ORAL ULCERS Part 2 D D of ULCERS

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ORAL ULCERS Part 2 D / D of ULCERS 1

ORAL ULCERS Part 2 D / D of ULCERS 1

DRUG - INDUCED 2

DRUG - INDUCED 2

CHEMOTHERAPY INDUCED ULCERATION Cytotoxicity induced ulcers: these have a non-specific appearance, but are widespread

CHEMOTHERAPY INDUCED ULCERATION Cytotoxicity induced ulcers: these have a non-specific appearance, but are widespread and very painful 3

Ulcer producing Cytotoxic agents – methotrexate Agents producing lichen-planus-like (lichenoid) lesions. NSAIDs, some antihypertensives,

Ulcer producing Cytotoxic agents – methotrexate Agents producing lichen-planus-like (lichenoid) lesions. NSAIDs, some antihypertensives, antidiabetics, antimalarials Agents causing local chemical burns(aspirin held in the mouth) Agents causing erythema multiforme(sulphonamides and barbiturates) 4

Patients receiving chemotherapy, with or without radiotherapy: Prevention of Mucositis: allopurinol for patients treated

Patients receiving chemotherapy, with or without radiotherapy: Prevention of Mucositis: allopurinol for patients treated with 5 FU cryotherapy for patients treated with 5 - FU Treatment of Mucositis symptoms topical dyclonine or lignocaine 5

INFECTIONS 6

INFECTIONS 6

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TUBERCULOSIS In HIV-infected people with active tuberculosis (TB), levels of HIV in the bloodstream

TUBERCULOSIS In HIV-infected people with active tuberculosis (TB), levels of HIV in the bloodstream --five- to 160 -fold Isoniazid and Rifampicin 8 Lupus vulgaris

“ PRIMARY SECONDRY TERTIARY SYPHILIS CONGENITAL ACQUIRED SMALL RED-BROWN MACULES PAPULES CONDYLOMA LATA 9

“ PRIMARY SECONDRY TERTIARY SYPHILIS CONGENITAL ACQUIRED SMALL RED-BROWN MACULES PAPULES CONDYLOMA LATA 9

patchy alopecia VDRL Test Snail-track” Procaine penicillin 1. 2 mega unit IM qd x

patchy alopecia VDRL Test Snail-track” Procaine penicillin 1. 2 mega unit IM qd x 10 days 10

GONNORRHEA Neisseria gonorrhoeae Attaches to oral or urogenital mucosa by fimbriae Females may be

GONNORRHEA Neisseria gonorrhoeae Attaches to oral or urogenital mucosa by fimbriae Females may be asymptomatic; males have painful urination and pus discharge Treatment with antibiotics Untreated may result in v Endocarditis v Meningitis v Arthritis 11

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VIRAL Acute onset Multiple lesions Systemic manifestations (malaise, fever, diarrhea, lymphadenpathy, lymphocytosis) often present

VIRAL Acute onset Multiple lesions Systemic manifestations (malaise, fever, diarrhea, lymphadenpathy, lymphocytosis) often present Vesicle stage present in all 13

HERPES Herpesvirus Infection: COLD SORES þ Primary Infection þ Vesicles- ulcers- crusting þ Anywhere

HERPES Herpesvirus Infection: COLD SORES þ Primary Infection þ Vesicles- ulcers- crusting þ Anywhere in the oral cavity small, grouped vesicles on erythematous bases, which then become pustules, umbilicate, and later crust larger and deeper – 14 immunocompromised

HERPES NEONATAL SECONDARY þ Secondary Infection þ Reactivation of latent virus þ Small vesicles

HERPES NEONATAL SECONDARY þ Secondary Infection þ Reactivation of latent virus þ Small vesicles þ Occur only on the hard palate and gingiva þ Prodromal signs acyclovir 60 mg/kg/day I. V. divided 8 h for 21 days. 15

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VERICELLA ZOSTER Hodgkin's disease or non-Hodgkin's lymphoma Acyclovir, 10 to 12 mg/kg every 8

VERICELLA ZOSTER Hodgkin's disease or non-Hodgkin's lymphoma Acyclovir, 10 to 12 mg/kg every 8 hours for 7 days 17

HIV RELATED • Candidiasis (Thrush) • Periodontal Problems • Oral Ulcerations 18 Erythematous candidiasis

HIV RELATED • Candidiasis (Thrush) • Periodontal Problems • Oral Ulcerations 18 Erythematous candidiasis Pseudomembranous candidiasis Angular Cheilitis NUP RAU HSV

CANDIDIASIS Candida þ Candida albicans þ Most common þ Predisposing factors Þ White creamy

CANDIDIASIS Candida þ Candida albicans þ Most common þ Predisposing factors Þ White creamy patches Erythematous candidiasis Pseudomembranous candidiasis Angular Cheilitis Denture stomatitis 19

ANGULAR CHEILITIS

ANGULAR CHEILITIS

CANDIDIASIS

CANDIDIASIS

CANDIDIASIS

CANDIDIASIS

Topical antifungals: Nystatin Swish and swallow Systematic therapies: ketoconazole, Itraconazole or fluconazole 23

