Oral ulceration

ORAL

ULERATION

Thilanka Umesh Sugathadasa

Thilanka Umesh Sugathadasa Page 1

ORAL ULCERATION

Main causes

1. Mechanical/ Chemical 2. Infections 3. RAU 4. Hematological 5. GIT causes 6. Mucocutaneous 7. Drugs 8. Endocrine 9. Malignancies 10. Others

RAU

Small, round or ovoid ulcers which have circumscribe margins, Erythematous haloes & yellow or grey floor.

Predisposing factors

1. Genetic predisposition

2. Hematinic deficiencies(Folate/ Vit B12/ Iron)

3. Drugs causes malabsorption of folic

4. Crohn’s disease - Histamine H2 receptor antagonists (cimetidine/omeprazole) can also impede vitamin B12

absorption.

5. Cessation of smoking.

6. Stress

7. Trauma from biting.

8. Sodium lauryl sulphate – Detergent in some tooth pastes.

9. Allergies

10. Endocrine factors – fall in progesterone level/ Contraceptive pills.

Aphthous like ulcers

1. Immune deficiencies. – HIV , Cyclic Neutropenia

2. Behcet’s syndrome – With genital ulceration & uveitis.

3. MAGIC syndrome – Behcet disease variant.

4. Sweet syndrome – Conjunctivitis, Episcleritis, Inflamed skin papules or nodules

5. Periodic fever, Aphthous stomatitis, Pharyngitis, Cervical adenitis syndrome (PFAPA)

6. Drugs

Ix

1. Hb

2. Serum Ferritin / Total Iron binding capacity

3. Serum Vit B12/ Folate


Mx

1. Correcting deficiency

2. Stress Reduction

3. Avoid allergens

So as supportive therapy

1. 0.2% Chlorhexidine mouthwash / Benzydamine mouthwash

2. Tetracycline Mouthwash(250mg capsule) if want add Nystatin

3. 5% Amlexanox paste

4. 0.2% Hyaluronic acid

Gastrointestinal Causes

Disease Other Oral Manifestation Clinical Features DD & Mx

Crohn’s disease

Inflammatory disease of unknown cause.

Heterogeneous group of disorders caused by commensal bacteria in people with genetically determined deregulations of mucosal T lymphocytes.

Inflammation mediated by TNF.

Sub mucosal Chronic inflammation

Non caseating granuloma in sub mucosa

Ulcers(Linear ulcers)

Facial / Labial swellings.

Mucosal tags

Cobblestone proliferation of mucosa (Irregular swellings with fibrosis in between)

Angular cheilitis

Melkerson Rosenthal syndrome* & Cheilitis granulomatosa may be incomplete manifestation of CD

Common in Iliocecal junction but can affect any part

Ulceration/ Fissuring/ Fibrosis

Weight loss

Internal/ External fistula

Perianal fissures

Abscesses

Renal damage

NSAID should avoid.

Antibiotics which could aggravate diarrheal situations must avoid.( co-amoxiclave, Clindamycin)

Mx may complicated by Steroids or Malabsorption.

Features Minor Major Herpetiform

Size 1-2mm >1cm Initially 2mm then coalesce

Site Mostly non-keratinize parts. Mainly anterior mouth.

Any site including keratinized posterior parts.

Same as Minor

No of ulcers 1-5 1-3 10-100

Sex F M F

Healing Within 2 weeks 1-3 Months Within 2 weeks


Ulcerative Colitis

Inflammatory bowel disease.

Affecting part or whole large intestine, frequently lower colon & rectum.

Cause inflammation & ulcers in superficial layers of large intestine mucosa followed by pseudo polyp formation.

Diarrhea with mucus +blood +pus

Pain, fever, anorexia

Extra abdominal signs are minimal

Commonest complication is Iron deficiency anaemia.

Skin lesions present like Erythema nodosum.

Carcinoma

Oral manifestations are rare.

Chronic ulceration can be occur. (Polystomatitis gangrenosum)

Polystomatitis vegetans (Multiple intraepithelial micro abscesses)

Lesions related to anaemia.

Antibiotics & NSAIDS should be avoided.

