: systemic
=E and discoid =E. $oth forms give rise to oral features
similar to those of lichen planus# and they may precedeor follo the cutaneous features. Discoid lesions and
facial erythema in a "utterfly& pattern appear on the
s'in# and erythematous and ulcerated areas develop on
the oral mucosa# ithout induration and ith the onset of
hitish striae and a tendency to "leeding.,6#,7
:e#terDs syndrome
eiter&s syndrome is characteri+ed "y arthritis# urethritis#
conunctivitis and oral ulcers similar to those of recurrent
aphtous stomatitis., It is an uncommon disease# and the
main diagnostic criterion is a positive reaction for human
leucocyte antigen $-5.-8
4u@erculos#s
!u"erculosis 0!$1 is a chronic granulomatous infectiousdisease# mainly caused "y ?yco"acterium tu"erculosis#
hich has regained prevalence as a severe complication of
human immunodeficiency virus 0;I
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Oral ulcers: clinical aspects ) ?. ?unBo+(Corcuera et al.
cyotoxic ! cell(mediated attac' on "asal
'eratinocytes.
) Around 38H of cases of P< "egin in the oral
mucosa# and its aetiology is related to the action
of anti"odies against specific proteins
0desmogleins1 located in desmosomes.
) ??P mainly affects mucosae. Patients produce
anti"odies that attac' several autoantigens of the
mucosal or epidermal "asal mem"rane.) Fystemic and discoid =E can give rise to oral
features similar to those of =P# and they may
precede or follo cutaneous features.
) Oral lesions in !$ are rare# resulting from
primary !$ of the oral cavity or secondary to
active pulmonary !$.
) ?ycoses of the oral cavity 0excluding
candidiases1 give rise to chronic oral ulcers
mainly in immunocompromised patients. )
Eosinophilic ulcer of the oral mucosa is
uncommon# "enign# self(limiting and generally
asymptomatic. It may resem"le a malignantlesion# "ut a "iopsy ill exclude a malignant
tumour.
) All oral cancers can produce ulcers# and the
detection of this type of ulcer is important
"ecause the tumour has a good prognosis if it is
diagnosed at an early stage.
:e%erences
, $ascones A# =lanes >. ?edicina $ucal# -nd edn. ?adrid:
Avances ?eKdico(dentales# ,774: 7/# -/,3-. -
$ascones A# >iguero E# Espar+a C. Klceras orales. ?ed
Clin 0$arc1 -883 ,-3: 3785.
Porter F# =eao LC. evie article: oral ulcers and its relevance
to systemic disorders. Aliment Pharmacol !her -883 -,: -73
84.
/Espar+a(oKme+ C# =lamas(?artKMne+ F# $ascones ?artMKne+
A. =esiones con peKrdida de sustancia: uKlceras. In: !ratado de
?edicina Interna# ,st edn 0Pere+agua(Clamagirand C# ed1.
$arcelona: Ariel# -883 /83.
3>ield EA# Allan $. evie article: oral ulceration
aetiopathogenesis# clinical diagnosis and management in the
gastrointestinal clinic. Aliment Pharmacol !her -88 ,6: 7/7 4-.
4A"dollahi ?# adfar ?. A revie of drug(induced oral reactions.
L Contemp Dent Pract -88 /: ,8,.
5Fcully C# $agan Lenoll A.
Pemphigus vulgaris. A presentation of ,/ cases and revie of
the literature. ?ed Oral Patol Oral Cir $ucal -883 ,8:
-6-6.
,4 Da Filva G# ?andel =. Early manifestation of pemphigus
vulgaris. A case report. N Q Ftate Dent L -885 5: /-/.
,5 Parisi E# aghavendra F# erth eller =# Anagnostopoulos C# $ouc'aert ?# au"enheimer EL.
;I< 9 !$ co(infection: literature revie and report of multiple
tu"erculosis oral ulcers. FADL -883 48: 8-.
-/ Fe+er $# eytinoglu ?# !uncay # nal !. Oral mucosal
ulceration: a manifestation of previously undiagnosed
pulmonary tu"erculosis. L Am Dent Assoc -88/ ,3:
4/8.
-3 ?ehra"i ?# $agheri F# =eonard ?G Lr# Perciaccante
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