ORAL ULCERS Part 1

1. ORAL ULCERSPart 1 Dept of Oral Medicine & Radiology Yenepoya Dental College

2. What is Ulcer ? A BREAK IN THE CONTINUITY OF THE COVERING EPITHELIUM – SKIN OR MUCOSA ( A. K. DAS ) A DEFICIT IN THE EPITHELIUM; A WELL CIRCUM- SCRIBED DEPRESSED LESION OVER WHICH THE EPITHELIAL LAYER HAS BEEN LOST ( BURKETT) A DEEP CRATER THAT EXTENDS THROUGH THE ENTIRE SURFACE EPITHELIUM & INVOLVES THE UNDERLYING CONNECTIVE TISSUE ( WOOD & GOAZ )

3. Classification GENERALIZED Contact stomatitis Rad Mucositis Cancer chemo CHRONIC Aids Neoplasia Gumme Syphilis TB Actinomycosis ACUTE Trauma RAS Behcets Herpes Herpangina DERMATOLOGIC EM LP MMP Pemphigus

4. GENRAL SURGERY: A.K.. DAS

5. BURKETT’S ORAL MEDICINE

6. Acc to rapidity of onset Acute ANUG, RAU Chronic Varicose ulcer Acc to nature of onset Primary Traumatic Secondary Herpetic Acc to number Solitary Traumatic Multiple  Herpetiform Acc to specificity Specific  TB Non specific Diabetic Acc to duration Short term< 3week Resistant  > 3week Acc to etiology ULCERS OF THE ORAL CAVITY

7. Trauma Physical Chemical Thermal Radiation Infection Bacterial Viral Fungal Immune dysfunction RAU, Behcets, Wegeners granulomatosis, AID’s Dermatologic diseases Pemphigus, Pemphigoid, Steven jhonsons syndrome, LP Neoplasm SCC, Rodent ulcer Miscellaneous Pyogenic granuloma, D M Acc to etiology

8. CLINICAL GRID PRIMARY & SECONDARY

9. Trauma: Sharp teeth or restorations Appliances Non-accidental injury Self-inflicted Iatrogenic Burns: Heat Cold Chemical Radiation Electric MAIN CAUSES OF ORAL ULCERS I. LOCAL CAUSES:

10. II . DRUGS: • Cytotoxics • NSAID’S • Nicorandil • Others III . RECURENT APTHOUS STOMATITIS: IV . MALIGNANT ULCERS:

11. V . SYSTEMIC DISEASES: Microbial diseases Mucocutaneous diseases Blood disorders GIT diseases Rheumatic diseases Endocrine disorders Disorders of uncertain pathogenesis

12. HISTORY • Onset & Duration • Pain • Aggravating factors • Relieving factors • Prodromal syndromes • Recurrence H/O medication, Radiotherapy, Chemotherapy Gastric-, Joint-, Skin-, Eye- or Renal- problems, Associated ulcers: Genital-, dermal-, ophthalmic ulcers

13. CLINICAL EXAMINATION • SITE, SIZE & SHAPE • NUMBER • POSITION • EDGE • DEPTH • FLOOR • DISCHARGE • BASE • TENDERNESS • SURROUDING TISSUES • BLEEDING • INDURATION • CRUSTING • PSUEDOMEMBRANE INSPECTION PALPATION

14. EXAMINATION OF THE LYMPH NODE

15. Examination of Ulcer • Edge • Floor • Base

17. Edge • Undermined  Tuberculosis ulcers • Punched out  Gummatous ulcers • Sloping  Healing traumatic ulcers • Raised out  Rodent ulcers • Rolled out  Sq Cell Ca

18. Undermined Punched out Sloping

19. Raised out Rolled out

20. Floor • Red granulation tissue • Pale & smooth granulation tissue • Wash leather slough • Bone EXPOSED SURFACE OF THE ULCER

21. Base ON WHICH THE ULCER RESTS PALPATION Thumb & Index Finger INDURATION & HARDNESS  Sq Cell Ca

22. INVESTIGATIONS • Biopsy • Blood Examination • Culture and antibacterial sensitivity testing • Tzanck test • Viral cultures • Immunofluorescence tests • Darkfield examination for syphilis • Endoscopy • Imaging

23. HISTOLOGIC PITFALL • LOSS OF EPITHELIUM – WITH NECROTIC • & FIBRINOUS C.T. • ACUTE – PMNL INFILTRATION • CHRONIC – LYMPHOCYTES , PLASMA CELLS, • MACROPHAGES & FIBROBLASTS • HEALING – GRANULATION TISSUE WITH FEW • MACROPHAGES, PLASMACELLS AND • LYMPHOCYTES

24. PROVISIONAL DIAGNOSIS & DIFFERENTIAL DIAGNOSIS • Many times history and examination alone • Sometimes investigations mandatory FINAL DIAGNOSIS • BASED ON: • INVESTIGATION RESULTS CORRELATED • WITH PROVISIONAL DIAGNOSIS

25. TREATMENT SYMPTOMATIC DEFINITIVE MEDICAL SURGICAL

26. Treat the underlying cause. • Remove aetiological factors. • Ensure any possible traumatic element is removed • Prescribe a chlorhexidine 0.2% aqueous mouthwash. • Maintain good oral hygiene. • Topical corticosteroids • Patients should not eat or drink for 30 minutes after using the steroid,in order to prolong contact with the lesion. • Adverse effects are important mainly with systemic steroids.

27. MANAGEMENT CONDITION DIAGNOSTIC TEST TREATMENT minor aphthous clinical steroid ointment, Aphthasol major aphthous biopsy as needed, hematology if severe steroid ointment or elixir, systemic/injection steroid HSV clinical, cytology, culture, serology oral acyclovir, topical pencyclovir erythema multiforme clinical, HSV IgG for recurrence oral steroid, oral acyclovir if HSV+ erosive lichen planus biopsy topical or oral steroid, DMDs pemphigus biopsy, DIF, IIF oral steroid, DMDs pemphigoid biopsy, DIF topical or oral steroid, dapsone malignancy biopsy surgery, irradiation infection biopsy, culture antimicrobial as indicated Back

28. Topical Steroid Ointments (apply t.i.d.) ultra-high potency clobetasol 0.05% high potency Fluocinonide 0.05%halcinonide 0.01% moderate potency triamcinolone 0.5%betamethasone dipropionate 0.05% low potency triamcinolone 0.01%betamethasone valerate 0.01%

29. ANTIFUNGAL Candidal: Mucosal: Topical clotrimazole Severe; Ketoconazole (400 mg PO qd) / fluconazole (100 mg PO qd) Histoplasmosis and Blastomycosis: Ketoconazole (400 mg PO qd)6 – 12 months Severe – Amphotersin B IV 10 weeks Mucormycosis: Surgical debridement with systemic Amphoteresin B

30. ODONTOGENIC INFECTIONS Can produce intra oral or extra oral ulcers

31. TRAUMATIC • Shallow base • Nonraised margins • Diffuse or localized • Painful • Sloughed base TRAUMATIC • Cheek or tongue bite, • Ill-fitting denture, • Trauma from a foreign • object or a toothbrush

32. SCC

33. Oral cancer

34. Radiation induced

35. RADIATION INDUCED Radiotherapy-inducedulceration (mucositis): 2 weeks; > 50 Gy Superficial ulcers in the path of radiotherapy

36. RAU MINOR MAJOR

37. HERPIS INFECTION

38. CHEMOTHERAPY INDUCED ULCERATION Cytotoxicity induced ulcers: these have a non-specific appearance,but are widespread and very painful