Oro-facial granulomatosis

Non- caseating granulomatous inflammation affecting soft tissues of oral & maxillofacial region

Two types- -Melkerson Rosenthal Syndrome -Cheilitis Granulomatosa (Swelling restricted to lips, Recurrent & persistent lip swelling in the absence of any other systemic disease)

Non tender recurrent labial swelling that eventually become persistent.

Lip hypertrophy

Initially soft then become firm due to fibrosis.

Recurrent facial swelling(Chin/ Cheeks/ Periorbital region) Intraorally may see hypertrophy/ Erythema/Non-specific erosions/ ulcerations on mucosa or tongue. Relapses are common though long term treatment is needed.

D/D

Angioedema

Sarcoidosis

Crohn’s disease

Infections (TB/Leprosy/ Deep fungal infection)

Amyloidosis

Minor Salivary gland tumor. Mx

Local/ Systemic corticosteroids or both

Intra lesional injection or Triamcinolone.

Local side effects- hypopigmentation & skin atrophy.

Systemic not using mostly due to side effects.

Coeliac disease Gluten sensitivity causes villous atrophy in the mucosa of small intestine.

*Melkerson Rosenthal Syndrome – Facial swelling

Facial palsy 3F

Fissured tongue

Difference between Crohn’s disease & Ulcerative colitis

Features CD UC

Site(Main) Ileum Colo- Rectum

Other sites Any part/ Skin lesion Terminal ileum

Iron deficiency Common Common

Fistula/ Abscess Possible Rare

Colonic cancer risk Present High


Pathology Transmural Inflammation Superficial inflammation

Abdominal pain Prominent Not Prominent

Bloody diarrhoea Not prominent Prominent

Mucocutaneous Conditions

Condition Causes/Predisposing factors

Aetiopathogenesis & other factors

Clinical features D/D & Mx

Oral lychen planus (Inflammatory Autoimmune Type of disease)

Dental materials Amalgam Gold

Diseases grafts verses hosts Liver diseases HIV Hepatitis B Virus

Stress

Drugs NSAIDS Antihypertensives Antidiabetes Antimalarial Many others

Not a classic autoimmune disease. Bcos It not having specific Autoantibody.

Early changes are close to the basal epithelium

Then band like dense mononuclear inflammatory cell infiltrate (Mainly CD8+) appears in the upper lamina propria.

Cell death occurs(Apoptosis) due to TNF-α

Due to those things thickening of spinous cell layer(Acanthosis)

Then granular cell layer become hyperkeratosis or hyperorthokeratosis

That account for the clinical white lesions

Rete ridges take saw tooth appearance.

Can be Reticular Plaque like Papular Atrophic Erosive oral Bullous ulcers

Desquamative gingivitis occur due to gingiva involved by Atrophic or erosive LP

In Erosive Lychen Planus irregular/painful & yellowish slough occur

Typically posterior, buccal, Tongue, gingival mucosa

Skin lesions (Flexor surfaces)

Vulvo-vaginal lesions (Vulvo vaginal – gingival syndrome)

Mostly Burning Sensation present.

D/D 1. Lupus

erythematosus 2. Chronic ulcerative

stomatitis 3. Keratosis 4. Carcinoma 5. Lichenoid lesions

Mx

Not really necessary Remove causes Rx for the diseases. Mild LP Topical corticosteroids (Low potency hydrocortisone/ Triamcenalone acetanoid 0.1%) Moderate LP Topical cyclosporine Severe LP Systemic

Pemphigus (Potentially life threatening chronic autoimmune condition)

Fairly strong genetic predisposition

Mostly idiopathic may triggered by medications (Captopril)

Radiation

Surgery

Certain foods(Garlic)

Emotional stress.

Serum Autoantibodies mainly IgG.

Directed mainly against desmosomes in stratified squamous epithelium

Intercellular immune deposits are detectable intra- epithelially.

Antigen- Antibody response causes loss of cell- cell contacts (Acantholysis) & intraepithelial vesiculation. Pemphigus vulgaris is the commonest form Commonly in middle aged to elderly more common. Female predisposition present.

Mucosa of Mouth pharynx Larynx Esophagus Rectum Nose Ano genital region Conjunctiva Blisters/Erosions/Ulcers can see

Start by blister formation in oral mucosa & scalp. Blisters are soft & easily broken.

Mainly go for the systemic immunosuppression.

