ULCERATIVE CONDITONS

By NAVARRA, NICOLAS, OCLIASO, OLMEDO,

ONG, PABLO

Transmitted most often through sexual

contact with an infected person

Other transmission is through body

fluids and childbirth

Reactive Lesions
Traumatic Ulcerations

Most common kind of ulcer in the

mouth

Break in the mucosa with a shallow

base and non-raised margins

May be diffuse or localized

Aspirin: the most common drug that

can cause ulceration

Sloughing is usually due to chemical

burns

Remove the cause for the treatment

Clean the area with sterile saline

solution

The "clap" or "drip

Symptoms
1. Greenish yellow or whitish
discharge from the vagina
2. Lower abdominal or pelvic pain
3. Burning when urinating
4. Conjunctivitis (red, itchy eyes)
5. Bleeding between periods
6. Spotting after intercourse
7. Swelling of the vulva (vulvitis)
8. Burning in the throat (due to oral
sex)
9. Swollen glands in the throat (due to
oral sex)

Tuverculosis

Caused by aerobic, nonspore-forming

bacillus
A. M. tuberculosis: air-borne
droplets

Bacterial Infections

B. M. bovis: transmitted via

infected milk of cows

Syphilis

Treponema pallidum.

C. M. avium

Stages of syphilis

D. M. intracellulare

1. Primary: presence of sores which

are hard and painless; occurs in
genitals or around the mouth after
10-90 days exposure; the sore will
heal after 6 weeks
2. Secondary: duration is 1-3 months
that begins within 6 months after
exposure; usually with a rosy
copper penny rash on palms and
sole also moist warts, white
patches and weight loss.
3. Latent: the infection is dormant
4. Tertiary: affects the heart, brain
and nerves.
Gonorrhea

Neisseria gonorrhoeae

Ability to resist degradation by

macrophages and to the development
of a type Iv hypersensitivity reaction
(Mantoux and tine skin test)

Reacts to Ziehl-Neelsen and Fite

technique (acid-fast bacilli)

Implantation of organisms found in

sputum or hematogenous deposition

Indurated, chronic, nonhealing ulcers

that are usually painful; bony
involvement (tuberculous
osteomyelitits)

Granulomtous inflammation showing

caseous necross

Leprosy

Severe, disfiguring skin sores and

nerve damage in the arms and legs.

Aka. Cancrum oris/gangrenous

stomatitis

Mycobacterium leprae; Hansen's

disease

Affects malnourished children (noma

neonatorum: low birth-weight infants)

Fusobacterium necrophorum

The skin sores and pales.

Main symptoms: skin sore, lumps or

bumps

Painful gingival ulcerations (gingival,

buccal), denudation of bone,
exfoliaton of loose teeth, fetid necrotic
lesions

Types

Fluids, electrolytes, general nutrition,

antibiotics

1. Tuberculoid: mild leprosy; one or

a few patches of flat, pale-colored
skin (paucibacillary leprosy);
affected area may feel numb
because of nerve damage; less
contagious than other forms
2. Lepromatous: severe form of the
disease with widespread skin
bumps and rashes (multibacillary
leprosy); numbness, and muscle
weakness; the nose, kidneys,
and male reproductive organs may
also be affected; more contagious
3. Borderline: have symptoms of
both the tuberculoid and
lepromatous forms.
Actinomycosis

Actionomyces israelii, part of the

normal flora in the nose and throat.

Usually triggered by DENTAL ABSCESS

or ORAL SURGERY also by IUD

Lumpy jaw

Symptoms
1. Draining sores in the skin,
especially on the chest wall from
lung infection with Actinomyces
2. Fever
3. Minimal or no pain
4. Swelling or a hard, red to reddishpurple lump on the face or upper
neck
5. Weight loss

Noma

Antibiotics and surgical drainage and

removal of the IUD.

Fungal Infections
Deep Fungal Diseases

Indurated, nonhealing, frequently

painful, chronic ulcer

Usually following implantation of

organism from the lungs

Cause:
1. Histoplasma capsulatum
2. Coccidioidesi immites

Treatment: antifungal drugs

Subcutaneous Fungal Infection:

Sporotrichosis

Sporothrix schenkii

Inoculation of the skin/mucosa by

contaminated soil or thorny plants

Nonspecific chronic ulcers

Granulomatous central abscess,

pseydoepitheliomatous hyperplasia

Solution of potassium iodide,

ketoconazole

Opportunistic Fungal Infection

Infection caused by pathogens,

particularly opportunistic pathogens.

