Solitary Oral Ulcers

Presented By

Harsh S Shah

Definition

bull Ulcer has been defined as a deeper crater that extends through the entire thickness of surface epithelium and involves the underlying connective tissue

Parts of an ulcer

Margin Margin is the border or transitional zone of skin around an ulcer

EdgeEdge is the mode of union between the floor and the margin of ulcer

FloorFloor of ulcer is the exposed surface of the ulcer we look for

Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]

bull Inflamed margin (red irregular margin with inflamed surrounding skin)

bull Fibrosed margin (thickened white)

Types of edges

bull Sloping edge rarr healing ulcer

bull Punched edge rarr trophic ulcer syphilic

bull Undermined edge rarr tuberculous ulcer

bull Everted edgerarr malignant ulcer

bull Raised edge rarr rodent ulcer

ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle

InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS

Bacterialbull Tuberculosisbull Syphilisbull ANUG

Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Definition

bull Ulcer has been defined as a deeper crater that extends through the entire thickness of surface epithelium and involves the underlying connective tissue

Parts of an ulcer

Margin Margin is the border or transitional zone of skin around an ulcer

EdgeEdge is the mode of union between the floor and the margin of ulcer

FloorFloor of ulcer is the exposed surface of the ulcer we look for

Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]

bull Inflamed margin (red irregular margin with inflamed surrounding skin)

bull Fibrosed margin (thickened white)

Types of edges

bull Sloping edge rarr healing ulcer

bull Punched edge rarr trophic ulcer syphilic

bull Undermined edge rarr tuberculous ulcer

bull Everted edgerarr malignant ulcer

bull Raised edge rarr rodent ulcer

ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle

InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS

Bacterialbull Tuberculosisbull Syphilisbull ANUG

Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Parts of an ulcer

Margin Margin is the border or transitional zone of skin around an ulcer

EdgeEdge is the mode of union between the floor and the margin of ulcer

FloorFloor of ulcer is the exposed surface of the ulcer we look for

Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]

bull Inflamed margin (red irregular margin with inflamed surrounding skin)

bull Fibrosed margin (thickened white)

Types of edges

bull Sloping edge rarr healing ulcer

bull Punched edge rarr trophic ulcer syphilic

bull Undermined edge rarr tuberculous ulcer

bull Everted edgerarr malignant ulcer

bull Raised edge rarr rodent ulcer

ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle

InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS

Bacterialbull Tuberculosisbull Syphilisbull ANUG

Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Types of margins bull Healing margin [white (outer) ndash blue (central) ndash red (Inner)]

bull Inflamed margin (red irregular margin with inflamed surrounding skin)

bull Fibrosed margin (thickened white)

Types of edges

bull Sloping edge rarr healing ulcer

bull Punched edge rarr trophic ulcer syphilic

bull Undermined edge rarr tuberculous ulcer

bull Everted edgerarr malignant ulcer

bull Raised edge rarr rodent ulcer

ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle

InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS

Bacterialbull Tuberculosisbull Syphilisbull ANUG

Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

ClassificationACCORDING TO ETIOLOGYLocal Traumabull Trauma due to sharp and malposed teethbull Trauma due to restorationbull Trauma from injecting needle

InfectionsViralbull Herpes Simplexbull Herpes Zosterbull Chicken Poxbull Small Poxbull Measlesbull Hand foot mouth diseasebull Herpanginabull AIDS

Bacterialbull Tuberculosisbull Syphilisbull ANUG

Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Bacterialbull Tuberculosisbull Syphilisbull ANUG

Fungal Infectionbull Candidiasisbull Histoplasmosisbull Blastomycosis

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Allergybull Local ( Stomatitis Venenata)bull Systemic ( Stomatitis medicamentosa)

Neoplasticbull Squamous cell carcinomabull Mucoepidermoid carcinomabull Basal cell carcinomabull Melanomabull Malignant Lymphoma

SystemicBlood disorderbull Agranulocytosisbull Cyclic Neutropeniabull Leukemia

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Traumatic Ulcer

bull Most common oral ulcer

bull Caused by Mechanical Chemical amp Thermal

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Etiology

bull Repeated trauma from tooth brushing

bull Drugs ndash Narcotic drugs

bull Denture induced

bull Self-inflicted in decerebrate and comatose patients

bull Placement of fixed acrylic tongue stent

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Features

bull Tender in the area of lesion

bull Borders Raised and reddish

bull Base Yellowish white necrotic that can be easily removed

bull Ulcer on vermilion border of lip ndash crusted surface because of absence of saliva