Before introducing corticosteroids we have to consider its complications also (Dehydration & secondary systemic infections.)

Refer to the Pulmonary specialist Detect


Pemphigus vulgaris is the most severe form of the pemphigus.

Nikolsky sign present(Spreading of the blister by pressure)

Erosions in the mouth irregular & initially red with whitish surround then yellowish slough form.

Mainly present in the soft palate & posterior hard palate, Buccal mucosa, Gingiva(Desquamative gingivitis)

paraneoplastic pemphigus

Gastroenterologists to detect possible esophageal involvement.

Systemically – Prednisolone 60mg/day

Pemphigoid (Chronic autoimmune disease- Vesiculobullous)

Drugs Furosemide Penicillamine

Genetic predisposition Sub epithelial vesiculobullous Disorders.

1. Pemphigoid variants

2. Dermatitis Herpetiformis

3. Acquired epidermolysis bullosa.

4. Toxic Epidermal Necrolysis.

5. Erythema Multiforme

6. Linear IgA disease 7. Chronic bullous

dermotosis in childrens

Auto antibodies & complement components are directed against BM (IgG mostly others & C3 less)

Autoantibodies are directed against hemidesmosomal components or components of the Lamina lucida.

Due to compliment mediated sequestration of leukocytes with resultant cytokines & enzymes release by leukocytes Detachment occur in the BM zone These immune deposits cause subepithelial split & blistering Eye – Blindness Genital Skin Laryngeal- stenosis These are rare.

Lesions- Oral mucosal pemphigoid - Bullous pemphigoid(Mainly in the skin) - Ocular pemphigoid (Conjunctivae)

Intact tense blisters can see some times like Angina bullosa hemorrhagica.

Nikolsky sign present.

Persistent irregular ulcer or erosions present after the blister burst.

Then covered with fibrinous yellowish slough & surrounded by inflammatory Erythema.

Though Resembles Erosive LP but without white lesions.

Scarring

Desquamative gingivitis in gingiva.

Mostly pts with mucous membrane pemphigoid having oral involvement only.

Systemic or topical steroids.

Ophthalmologist referral. Autoimmune blistering Mucocutaneous disorders are mainly two types.

1. Pemphigoid subset Autoantibodies are target the extracellular components that links epithelial BM components either to lower most epithelial cell layer or LP components

2. Pemphigus Subset Autoantibodies are target the extracellular components that link one epithelial cell to another.


Erythema Multiforme (Acute, often recurrent hypersensitive reaction) Mostly occur in younger adults. More common in Males.

Genetic predisposition

HSV

Drugs(Antimicrobials / Antihypertensives/NSAIDS / Anticonvulsants)

Also immune conditions such as Sarcoidosis , Hep B immunization, SLE, Graft versus host reactions, Polyarteritis nodosa.

Antigenic change induced by HSV or drug

Cytotoxic secretions by lymphocytes/ Macrophages/ Neutrophils.

Apoptosis of Keratinocytes.

Satellite cell necrosis

Sub & intraepithelial vesiculation Forms of EM

1. Minor EM – Affects only one site the mouth, skin or other mucosa Rashes are various but typically target or bullae lesions.

2. Major EM – (Steven- Johnson syndrome) Begins with 1-3 weeks after starting a new drugs. Present with flu like symptoms/ sore throat/ headache/ Arthralgia/ Myalgia Almost invariably involve the mucosa. Causes widespread lesions Eyes Genitals Pharynx

Larynx Oesophagus

3. HSV induced EM – Usually extremities.

4. Drug induced EM 5. TEN(Toxic epidermal

necrolysis) – Fatal very serious condition.

Can be vary in mild to severe life threatening condition. Oral lesions

Diffuse widespread macules that progress for the blister & ulcer mostly.

Lips become swollen, bleeding & crusted, cracked. Serosanguinous exudate mostly frm lips.

Lesions on the non-keratinized mucosa are more pronounced & anterior region

Recur mostly 25%

Periodicity of attacks varies from 10-20 days to years. But mostly 10-20 days.

Resolves after about 6 episodes. Skin Lesions

Mostly distal extremities, Extensor surfaces of arms/ legs/ Elbows/ Knees/ dorsum of the hands & feets.

