EXAMINATION OF

ULCER

Guided by:
Dr. Munish
Kumar
Dr.Ravi Narula

Presented by:
Amritveer Kaur

An ulcer is the break in the continuity of

covering epithelium-skin or mucous
membrane

Follow the molecular death of the

covering epithelium or its traumatic
removal

S .DAS

PARTS OF ULCER

Margin
Edge
Floor
Base

S .DAS

CLASSIFICATION OF
ULCERS
TWO TYPES OF CLASSIFICATON OF ULCERS IS POSSIBLE:1.

CLINICAL:

2.

PATHOLOGICAL

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Callous/ Chronic

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Arterial, Traumatic,

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HISTORY

Mode of onset
Duration
Pain
Discharge
Associated disease

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1) Mode of onset

How ulcer developed ??

Traumatic- Eg.dental ulcer of the tongue

Spontaneously- may develop following a

swelling which may be matted tuberculous
lymph node or gumma or a rapidly growing
malignant tumour ( malignant melanoma)

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Marjolins ulcer- on burn

scar

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2) DURATION

How long??

Acute ulcer,chronic ulcer

Incubation period-time interval between

exposure and the onset

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3) PAIN

IsInflammatory
the ulcer
painful??
ulcers

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4) DISCHARGE

Does the ulcer discharge or not??

Nature of discharge-serum, pus or blood

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5) ASSOCIATED DISEASE

Nervous diseases
Tuberculosis
Diabetes
syphillis

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LOCAL EXAMINATION

Inspection
Palpation
Lymph Nodes

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A ) Inspection

Size & Shape

Number
Position
Edge, Margin, Floor
Discharge
Surrounding area

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1. Size & Shape

Tuberculous

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2. Number

Tuberculous ,gummatous,varicose
ulcers and soft chancres may be more
than one in number

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3. Position
RODENT ULCERS

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Anywhere
Over
Where
subcutaneous
in the
bones such as

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4.EDGE

Area between the margin and the floor

An ulcer has a margin or edge which takes

characteristic shape in a particular form of
ulcer

Gives clue to the diagnosis of ulcer also to

the condition of ulcer

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TYPES OF EDGES

Undermined edges
Punched out edges
Sloping
Raised and pearly white beaded
Everted

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UNDERMINED EDGES

Mostly seen in tuberculosis

Subcutaneous tissue destroyed faster than
skin
Overlying skin is thin friable ,reddish blue
and unhealthy

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Undermining of edges

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PUNCHED OUT EDGE

Gummatus ulcer or in deep trophic ulcer

Edge drops down at right angles to skin
surface
Disease which causes the ulcer itself do not
tend to spread to the surrounding tissue

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Punched out ulcers as seen in

vasculitis

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SLOPING EDGE

Healing traumatic or venous ulcers

Reddish purple in color
Consists of new healthy epithelium

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Healing traumatic ulcer

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RAISED AND PEARLY WHITE

BEADED EDGE

Rodent ulcer
Develops in invasive cellular disease
and becomes necrotic at centre

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BCC WITH TYPICAL ROLLED

PEARLY WHITE EDGES

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ROLLED OUT EVERTED

EDGE
Squamous cell carcinoma or an ulcerated
adenocarcinoma
Caused by fast growing cellular disease ,
growing portion at the edge of ulcer heaps up
and spills over normal skin to produce an everted
edge

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SCC BUCCAL MUCOSA

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Healing ulcer- blue zone (growing

spreading ulcer- edge is
inflammed and oedematous epi) and a white zone (fibrosis)
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5.FLOOR

Exposed surface of the ulcer

When floor is covered with red granulation

tissue ulcer seems to be healthy and healing

Pale and smooth granulation tissue-slowely

healing ulcer

Wash leather slough-gummatous ulcer

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Trophic ulcer penetrates down even to the

bone-which forms the floor in that case

A black mass at the floor suggests malignat

melanoma

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A black mass at floor suggests malignant

melanoma
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6.Discharge

Character

Its amount and smell

Healing ulcer-scanty serous discharge

Spreading and inflammed ulcer-purulent discharge

Malignant ulcer-sero-sanguineous discharge

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7. Surrounding area

glossy ,red and oedematous Acutely

inflammed-

Scar or wrinkling old case of tuberculosis

Dark pigmentation & eczema varicose ulcer

Hypopigmentation non-healing ulcer

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B. PALPATION

Tenderness
Edge and margin
Base
Depth
Bleeding
Relations to deeper structures
Surrounding skin

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1. Tenderness
Acutely

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2. Edge and margin

Marked Induration-squamous cell

carcinoma

Slight induration- chronic ulcer

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3. Base

On which the ulcer rests

Better felt than seen

If an attempt is made to lift the ulcer between

the thumb and index finger, base will be felt

Slight induration at the base-chronic ulcer

Marked induration (hardness)-squamous cell
carcinoma

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Relations to deeper structures