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Management

bull Heals in 10 days

bull Fluocinonide (005 ) or triamcinolone (01 ) acetonide in a emollient base before bedtime

bull Base protects the denuded tissue from contamination and corticosteroid therapy tends to arrest inflammatory cycle

bull Oral Bandage materials Hydroxypropylmethylcellulose also promote healing

bull Chlorhexidine mouthrinse

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

RECURRENT ORAL ULCERS

Recurrent Aphthous Ulcer

RIHS Recurrent intraoral herpes simplex

Major Aphthous ulcer

Herpetiform Aphthae

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Comparison of Clinical Features

RAU RIHS

LocationNonkeratinized mucosa Keratinized Mucosa

Initial Lesion Erythematous macule or papule followed by necrosis and ulceration

Cluster of small discrete vesicleswithout red erythematous halo Vesicles rupture to form smallpunctate ulcers

Mature lesion Shallow ulcer with yellow necrotic centerSmooth border and red halo

Shallow ulcer but many in number and border is scalloped

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Recurrent Aphthous Ulcer

Minor RAU Most common RAU Etiology bull Mononuclear peripheral blood cells target and

destroy oral epithelial cells that posses class I and class II major histocompatibility complex antigens

bull After this the oral mucosa permits additional local factors to come into play

bull Cause of destruction of epithelium increase in leukocyte TNF

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Mononuclear

peripheral

blood cells

Destruction of oral

epithelium (which contains

MHC ndash I and MHC ndash II for

immune response)

This permits entry of local factors

into the oral mucosa

Cause of destruction of epithelium Increase in leukocyte and TNF ndashα count

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Minor RAU

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Management

1 Heals in 7 ndash 10 days

2 Placement of tetracycline solution or a 012

Chlorhexidine solution by cotton applicator to

dried lesion covered by oral banadage

3 Oral Bandage Cyanoacrylate Benzocaine

(Orabase) or hydroxypropyl cellulose (Zilactin)

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Recurrent Intraoral Herpes Simplexbull After primary infection HSV enters a latent

stage and later becomes reactivated by various stimulae and recur as a vesiculoulcerative lesion on the skin perioraltissue and oral mucosa

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull Herpetic Whitlow is an occupational disease of practising dentists and dental workers

bull This may be contracted while working on a patient with the herpetic lesion

bull Lesions of finger are recurrent and may spread to whole hand

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Diagnostic Difficulties

bull Viruses are shed quickly after vesicles rupture HSV can be cultured from intact vesicles and cytologic smears from freshly ruptured vesicles show typical MNG cells

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Atypical RIHS Lesion

bull RIHS of gingival papilla

bull Persistent infection of gingival papilla

bull Persistent enlarged ulcers

bull RIHS in immuno-incompetence

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Major RAU

bull Also known as Suttonrsquos disease or Periadenitismucosa necrotica recurrens

bull Much larger than the minor type upto 2cm

bull Quite deep and very painful and persist for months

bull Heal with formation of scar

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Treatment modalities

bull Excision with primary closure

bull Cryosurgery

bull Topical application of tetracycline followed by cortisone (1 hydrocortisone) ointment

bull Injection of corticosteroid directly into the lesion alone or with prednisolone

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Treatment by Cryosurgery

(a) Major recurrent aphthous ulceration on the right border of the tongue (b) intralesional injection of corticosteroids (c) partial regression of the lesions was achieved one week after the administration of

intralesional corticosteroids (d) the major recurrent aphthous ulceration was resolved and no recurrence was

observed after four weeks treatment with levamisole

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Herpetiform Aphthaebull More common in female patients and cause is

unknown

bull Many small painful punctate ulcers over the mucosal surfaces sometimes in clusters

bull Management by mouthrinse only

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Behcetrsquos Syndrome

bull Oral ulcers

bull Recurrent ulcers of genital region

bull Ocular lesions including conjunctvitis retinitis and uveitis

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Ulcer from Odontogenic Infectionsbull The ulcer may serve as cloacal opening of sinus

draining a chronic alveolar abscess or ulcer may be the site of a superficial space abscess that has spontaneously ruptured

bull Ulcer generally occurs on alveolar ridge on buccalor lingual surface near the mucobuccal fold and rarely on palate

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Sloughing Pseudomembranous ulcers

bull Crushing type of traumatic ulcers

bull Acute necrotizing ulcerative gingivitis (Interdental papillae)

bull Candidiasis

bull Gangrenous Stomatitis

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Squamous Cell Carcinoma

bull Most common persistent ulcer in the oral cavity or on the lips

bull Patient is usually unaware as the ulcer is painless

bull Craterlike lesion having a velvety base and a rolled indurated border

bull Intraoral ulcer is usually devoid of the necrotic material and is situated in the highrisk Oval

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull This region includes the lower lip floor of the mouth ventral and lateral borders of the tongue retromlar areas tonsillar pillars and lateral soft palate