Macules are symmetrical/ Round/ Erythematous / Pruritic or not

Target lesions are large annular(Ring shape) & well demarcated.

Diagnosis

Nickolsky sign present. Mx

Spontaneous healing.

No specific Rx

Supportive care

Increase oral hygiene.

Precipitating factors should remove.

Antivirals to HSV.

Epidermolysis bullosa(Inherited Mucocutaneous bullous disease)

Subtypes - Autosomal recessive non scarring letalis type - Autosomal recessive scarring dermolytic type.

Scarring follows may cause severe microstomia

Buccal sulcus get obliterated by scar tissues

Tongue become fixed

Tongue becomes depapillated. Oral hygiene is difficult as tooth brushing cause oral ulceration.


Dermatitis Herpetiformis(Gluten sensitivity skin disorder)

Associated with coeliac disease

Mostly males.

Clinically symmetrical papulovascular eruptions of extensor surfaces. Oral lesions are vesicles, erythematous, erosive similar to the pemphigoid or like Desquamative gingivitis.

Take gluten free diet.

Lupus Erythematous(Rare Autoimmune disease usually in Females. )

Genetic Predisposition

Drugs

Hormone

Viruses

2 types SLE – systemic condition Oral ulceration like DLE but usually more severe ulceration May associated with Sjogren syndrome Rarely TMJ arthritis occur. DLE(Discoid Lupus Erythematosus) – Mucocutaneous involvement Characterized by central erythema. White spot or papules present, Radiating white striae at margins & peripheral telangiectasia. It can ulcerate. Oral lesions can see 25% of times mostly buccal mucosa, Gingiva & lips.

DLE- Topical corticosteroids. Cryosurgery Excision of localized lesions.

SLE – Systemic corticosteroids.

Behcet syndrome

Foods(Pork/ walnuts)

Genetic predisposition D/D

1. Sweet syndrome 2. Erythema

multiforme 3. Pemphigoid 4. Pemphigus 5. Reiter’s syndrome 6. Ulcerative colitis 7. HSV 8. Syphilis 9. Lupus

Erythematosus 10. Mixed CT disease.

Triple symptoms present Apthous like ulceration Genital ulceration(Recurrent & painful) Eye disease

Necrotizing vasculitis also may can be seen.

20-30 years mostly men’s are affected.

CNS lesions are predominantly subtentorial

Skin lesions include Erythema Nodosum.

Involvement can be seen of joints, epididymis, heart, intestinal tract & vascular systems.

Diagnosis by Aphthous like ulcers + 2 or more following things -recurrent genital ulceration -Eye lesions -skin lesions & mainly using pathergy(A >2mm diameter erythematous nodule or pustule forming 24-48 hrs after sterile puncture of the forearm skin)

Mx – Topical Rx of RAU, Tetracycline mouthwash & topical cortico….


Reiter’s syndrome

This follows shigella infection of the gut.

Almost always affect mens & comprises arthritis, a non- gonococcal urethritis & eye lesions.

In mouth it causes painless, red patches which may be granular or vesicular with a scalloped white line surrounding them.

These are similar to be lesions of Erythema Migrans(Geographic tongue)

Mostly buccal mucosa & male genitalia can affect then erythema migrans like patches can ulcerate.

Sweet syndrome

Oral ulcers / Conjunctivitis / Episcleritis / Inflamed tender skin papules or nodules.

Viral Infections

Herpes simplex virus

Two types - Primary herpetic gingivostomatitis Secondary infections (Recurrent herpes)

Primary infection associated with widespread oral ulceration preceded by eruption of vesicles on all areas of the oral mucosa & gingiva.

Mostly accompanied with fever & often affects the children.

Secondary infection occurs when the virus that had remain dormant in the gasserion ganglion become activated causing limited ulceration either on the lips(Herpes labialis) or intraorally.

Varicella zoster virus

Produce chicken pox in the primary infections oral ulceration is very rare.

In the recurrent infections after it dormant in the trigeminal ganglion.

Blisters appears unilaterally on the skin/mucosa supplied by one or more branches of the trigeminal nerve

Ulcers are mostly unilateral

EBV Produce occasional oral ulceration as part of the systemic infection of infectious mononucleosis

Lesions having creamy exudates accompanied by palatal petechiae & sore throat.