Gummatous ulcer over subcutaneous

bone (tibia,sternum) often fixed
Malignant also fixed

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Surrounding skin

temperature & tenderness

Mobility
Fixity to deeper structure malignant lesion
For nerve lesion

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C.EXAMINATION OF LYMPH
NODES

Acute ulcers regional lymph nodes enlarged

tender

Tuberculous ulcers-enlarged ,matted ,slightly

tender

Malignant ulcers-stony hard and fixed

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SPECIAL
INVESTIGATIONS

Routine blood examination

Bacteriological examination of the
discharge
Chest X-Ray
Biopsy

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ORAL ULCERS

Erosion / Ulcer

Erosion shallow crater in the epithelial

surface , erythematous area, implies only
superficial damage

Ulcer deeper crater that extends trough the

entire thickness of the surface epithelium and
involves the underlying connective tissue
WOOD AND GOAZ

Oral ulcers may be divided into 2

groupsShort term (those that usually disappear
within 3 weeks)
Persistent (last longer than 3 weeks)

WOOD AND GOAZ

Differential list of short term

ulcers

Traumatic ulcer
Recurrent aphthous ulcers-minor
Recurrent intraoral herpes simplex
Ulcer occurring as a result of odontogenic
infection
Ulcers occurring as a result of
vesiculobullous diseases
Ulcers secondary to infectious diseases
WOOD AND GOAZ

Differential list of persistent

ulcers

Traumatic ulcer
Major aphthous ulcer
Squamous cell carcinoma
Ulcers in human immunodeficiency virus
disease
Low grade mucoepidermoid tumour
Systemic mucosis
Chancre
Gumma
WOOD AND GOAZ

Traumatic ulcer

Vary greatly in size

and shape

Seldom are multiple or

recurrent

On
tongue,lips,mucobucc
al fold,gingivae and
palate
WOOD AND GOAZ

Borders are raised and reddish

Bases may have yellowish white necrotic

surface that may be readily removed

Frequently tender or regional lymphadenitis

occurs as a result of contamination of the
ulcer by oral flora
WOOD AND GOAZ

Recurrent aphthous ulcer-minor

Shallow ulcer 0.5 to 2

cm in dia

Occur on movable
mucosa (non
keratinized) lips,
buccal mucosa,
tongue floor of mouth,
mucobuccal fold , soft
palate
WOOD AND GOAZ

Yellow necrotic
centre,smooth
contoured border,
red halo,symmetric
and circular

Lesions occur singly

, occasionally two or
three and are widely
distributed
WOOD AND GOAZ

Recurrent intra oral herpes

simplex
Shallow ulcer,not
more than 0.5 cm in
dia with red
halo,number of
vesicles may occur in
tight clusters,rupture
to form lager ulcer
upto 1.5 cm in dia
Sclloped border

WOOD AND GOAZ

Lesion occurs on fixed mucosa , it is

tightly bound to periosteum (keratinized)
hard palate, gingivae, alveolar ridge

Lesion often returns to same location

WOOD AND GOAZ

Major aphthous ulcer

Severe form of the
minor RAU
Usually single or at the
most there are three
Larger than 2 cm,deep
very painful occur in
the posterior of the
mouth
Heal with scar
formation

WOOD AND GOAZ

Syphillis

Primary(chancre)-

Develop approximately 3
weeks after inoculation

single, indurated
nonpainful ulcer at the
site of sprirochete entry,
spontaneously heals in
4-6 weeks.
WOOD AND GOAZ

Oral lesions occur most often on lips, tip of

tongue or gingiva

Measures 0.5 to 2 cm in dia,shallow ,oval or

round in shape, have a narrow copper colored
slightly raised borders with reddish brown base
or centre

regional lymph nodes are enlarged, firm

discrete and painless

WOOD AND GOAZ

Secondarymaculopapular rash on
skin

oral ulcers covered

by mucous
membrane(mucous
patches)

WOOD AND GOAZ

Snail track ulcers-multiple small

,rounded superficial erosions which
coalesce to form narrow curved shallow
ulcers

Lymph nodes enlarged and painless

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3 Stage- gumma
Occur most often In palate
or tongue starting at small
firm nodular masses

Necrosis commences
within nodules and
produces ulceration of
surface epi

Necrotic tissue at the base

of ulcer sloughs awaypunched out lesion is seen
WOOD AND GOAZ

T.B

Oval in shape with

irregular cresentric border
Often multile

Slightly Indurated, chronic

ulcer that may be painfulon any mucosal surface

Reddish blue Undermined

edges

WOOD AND GOAZ

Ulcers from odontogenic infections

In most cases of chronic alveolar abscess, ulcer is

seen on alveolar ridge on buccal or lingual surface
near mucobuccal fold, seldom on palate

Pressure on adjacent soft tissues causes pus to

exude from ulcer , Identifies the condition

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A gutta percha point may be

placed in the ulcer and
passed into the tract as far
as it will go without undue
force
radiograph is taken
If the point is seen to reach
the apex infected tooth
diagnosis is ensured
WOOD AND GOAZ

U
O
Y
K
THAN