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull The base and borders are firm on palpation When deep infiltration occurs and tumor is on ldquomovablerdquo mucosa mucosa becomes fixed to deeper structures

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Syphilitic Ulcer

bull Veneral disease caused by motile spirochete Treponema Pallidum

bull Primary Lesion ndash Chancre (solitary)

bull Secondary lesions ndash numerous macules papules condylomas or combinations

bull Tertiary lesions ndash Gumma and interstitial glossitis

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Chancrebull Develop 3 weeks after inoculation and may

persist upto 2 months

bull Primary oral lesion occurs most often on the lips on tip of the tongue in tonsillar region or on the gingivae ndash commencing as macules and papules and then ulcerate

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull Mature chancre measure from 05-2cm and have narrow copper coloured slightly raised borders with reddish brown base or center

bull Chancre is extremely contagious

bull Management Systemic Penicillin from the early days

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Gumma

bull Occur in midline of the palate or tongue starting as small firm nodular masses and often growing to several centimeters

bull Necrosis commences within the nodules and produces ulceration in the surface epithelium

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Occasionally necrosis is destructive causing perforation of palate and formation of persistent oronasal fistula

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Ulcer secondary to systemic disease

bull Uncontrolled Diabetesbull Uremiabull Blood Dyscrasias ( Pancytopenia Leukemia

Neuropenia sickle cell anemia)

bull The ulcers are tender usually demarcated and shallow with a narrow erythematous halo and yellowish necrotic material

bull A painful regional cervical lymphadenitis is almost invariably present

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull In SCA ulcers form in regions of chemical infarcts caused by plugging of small blood cells by sickle cell thrombi

bull Such ulcers are usually painless and frequently involve marginal gingiva and interdentalpapillae

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull Chronic Renal Failure manifests as uremic stomatitis (Fetid odor)

bull Oral manifestations persist usually for 2 to 3 weeks and may heal spontaneously with resolution

of underlying uremia and lowering of blood urea nitrogen (BUN) levels

bull Hydrogen peroxide mouth rinses can contribute to the elimination of anaerobic bacteria

producing ammonia to neutralize ammonia and the condition of acidosis Additional treatment

may include vitamin supplements antiseptic mouthwashes and antimicrobialantifungal agents

against microbial or fungal infections

Uremic Stomatitis

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Some Chronic oral ulcerDiagnosis Clinical features

Drug-induced ulcersSingle isolated ulcers located on the side of the tongue surrounded by an erythematous halo and resistant to usual treatments

Erosive lichen planusAreas of atrophy erosions or painful ulcers generally resistant to conventional treatments

Pemphigus vulgarisBullae appear in oral cavity (posterior region) forming painful ulcers with necrotic fundus and erythematous halo

Mucous membrane pemphigoidSpontaneous onset of bullae that readily rupture giving rise to a highly painful ulcerated area (most common areas are palate and gingiva)

Lupus erythematosusErythema and oral ulcers without induration and accompanied by whitish striae and a tendency to bleeding

Reiters syndromeArthritis urethritis conjunctivitis and oral ulcers similar to those of recurrent aphtous stomatitis

Tuberculosis

Primary tuberculosis deep irregular persistent and painful ulcer on the tongue with rolled border and granulation tissue in the fundusSecondary tuberculosis chronic ulcer painful and indurated

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Erosive Lichen Planus Mucous membrane pemphigoid

Tuberculous ulcer Pemphigus Vulgaris

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Management of pemphigus vulgaris1 High doses of systemic corticosteroids

(1-2mgkgdl)2 Adjuvant therapy adjuvant drugs are

immunosuppressie drugs likemycophenolate mofetil azathioprine cyclophosphamide and cyclophosphamide pulse therapy

3 Prednisolone tablets4Dapsone5 Recalcitrant cases are treated rituximab

Paraneoplastic pemphigus PNPP - multiorgan disease with

underlying neoplasmCastleman disease and Waldenstrom

macroglobulinemia are associated with PNPP

Oral lesions ulcers amp erythemaHemoorhagic crusts on lips are characteristic

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Erythema Multiformebull It is an acute self-limited inflammatory mucocutaneus disease that

manifests on skin and often oral mucosa

bull It represents a hypersensitivity reaction to infectious agents (HSV mycoplasma and Chlamydia pneumonia) or medications (NSAIDS anticonvulsants)

bull Classic skin lesions lsquotargetrsquo or lsquoirisrsquo lesions

bull Ulceration and crusting is common in lip and ulcers on oral mucosa

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Histoplasmosis

bull Most common fungal disease caused by organism Histoplasma Capsulatum

bull Three forms

bull Acute Histoplasmosis

bull Chronic Histoplasmosis

bull Disseminated Histoplasmosis

bull Most oral lesions of histoplasmosis occur with the disseminated form of the disease