Coxsackie A virus

Can cause oral ulceration & hand , foot , mouth disease or herpangina

Bacterial Infections

ANUG

Combination of anaerobic fusiform bacteria & spirochetes

Cause oral ulceration on the tips of the interdental papillae.

Sometimes spreading along the gingival margins.

Soreness/ Gingival bleeding / Halitosis present. D/D

Leukaemia

Herpetic gingivostomatitis. Mx

Local debridement.

Metronidazole accompanied by peroxide or perborate mouthwash.

TB

Mostly who suffer from pulmonary TB.

Occasionally the initial presentation.

Usually a solitary chronic stellate ulcer is found on dorsum of the tongue. Syphillis Spirochetes(Treponima Pallidum)

Primary syphilis Painless indurated ulcers known as chancre may be proceeded by papule or noduleon the lip or tongue. Heals spontaneously.

Secondary syphilis * Tertiary syphillis Snail track ulcers Ulcers in the tongue or palate known as the Gumma


Parasitic infections

Leishmania donovani

Indolent ulcer(Non healing persisting ulcer on the lips)

Hematological conditions

Either due to problems in the blood cells themselves(RBC /WBC) or problems in the blood forming tissues.

RBC disease

Classifications - Morphological

Normocytic Anaemia Microcytic Anaemia Hypochromic microcytic Anaemia

Macrocytic Anaemia

1. Acutely following blood loses mostly.

2. Chronic disease 3. Endocrine disorders

Hypopituitarism Hypothyroidism Hypoadrenalism

4. Hematological disorders Aplastic anaemias Some hemolytic anaemias

1. Anaemia of the chronic disease. Tuberculosis crohn’s disease RA SLE Here decrease release of the iron from the bone marrow to developing erythroblasts.

1. Iron deficiency anaemia 2. Chronic disease 3. Sideroblastic Anaemia 4. Thalassaemia

1. Megaloblastic anaemia Vit B12 deficiency Folic acid deficiency Other defects of DNA synthesis Myelodysplasia due to dyserythropoiesis

2. Non Megaloblastic Alcohol excess Liver disease Hypothyroidism Reticulocytosis

- Etiologically

Loss of blood Excessive destruction of RBC Impaired production

Inadequate production of mature RBC

1. Extracorpuscular causes Antibiotics lypomas Infections Chemicals

2. Intracorpuscular causes Hereditory – Disorders of glycolysis/Abnormalities in the RBC membrane. Acquired – Pb poisoning

1. Deficiency of RBC 2. Infiltration of bone marrow 3. Endocrine abnormalities 4. Chronic renal failure 5. Chronic inflammatory disease.

WBC disorders

Quantitative disorders Qualitative Disorders

Decrease in No - Granulocytopenia Agranulocytopenia Leukopenia Neutropenia – Familial/ Cyclic/ Chronic/ Hypoplastic/

1. Lazy leukocyte syndrome.

2. Chediack Higashi syndrome

3. Multiple myeloma


Primary splenic

Increase in No - Granulocytosis Neutrophelia Basophilic leukocytosis Eosinophilic leukocytosis Lymphocytosis Monocytosis

4. IM

5. Lymphoma

6. Leukemia

Platelet disorders

1. Idiopathic thrombocytopenic purpura

2. Secondary thrombocytopenic purpura

3. Thrombotic thrombocytopenic purpura.

4. Thrombocytosis

WBC disorders

Condition Causes Oral features Clinical features D/D & Mx

Granulocytopenia(Marked leukopenia with reduction/ absence of neutrophils Mild(1000-2000mm2) Moderate(500-1000mm2) Severe(<500) Agranulocytosis – No Neutrophiles

Idiosyncrasy – Sensitization to drugs such as Chlorempenicol

Deficiency- Vit B12 & folic

Diseases – SLE

Infections

Hemodialysis

Irradiation

Necrotizing ulceration in oral mucosa with foul sense.

Pain, excessive salivation & spontaneous oral bleeding

Most common sites are Gingivae, Palate, Tonsils, Pharynx

Rapid spread can see in the gingiva.

Common in elderly female.

Sudden or gradual onset.

Begins with sore throat, high fever & rigors.

Pale & Anaemic skin.

Rapidly advancing necrotic ulceration of throat & mouth.