Those that take advantage of certain

situationssuch as bacterial, viral,
fungal or protozoan infections that

usually do not cause disease in a

healthy host, one with a healthy
immune system.

Occurs in compromised host

Necrotic, nonhealing ulcers

Cause:
1. Mucormycosis
2. Rhizopus

Treatment: depends on the type of

opportunistic infection, but usually
involves different antibiotics.

Immunologic Diseases

Behcets Syndrome

Unknown etiology; can be due to

immunodysfunction and genetic
predisposition (prominence of HLAB51)

Ulcers identical to that of aphthous

stomatitis

Magic syndrome <mouth and genital

ulcers with inflamed cartilage>
(Behcets stigmata + recurrent
polychondritis), recurrent arthritis

Prominent T-lymphocytes, PMN

infiltrate in the vessel walls

Immunosuppressive drugs
(chlorambucil, azathioprine)

Aphthous Ulcers

Aka Canker Sores

Recurrent, painful ulcers found on

nonkeratinized oral mucosa (tongue,
vestibular mucosa, floor of the mouth
and facial pillars.)

They are not found on skin, vermillion,

attached gingiva or hard palate.

Usually round or oval

Etiology:
1. May probably an immune defect
mediated by T-cells
2. Precipitated by emotional stress
3. Trauma on oral tissues
4. Diet
5. Hormones

Reiters Syndrome

A triad of nonspecific urethritis,

conjunctivitis, and arthritis

Follows bacterial dysentery or

exposure to a sexually transmissible
disease

Male with HLA-B27 has a 20% risk for

Reiter's disease after an episode of
Shigella dysentery

Acute onset

Occurs predominantly in white men in

their third decade

Oral Manifestations

3 types:

1. Minor:
Most common type
Usually solitary
<0.5 cm in diameter
May heal 1-2 weeks
2. Major:
Very painful; severe
>0.5 cm in diameter
May take several weeks to heal
3. Herpetiform:
Multiple
Recurrent crops of ulcers
Treatment:
1. Tetracycline
2. Corticosteroids

1. Painless aphthous-type ulcers

2. Seen anywhere in the mouth
3. Tongue lesions resemble
geographic tongue

Duration varies from weeks to months,

and recurrences are not uncommon

NSAIDS are generally used as a

treatment

Drug Reactions

Pathogenesis may be related to either

immunologic or nonimmunologic
mechanisms

Allergy

Non-immunologic
Overdose, toxicity, side
effects

Patch testing and history taking may

be helpful for diagnosis.

Biopsy findings may be confirmatory.

Not AB dependent

Treatment:

Clinical Features

1. Elimination of offending
material
2. Topical steroids may hasten the
healing process

Erythema Multiforme

Oral Manifestations
1. Erythematous, vesicular, or
ulcerative
2. Lichenoid drug reactions mimic
erosive lichen planus

Treatment: identification and

withdrawal of the causative agent

Contact with foreign antigen

Toothpaste
Cinnamon
Mouthwash
Denture base material

1. Changes appear rapidly

2. Urticaria, maculopapular rash,
erythema, vesicles, ulcers
3. Acquired angioedema IgEmediated allergic reactions caused
by drugs or foods like nuts and
shellfish
4. Hereditary angioedema rare
autosomal dominant trait with the
deficiency of the first component of
complement C1 esterease
5. Appears as soft, diffuse, painless
swelling (lips, face, neck)

Etiology:
1.
2.
3.
4.
5.

Immunologic

Antihistamines and
corticosteroids for the
management of oral and
cutaneous eruptions

Contact Allergy

Lesions due to direct contact with

foreign antigen.

Erythema, vesicles and ulcers may be

seen

Primarily affects the attached gingiva

as bright red in color

Self-limiting
o

Minor form: HSV trigger (HSV

type I and II), TB,
Histoplasmosis

Major severe form: caused by

systemic drugs (barbiturates,
sulfonamides, carbamazepine,
phenytoin)

A few aphthous-type lesions to

multiple superficial widespread ulcers
in EM major

Stevens-Johnson syndrome: crusting

of lips, superficial ulceration preceded
by bullae

Epithelial hyperplasia and spongiosis,

parabasal apoptotic keratinocytes

Differential diagnosis: Primary HSV

infection, aphthous ulcers, pemphigus
vulgaris, mucous membrane
pemphigoid, erosive lichen planus

Topical corticosteroids with

antifungals, acyclovic (HSV-triggered
disease)

Wegeners Granulomatosis

A rare, serious, systemic,

inflammatory condition of an unknown
etiology

May be inherited or acquired

Oral ulcers with periodicity

Involvement of upper respiratory tract,

lung, and kidney

Infections

Intraoral lesions consist of red,

hyperplastic, granular lesions on the
attached gingiva

1. Adenopathy
2. Periodontal disease

Cause: mutations in neutrophil

elastase gene

Treatment: no ideal therapy for

neutropenia, but recombinant G-CSF
(granulocyte-colony stimulating factor)
such as filgrastim (Neupogen) can be
effective in chemotherapy patients.