Topical antifungals: Nystatin Swish and swallow Systematic therapies: ketoconazole, Itraconazole or fluconazole 23

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AUTOIMMUNE DISEASES Characterized by: Blisters and painful ulcers of slow onset Persistent and chronic

AUTOIMMUNE DISEASES Characterized by: Blisters and painful ulcers of slow onset Persistent and chronic Do not heal in a predictable period Lymphadenopathy typically not present 25

LICHEN PLANUS Erythemathous mucosal lesions usually with areas of ulceration • Hyperkaratosis • Saw-tooth

LICHEN PLANUS Erythemathous mucosal lesions usually with areas of ulceration • Hyperkaratosis • Saw-tooth rete ridges, • Liquefactive degeneration of the basal cell layer • Band-like subepithelial inflammatory infiltrate, • Civatte bodies 26

EM Ulcers and lip swelling Usually accompanied by skin lesions - "iris, " lesion

EM Ulcers and lip swelling Usually accompanied by skin lesions - "iris, " lesion • Strong association between HSV and erythema multiforme, especially recurrent erythema multiforme Stevens-Johnson syndrome- combination of oral, ocular and genital lesions 27

SLE Malar rashes Ulceration and crusting of the lips, nose and oral cavity Shallow

SLE Malar rashes Ulceration and crusting of the lips, nose and oral cavity Shallow oral ulcers and gingivitis 28

PEMPHIGUS VULGARIS • Thin-walled intraepithelial bullae on cutaneous and mucosal surface • Oral involvement

PEMPHIGUS VULGARIS • Thin-walled intraepithelial bullae on cutaneous and mucosal surface • Oral involvement can be the first sign of lesions (desquamative gingivitis) • Positive Nikolsky sign • Rounded, acantholytic epithelial cells in exfoliative cytology TT: Mild – short duration therapy Severe - 1 -2 mg/kg/d Prednisone +/- Azathioprim or Cyclophosphamide Taper dose when relief occurs 29

MMP v Auto-immune disease v Affects 40 to 50 year old aged women v

MMP v Auto-immune disease v Affects 40 to 50 year old aged women v Hemorrhagic and may heal with scarring (cicatricial pemphigoid) v Cleavage occurs in the subepithelial zone v Autoantibodies are produced against various Ags 30

RECURRENT APHTHOUS ULCER Canker sores Appears as a painful white or yellow sore (ulcer)

RECURRENT APHTHOUS ULCER Canker sores Appears as a painful white or yellow sore (ulcer) surrounded by a bright red area early onset between the ages of 10 and 40 dietary deficiencies menstrual periods hormonal changes recurrent ulcers usually lasting 1 week to 1 month 31

Recurrent small Round or ovoid ulcers Circumscribed margins Erythematous haloes Yellow or grey floors

Recurrent small Round or ovoid ulcers Circumscribed margins Erythematous haloes Yellow or grey floors v Associated with other disease v Extremly painful v v v Minor Major 32 m Herpetifor

Aetiology: Unclear Typically early onset with recurrent ulcers usually lasting 1 week or 1

Aetiology: Unclear Typically early onset with recurrent ulcers usually lasting 1 week or 1 month Three distinct clinical patterns: . Minor – small ulcers (<4 mm) on mobile mucosae, healing within 14 days, no scarring. Major – large ulcers (may be >1 cm), any site including dorsum of tongue and hard palate, healing within 1– 3 months, with scarring. Herpetiform ulcers–multiple minute ulcers that coalesce to produce ragged ulcers 33

MINOR q 80% - minor form – 2 -4 mm q Non-keratinized sites (mobile

MINOR q 80% - minor form – 2 -4 mm q Non-keratinized sites (mobile mucosae) q Either single or in crops of four or five 34

MAJOR Ø Ø 36 10% of patients more severe Sutton's disease any site of

MAJOR Ø Ø 36 10% of patients more severe Sutton's disease any site of the oral mucosa including keratinized sites scarring

MAJOR 37

MAJOR 37

HERPETIFORM 38

HERPETIFORM 38

Management: Diagnosed from history and clinical features No diagnostic test A blood picture is

Management: Diagnosed from history and clinical features No diagnostic test A blood picture is useful to exclude possible deficiencies and coeliac disease Treat any underlying predisposing factors 39

Symptomatic treatment with topical anaesthetic or NSAID ( topical diclofenac) Treat aphthae with chlorhexidine

Symptomatic treatment with topical anaesthetic or NSAID ( topical diclofenac) Treat aphthae with chlorhexidine aqueous mouthwash or topical corticosteroids Vitamin supplementation – B-complex with zinc 40

BEHCET’S DISEASE Hulusi Behçet 1937 o Mediterranean region, Middle East o Male-to-female ratio was

BEHCET’S DISEASE Hulusi Behçet 1937 o Mediterranean region, Middle East o Male-to-female ratio was 24: 1 o Third decade of life o Recurrent mucosal membrane ulcerations 6 months to 5 yrs o Heal in days to weeks with scarring o Vasculitis with triad of oral and genital ulcers and uveitis or iritis 41

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