Most of the times patients are dying with in 3-5 days due to toxemia & septicemia.

D/D 1. Leukemia 2. Cyclic neutropenia 3. wegner’s granulomatosis 4. ANUG 5. Necrotizing sialometaplasia 6. Erythema Multiforme.

Mx 1. Removing causative agents. 2. Transfusion 3. Antibiotics 4. Oral & Dental Mx

Cyclic Neutropenia (Characterized by peiriodic reduction in circulating neutrophils due to failure of stem cells of bone marrow)

Episodes 2-4 weeks 3-5 days 21 days

Severe gingivitis

Painful ragged ulcers with core like centre on lips, buccal mucosa

Heals with scarring.

Sore throat

Fever

Stomatitis

Lymphadenopathy

Headache

Arthritis


RBC disorders

Condition Causes Clinical features Oral manifestations

Iron deficiency anaemia(Normal iron intake should be 0.6mg/day) But in pregnancy 1-2mg/ day

Inadequate intake

Decrease absorption(Chelation/ gastrectomy/ Malabsorption).

Increase requirements.(Growing child/ pregnancy/ surgery)

Increase loss.- blood lose (Rapid-RTA/ chronic- hook warm disease/ increased menstruation) stages 1. Pre latent iron deficiency Body storage is reduced. But circulating HB & serum iron is normal. 2. Latent iron deficiency Body storage is exhausted & serum iron is reduced but HB is 3. Mild anaemia Serum iron is low & also circulating HB also reduced. 4.Marked anaemia HB is below 10g/dl

Brittle nails

Koilonychia (Spoon shaped nails)

Neuropathy (Tingling, pins & needle sensation in extremities)

Dysphasia

Tenderness & headache

Palpable spleen & liver

CVS- Angina, MI, Cardiac failure/ Cramps

Pallor oral mucosa.

Atrophy of oral mucosa then ulcerate.

Recurrent ulceration

Red/ atrophy of papillae of the tongue.

Burning sensation

Plummer – vinson or Peterson- Brown- Kelly syndrome(Dysphagia+ Glossitis)

Aplastic anaemia(Rare disorder characterized by pancytopenia- Anaemia / Leucocytopenia/ Thrombocytopenia) due to bone marrow suppression

Primary causes Congenital(Common in young adults)

Secondary causes Chemicals(Hg) Drugs(Carbamazepine/ Chlorampenicol) Infections(HIV/ Hepatitis) insectisides paroxysmal nocturnal hemoglobinuria Causes for Pancytopenia

Aplastic anaemia

Megaloblastic anaemia

Drugs

Bone marrow infiltration & replacement(Hodgkin’s & Non-Hodgkin’s lymphoma)

SLE

Weakness

Pallor

Breathlessness

Headache

Anginal pain

Bleeding from various sites

Fever

Recurrent infections IX

RBC/WBC/ Platelete decrease

Decrease reticulocytes

Prolong BT with normal CT because clotting factors are not affected.

Normocytic Anaemia

Pallor mucosa

Spontaneous gingival bleeding

Petechiae

Sub mucosal ecchymosis

Large ragged ulcers covered by grey necrotic membrane Mx

Withdrawal of etiological agents

Supportive therapy

Stimulate haemopoiesis by androgens.

Bone marrow transplantation.

Leukemia

Impairment of normal haemopoisis resulting Anemia, granulocytopenia & Thrombocytopenia.

Neoplastic proliferation of WBC in bone marrow, circulating blood & sometimes in other organs likes spleen & liver.


Causes

1. Viruses(EBV/HTLM)

2. Radiation

3. Chemical Agent

4. Anticancer drugs

5. Genetic & chromosomal factors

6. Immunological deficiency syndrome

Classification

Acute Chronic

ALL L1- Primarily pediatric L2- Primarily adult L3- Burkitt’s

AML M1-Without maturation M2-With maturation M3-Promyelocytic M4-Myelomonocytic M5-Monocytic M6-Erythroleukemia M7-Megakaryocytic

CLL

CML

Condition Clinical features & others Oral manifestations

ALL

Mostly males

Childrens & young adults

Sudden onset of fever+ splenomegaly

Weakness/ Headache

Generalized Lymphadenopathy

Petechiae

Hemorrhage in to skin & mucosa

Bone pain & tenderness

Anaemic & thrombocytopenic features

Increase susceptibility to infections

Paresthesia of lower lip

Cervical lymphadenopathy

Toothache due to infiltration of leukemic cells in to dental pulp

Pallor mucosa with ulceration & necrosis

Gingival hyperplasia with cyanotic discolouration.