Midline Granuloma

A diagnosis made by exclusion of

other granulomatous and necrotizing
midfacial lesions

Unifocal destructive process

Seen in the midline of the oronasal

region

Aggressive necrotic ulcers, progressive

and nonhealing

May extend to soft tissue, cartilage,

and bone

May be treated with local radiation

Chronic Granulomatous Disease

Rare sytemic (X-linked or autosomal

recessive) disease
Defects in the nicotinamide adenine
dinucleotide phosphate (NADPH)
oxidase complex which alters
neutrophils and macrophages function

Manifestations seen during childhood,

more prevalent in males

May affect many organs

Oral lesions are seen in the form of

multiple ulcers that are recurrent or
persistent

Cyclic Neutropenia

Rare blood disorder characterized by

recurrent episodes of abnormally low
levels of neutrophils in the body.

Neoplasms
Maxillary Sinus Carcinoma

Uncommon

Exposure to wood dust

People working in nickel and chrome

industries are more prone; people
working in leather industries

Symptoms of sinusitis or referred pain

to teeth

May cause malocclusion or mobile

teeth

May appear as ulcerative mass in

palate or alveolus.

Treatment:
1.
2.
3.
4.

Surgery
Radiotherapy
Chemotherapy
Combined management
modality

Squamous Cell Carcinoma

Etiology:
1. Tobacco smoking
2. Reverse smoking habit in
India and South American
countries

3. Alcohol adds to risk of oral

cancer
4. Candida albicans carcinogen
N-nitrosobenzylmethylamine
5. UV light
6. Chronic irritation, poor oral
hygiene

Loss of cell cycle control

through increased proliferation
and reduced apoptosis

Increased tumor cell motility

Carcinoma of the Lips

Carcinoma of the Tongue

Most common intraoral
malignancy, 25-40%
Common in men in their 6th, 7th
and 8th decades
Lingual carcinoma
1. Asymptomatic
2. later stages: pain and/or
dysphagia
Presents in one of four ways:
1. Indurated, nonhealing
ulcer
2. Red lesion
3. White lesion
4. Red and white lesion
May be endophytic or exophytic
Posterior-lateral border most
common location; 45% of all
tongue lesions
Posterior 1/3 or base of tongue
25% of lesions

Carcinoma of the Floor of the Mouth

Second most common intraoral
location; 15-20% of all cases
Painless, nonhealing, indurated
ulcer
White or red patch
Infiltrates floor of mouth,
causing decreased tongue
mobility
Metastasis to submandibular
lymph nodes

Pathogenesis: 2 stages

More common in lower lip than

upper lip
Account for 25-30% of all oral
cancers
50-70 years of age; affect men
more often than women
Arise on the vermillion as a
chronic, nonhealing lesion that
is verrucous in nature
Metastasis to submental or
submandibular lymph nodes
with larger lesions

Metastatic deposits are usually

found in the lymph nodes of the
neck, ipsilateral side

Carcinoma of the Buccal Mucosa and

Gingiva
Account for 10% of oral
squamous cell carcinomas
Varies from a white patch to a
nonhealing ulcer to an
exophytic lesion
Verrucous carcinoma broadbased, wart-like mass
Rarely metastasizes

Carcinoma of the Palate

Common occurrence at the soft
palate (10-20%), rare at the
hard palate
Asymptomatic red or white
plaques
Ulcerated keratotic mass
Histopathology
o Spindle-cell carcinoma
(sarcomatoid carcinoma)
o Appears as proliferation
of spindle cells mistaken
as sarcoma
o Verrucous carcinoma
Well-differentiated
epithelial cells that
appear more
hyperplastic than
neoplastic
Key feature:
invasive nature of
the lesion in the
form of broad,
pushing margins

Basaloid-squamous
carcinoma

Basaloid pattern of
tumor cells is seen
adjacent to tumor
cells that exhibit
squamous
differentiation

Has a predilection
for the base of the
tongue and the
pharynx

Treatment
1. Simple excision
2. Curettage and
electrodessication
3. Radiation therapy
4. Cryosurgery
5. For advanced cancer:
A. lymph node dissection
B. Systemic chemotherapy