ORAL ULCERS Part 2 D D of ULCERS
- Slides: 42
ORAL ULCERS Part 2 D / D of ULCERS 1
DRUG - INDUCED 2
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, 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 with 5 FU cryotherapy for patients treated with 5 - FU Treatment of Mucositis symptoms topical dyclonine or lignocaine 5
INFECTIONS 6
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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
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 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 Vesicle stage present in all 13
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 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 hours for 7 days 17
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 patches Erythematous candidiasis Pseudomembranous candidiasis Angular Cheilitis Denture stomatitis 19
ANGULAR CHEILITIS
CANDIDIASIS
CANDIDIASIS
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 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 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 • 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 oral ulcers and gingivitis 28
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 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) 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 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 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 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 the oral mucosa including keratinized sites scarring
MAJOR 37
HERPETIFORM 38
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 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 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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