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull Solitary variably painful ulcerations of several weeks duration

bull Margins Firm rolled margins

bull Clinically it may be confused with malignancy

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Drug induced ulcers

bull Single isolated ulcers located on the side of the tongue surrounded by an erythematoushalo and resistant to usual treatments

bull widespread mucositis and ulceration mainly caused by cytotoxic drugs used for anti-tumorchemotherapy

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

bull cytotoxic drugs include 5-fluorouracil methotrexate bleomycin and cisplatin

bull NSAIDs are popular drugs that are well-known to induce oral ulcerations

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Leukemic ulcer

1 Etiology of these ulcers in Acute Myeloid Leukemia mainly acute monocytic (M5)

acute myelomonocytic (M4) and acute myelocytic (M1 M2) leukemias Oral lesions

may be the presenting feature of acute leukemias and are therefore important

diagnostic indicators of the disease

2 Most signs and symptoms of AML are caused by the replacement of normal bloodcells

with leukemic cells

3 Oral cavity usually is involved as part of a widespread disease however oral ulcers

can be the first presentation of the disease which can lead physicians to make exact

diagnosis

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Differential Diagnosis

bull Short Term Ulcers (Shallow and not raised)

bull Persistent Ulcers (Extensive borders and bases)

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Differential list of Short term Ulcers

Differential list of Short term Ulcers

Traumatic Ulcer

RAU RIHS and herpetiform ulcers

Ulcer as a result of odontogenic infection

Ulcer occuring as a herald disease of generalized mucositis or vesiculobullous disease

Ulcer secondary to noninfectious systemic disease

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Differential List of Persistent UlcerDifferential List of Persistent Ulcer

Traumatic ulcer

Ulcer from odontogenic infection

Major aphthous ulcer

Squamous cell carcinoma

Ulcer secondary to systemic disease

Ulcer in HIV disease

Traumatized tumour that does not ulcerate

Low grade mucoepidermoid tumor

Metastatic tumor

Keratoacanthoma

Necrotizing sialometaplasia

Systemic mycosis

Chancre

Gumma

Other rarities

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Necrotizing Sialometaplasia Keratoacanthoma

Mycosis HIV Ulcer

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Management

bull Amphotericin B is indicated ( More potent )

bull Daily Itraconazole for 6-18 months ( Less potent indicated in nonimmuno-compromised patients )

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

RARITIESbull Actinomycosisbull Adenoid squamous cell

carcinoma bull Animal diseases bull Basal cell carcinoma bull Botryomycosis hominisbull Cancrum orisbull Child abuse bull Contact allergy bull Crohns disease bull Eosinophilic ulcer bull Foot-and-mouth

disease bull Fungal infections

bull Aspergillosis bull blastomycosis bull coccidioidomycosis bull cryptococcosis bull histoplasmosis bull paracoccidioidomycosisbull sporotrichosisbull Gastrointestinal disease bull Glycogen storage disease bull Gonococcal stomatitisbull Graft-versus-host disease bull Granuloma inguinalebull Granulomatous disease of the

newborn bull Hand-foot-and-mouth disease

bull Helminthic infection bull Herpanginabull Herpes zoster infection bull Leishmaniasis Leukemiabull Lymphoma bull Median rhomboid glossitis-

ulcerative variety bull Metastatic tumorbull Neurotrophic ulcer bull Phycomycosisbull Self-mutilation wounds bull Waldenstrtims

macroglobulinemiabull Warty dyskeratoma

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Conclusion

bull Ulcerations seen in the oral cavity should never be diagnosed without a proper medical history of the patient

bull Ulcer are diagnostic for many of the diseases which are asymptomatic before they attain lethal stages

bull Proper clinicopathological investigation may help in avoiding these lethal diseases

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources

Referencesbull ndash Norman K Wood Paul W Goaz Solitary oral ulcers and

fissures Textbook of Differential Diagnosis in oral medicie and Radiology

bull Oral ulcerations due to drug medications Yoshinori Jimbu Toshio Dimitsu

bull Siegel RD Granich R Letter to editor Oral Surgery 764061993

bull J Indian Soc Periodontol 2009 Sep-Dec 13(3) 157ndash159

doi 1041030972-124X60230 PMCID PMC2848788 Oral

histoplasmosis Karthikeya Patil V G Mahima and R M

Prathibha Rani

bull Regression of Major Recurrent Aphthous Ulcerations Using a Combination of Intralesional Corticosteroids and Levamisole A Case Report Bruna Lavinas Sayed Picciani Geraldo Oliveira Silva-Junior Davi Silva Barbirato Ruth Tramontani Ramos and Marilia Heffer Cantisano

bull Web Sources