Download - Oral ulcers
Oral ulcers Diagnosis• A-Multiple ulcers:• 1-acute • 2- chronic
• B-recurrent ulcers
• C-single ulcer
Acute multiple ulcers
1 -1ry herpes simplex
Onset: after 6 months ,Peak within 2-3 yearsClinical features:1-Prodrome :1-2 days before appearance of local lesions fever ,headache ,lymphadenopathy, malaise ,vomiting)2-generalized acute marginal gingivitis3-multiple vesicles turn to painful, bilateral ulcers surrounded by erythtematous halo4-mainly keratinized gingiva5-mainly at anterior area of oral cavity
2-Herpangina By coxsackievirus A4Affect children from 3-10 years ,peak from June to October Clinical picture :1-prodrome ,milder than herpes simplex (fever ,anorexia ,malaise)
2-sore throat ,dysphagia
3-ulcers mainly at post .area of oral cavity (soft palate ,fauces ,tonsils ,posterior pharynx)4-ulcers smaller than herpes5 -at post area and more painful.6-no marginal gingivitis7 -mainly in epidemics
3-Hand- foot and mouth disease
Caused by coxsakievirus A16,from 8 months to 33 years ,75%under 4 years.Clinical picture:1-low grade fever2-oral vesicles and ulcers more extensive than herpes(mainly palate ,buccal mucosa)
3-macules and papules on extensor surface of hand and feet.4-examine hands and feet for maculopapular lesions and vesicles if there is acute stomatitis and fever
4-Chicken pox
1ry infection of varicella –zoster virus:Cutaneous lesions:Maculopapular lesion then turn to vesicles on erythematous baseOral lesions ,not diagnostic
5-Herpes zoster (shingles)Clinical picture:1-Prodrome: 2-4 days (shooting pain, paresthesia,burning sensation) along the course of the nerve2-unilateral vesicles on erythematous base ,appears as clusters along the course of the nerve.the most diagnostic manifestation is the unilateral appearance of lesions
6-Erythema multiformeAffects children and young aged
Rare after 50Clinical picture :No prodrome ,systemic and local
lesions appear together, with very rapid onset.
oral lesions 1 - bullae or vesicles on
erythematous base ,then rupture.
2-lesions orally are anywhere but lips are more prominent, and rare gingival involvement most diagnostic), where lips are extensively eroded and large portion are denuded of epithelium.
3-E.M lesions are large, irregular, deep and often bleeds and there are tissue remnants
• Cutaneous lesions:• -Appears on hands and
feet ,extensor surface.• -Macules ,papules ,vesicles, or
bullae• -target lesion or Iris lesion (central
bulla or pale surrounded by edema or erythema)
B-Chronic multiple ulcers
1-Pemphigus vulgaris• 1-Cutaneous lesions:• Thin walled bullae arising on
normal skin and mucosa.• Bullae breaks rapidly leaving
erosions and continuously spread peripherally.
• The mostly diagnostic manifestation:
• A -apply pressure to intact area leads to formation of new lesion (KOEBNER PHENOMENA)
• B -apply pressure to bullae extend peripherally
2-oral lesions:usually presents 4 month before
cutaneous lesions
Clinical manifestations: classical bulla on uninflammed area ,then rapidly breaks leaving irregular erosions and ulcers ,that extend peripherally.
-leaves denuded area
Mainly at buccal mucosa (N.B: E.M : mainly lips)
Differential diagnosis
1- Its chronic appearance differentiate it from (H.S, H.Z and E.M)
2-From R.A.S that its lesions are recurrent and heals rapidly, but pemphigous lesions extends peripherally and takes a period of weeks to months.
3-lesions of pemphigous are not small ,rounded and symmetrical like R.A.S and viral ulcers, and there is detached epithelium at the peripheries.
4-+ve nikolysks sign AND KOEBNER PHENOMENA
5-bullae extend peripherally
2-Mucous membrane pemphigoid
• Age over 50.• Mainly mucosal surfaces( oral
cavity)• Clinical manifestation:• 1-Desquamative gingivitis. • 2-vesicles that rupture leaving
erosions that spread peripherally more slowly and self limited than pemphigus.
• 3- +ve nikolyskis sign• 4- no cutaneous involvement.
C-recurrent oral ulcers
1-Recurrent aphthous stomatitis• Mostly begin during the 2nd
decade• Clinical picture:1-Prodrome :from 2-48 hrs before
ulcer appear burning sensation)2-Localized erythema then small
white papule then ulcerates3-not preceded by vesicles, uniform,
rounded ,painful covered by yellowish membrane and surrounded by erythematous halo about 10mm).
4-no tissue remnants on borders, (there are no vesicles.)
5-mainly on lining mucosa rare on keratinized mucosa
Minor
Major aphthous: (1- 5cm)Appears on keratinized and non
keratinized mucosa.• -Indurated base ,everted edges, very
painful and leave scar. • Takes more than a month to heal.
Herpetiform (least common)• Dozens or hundreds of ulcers about
1-2 mm,very painful surrounded by erythematous halo.
majormajor
herpetiform
2-Behcets disease• Between 20-40• Diagnosis: oral recurrent ulcers (minor
aphthae)at least 3 times within 12 months + 2 of the following
• A-recurrent genital ulcers• B-eye lesions: (uveitis,retinal
vasculitis , corneal inflammation)• C-skin lesions: maculoppapular
lesions,erythema nodosum (reddish ,painful, tender lumps )
• D-+ve pathergy test :cutaneous hyperactivity to intra-cutaneous injection, within 24 hrs) (appearance of small red bump or pustule)
Erythema nodosum
Pathergy test
3-Recurrent herpes simplex 1 -recurrent herpes labialis common
(cold sores, fever blisters(PPt. by
fever ,menstruation ,u.v,emotional stress
Clinical picture:Prodrome, tingling and burning
sensation then edema and clusters of vesicles at mucocutaneous junction and spread to skin ,then coalesce and weep exudate and then rupture and crust
2-recurrent intraoral herpes: vesicles turn to ulcers ,mainly keratinized mucosa (gingiva –hard palate)