CLL Over 45 years

Anaemia

Thrombocytopenia

Moderate enlargement of lymph nodes

Skin nodule

Increase susceptibility to infection.

Gingival hypertrophy with ulceration, Necrosis & gangrenous degeneration giving very foul smell

Swollen dark tongue

Regional lymphadenopathy

Rapid loosening of teeth due to periodontal breakdowns.

Multiple myeloma

Malignant neoplasm of plasma cells of bone marrow with involvement of skeletal system Commonly seen in the males.

Pain/ swelling & numbness in the jaws

Epulis formation & Mobility of teeth

Ulcerated Intraoral swellings & gingival bleeding

Oral amyloidosis & high susceptibility to oral infections


Traumatic ulcers

Peripheral keratotic border present. If cause is persist Hyperkeratosis or hyperplasia may occur.

Malignant lesions

1. SCC

2. Salivary gland

3. Kaposi sarcoma

4. Malignant melanoma – rarely

Drugs

1. NSAIDS

2. Drugs causing Neutropenia- Cotrimoxazole

Endocrine conditions

1. DM

2. Glucogonoma

Chemical

1. Nelli burns

2. Aspirin Burns

Thermal

Radiation

Others

1. Eosinophilic ulcers

2. Angina bullosa hemorrhagica.

3. Necrotizing sialometaplasia


RAU

herpetiform

minor

Major

Crohn’s


Melkerson Rosenthal syndrome

Cheilitis granulomatosa (or granulomatous cheilitis) is a chronic swelling of the lip due to granulomatous inflammation.

Miescher cheilitis is the term used when the granulomatous changes are confined to the lip. Miescher cheilitis is

generally regarded as a monosymptomatic form of the Melkersson-Rosenthal syndrome

Labial swelling and angular cheilitis

OFG


LP

Erythema Multiforme


Steven – Johnson syndrome

Pemphigus

Pemphigoid Angina bullosa hemorrhagica


SLE DLE

Geographic tongue Primary herpetic gingivostomatitis

Traumatic ulcers TB ulcer

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Primary herpetic gingivostomatitis: erythema and multiple ulcers on the gingiva.

Primary herpetic gingivostomatitis: multiple ulcers on the tongue.

Secondary herpetic stomatitis: small round ulcers on the palate

Herpes zoster: clusters of vesicles on the palate.

Herpes zoster: vesicles and erosions on the lower gingiva

Herpangina: numerous shallow ulcers on the soft palate.


Erythema multiforme: multiple erosions on the lips and tongue.

Erythema multiforme: typical target- or iris-like lesions of the skin.

Stevens–Johnson syndrome: severe erosions on the lips, tongue, and the nose in an 8-year-old boy.

Stevens–Johnson syndrome: genital lesions.

Toxic epidermal necrolysis: severe erosions covered by hemorrhagic crusting

on the lips.

Pemphigus vulgaris: hemorrhagic cluster of bullae on the buccal mucosa


Pemphigus vulgaris: erosions on the dorsum of the tongue.

Pemphigus vulgaris: severe lesions of the skin of the face.

Cicatricial pemphigoid: erosions on the buccosal mucosa.

Bullous pemphigoid: bullae on the buccal mucosa.

Bullous pemphigoid: skin lesions.

Pemphigoid gestationis, multiple small bullae on the skin.


Pemphigoid gestationis, hemorrhagic bullae on the soft palate.

Linear IgA disease: erosion on the tongue, covered by a whitish

pseudomembrane

Linear IgA disease: early gingival lesions.

Dermatitis herpetiformis: intact bulla on the lower lip mucosa and small erosions on the gingiva

Lichen planus of the buccal mucosa: bullous form.

Epidermolysis bullosa simplex: hemorrhagic bulla on the buccal mucosa.


Epidermolysis bullosa, recessive dystrophic form: bulla and scarring on the tongue.

Epidermolysis bullosa, skin scarring.

Epidermolysis bullosa, dystrophic: severe scarring and dystrophy of the

hands.

Epidermolysis bullosa acquisita, hemorrhagic bulla on the buccal mucosa.

Angina bullosa hemorrhagica, multiple hemorrhagic bullae on the buccal

mucosa.

Traumatic ulcer of the tongue.


Traumatic ulcer of the tongue.

Eosinophilic ulcer on the lower lip and the commissure.

Necrotizing sialadenometaplasia: two ulcers on the palate

Necrotizing sialadenometaplasia on the palate.

Severe necrotizing gingivitis in a 32-year-old HIV-seropositive homosexual man .

Necrotizing gingivitis and stomatitis in a 30-year-old man with AIDS. Note the extensive soft-tissue necrosis beyond the gingiva.


Chronic ulcerative stomatitis, gingival lesions in the form of desquamative gingivitis.

Chronic ulcerative stomatitis, erosions on the buccal mucosa identical to lichen planus .

Noma, early necrotic ulcer of the lower lip.

Solitary chancre on the ventral surface of the tongue.

Condylomata lata on the palate.

Tuberculosis: typical ulcer on the dorsal surface of the tongue.


Cryptococcosis, abnormal ulceration on the tongue.

Aspergillosis, black necrotic ulceration on the palate.

Mucormycosis, black necrotic lesion on the upper lip.

Minor aphthous ulcer.

Major aphthous ulcer on the lower lip.


Multiple herpetiform ulcers on the tongue.

Behçet disease: multiple ulcers on the labia majora.

Behçet disease: major aphthous ulcer on the buccal mucosa.

Behçet syndrome: conjunctivitis and iritis.

Graft-versus-host disease: superficial ulceration on the buccal mucosa.

Wegener granulomatosis: large ulcer surrounded by an erythematous zone

on the tongue.


Malignant granuloma: nonhealing ulcer and necrosis on the palate.

Early squamous-cell carcinoma of the lateral border of the tongue.

Non-Hodgkin lymphoma: large ulcer on the soft palate.

quamous-cell carcinoma presenting as exophytic ulcerated tumor of the

lateral border of the tongue.

Cyclic neutropenia: ulcer on the labial mucosa.

Cyclic neutropenia: localized gingivitis.


Agranulocytosis: ulcer on the tongue.

Agranulocytosis: severe periodontal destruction.

Myelodysplastic syndrome: persistent ulcerations on the upper lip.

Chronic lymphocytic leukemia: ulcer on the palate.

Acute myelocytic leukemia, ulcers on the tongue.

Chronic lymphocytic leukemia: severe gingival enlargement and ulcerations.


Langerhans cell histiocytosis, ulcer on the palate.

Langerhans cell histiocytosis, gingival enlargement and periodontitis.

FAPA syndrome, major aphthous ulcer on the soft palate.

Sweet syndrome: vesiculobullous lesions and edema of the fingers.

Sweet syndrome, major aphthous-like ulcers on the lipmucosa.

Staphylococcal infection, necrotic ulcer of the tongue.


Ulcerative conditions

Traumatic ulcer

Eosinophilic ulcer

Necrotizing sialadenometaplasia

Necrotizing ulcerative gingivitis

Necrotizing ulcerative stomatitis

Chronic ulcerative stomatitis

Noma

Syphilis

Tuberculosis

Systemic mycoses

Recurrent aphthous ulcers

Behçet disease

Graft-versus-host disease

Wegener granulomatosis

Malignant granuloma

Non-Hodgkin lymphoma

Squamous-cell carcinoma

Cyclic neutropenia

Agranulocytosis

Myelic aplasia

Myelodysplastic syndrome

Leukemias

Langerhans cell histiocytosis

Glycogen storage disease,

FAPA syndrome

Sweet syndrome

Staphylococcal infection

Congenital neutropenia

Cytomegalovirus infection



Mechanical / Chemical

Ulcers

Mucocutaneous

LP

GIT Hematological

Drugs Endocrine RAU Infections Malignancy others




Oral ulceration

Education

cause inflammation ulcers

behcets syndrome

ovoid ulcers

oral ulceration main

sweet syndrome conjunctivitis

mucosal chronic inflammation

clindamycin mx

iron deficiency anaemia