Download - SINGLE ULCERS
GOOD MORNIN
G
SEMINAR
YASMIN MOIDIN 2008 BATCH
AL AZHAR DENTAL COLLEGETHODUPUZHA
SINGLE ULCERS
INTRODUCTION
The most common cause of single ulcers on
the oral mucosa is trauma
TYPES
Traumatic ulcer
Eosinophilic ulcer of tongue
Histoplasmosis
Blastomycosis
Mucormycosis
Syphilitic ulcer
TRAUMATIC ULCER
Most common oral mucosal ulcer
Types of trauma
Mechanical
Chemical
Thermal
Radiation
Self-inflicted
Iatrogenic
CLINICAL FEATURES
Tenderness or pain in the area of lesion
Sites : tongue, lips, mucobuccal fold, gingiva and palate
Persist for few days or lasts for weeks
Vary in size and shape
Borders are raised and reddish
Bases are yellowish necrotic surface
Frequently, a painful regional lymphadenitis occur as a result
of contamination of ulcer by oral flora
DIFFERENTIAL DIAGNOSIS
Carcinomatous ulcer
Recurrent aphthous ulcerations
MANAGEMENT
Removal of traumatic factor
Most traumatic ulcer become painless within 3 to 4 days
After the injury producing agent has been eliminated,
most heal with 10 days
Less serious varieties, treat with triamicinolone
acetonide with emolient before bed time and after
meals usually relieves the pain and hastens the
healing
Orabase protects the denuded CT from continued
contamination by oral liquids and cortisone
component tend to arrest the inflammatory cycle
Persistent ulcers are surgically excised
EOSINOPHILIC ULCER OF TONGUE
ETIOLOGYAND
PATHOGENESIS
Inflicting crush injury
on tongue-most
common site
Deep and penetrating
RIGA-FEDE DISEASE
Lesion seen on ventral tongue
Infants
Cause- tongue rasping against newly erupted
primary incisors
CLINICAL MANIFESTATIONS
Bimodal age distribution
1st group- in 1st 2 years of life-lesion
associated with erupting primary dentition
2nd group – adults – 5th and 6th decades
ORAL FINDINGS
Children – anterior ventral or dorsal tongue
associated with erupting mandibular or
maxillary incisors
Adults – posterior and lateral aspect of tongue
Ulcer – not painful & persist for months
History of trauma
Appear cleanly punched out, with surrounding
erythema & whiteness
Size – 0.5cm
Surrounding tissue is indurated5 % - multifocal and recurrences are not
uncommon
In some cases , lesions are ulcerated , mushroom-
shaped , polypoid mass on the lateral tongue
DIFFERENTIAL DIAGNOSIS
Recurrent aphthous ulcers
Squamous cell carcinoma
T-cell lymphomas
LABORATORY FINDINGS
Biopsy is needed to make diagnosis
MANAGEMENT
Intralesional steroid injections
Wound debridement
Use of nightguard on lower incisor – reduce
nighttime trauma
HISTOPLASMOSIS
ETIOLOGY AND PATHOGENESIS
Caused by fungus Histoplasma capsulatum
Infection results from inhaling dust
contaminated with droppings, from infected
birds or bats
CLINICAL MANIFESTATIONS
The expression of the disease depends on the quantity
of spores inhaled, the immune status of the host and
the strains of the organism
Asymptomatic and mild flulike illness for 1 to 2 weeks
The inhaled spores are ingested by macrophages
within 24 to 48 hours and specific T lymphocyte
immunity develops in 2 to 3 weeks
TYPES
Acute histoplasmosis
Self –limited pulmonary infection
Acute symptoms are fever, headache, myalgia,
nonproductive cough, anorexia
Patient is ill for 2 weeks
Calcification of hilar lymph nodes
Chronic histoplasmosis
Primarily affects the lungs
Affects older, emphysematous, white men or
immunosuppressed patients
Patients typically exhibit cough, weight loss, fever,
dyspnoea, chest pain, hemoptysis, weakness and
fatigue
Disseminated histoplasmosis Less common
It is characterized by progressive spread of the
infection to extrapulmonary sites
It occurs in older, debilitated, immunosuppressed
patients and patients with AIDS
Tissues that affect include: spleen , adrenal glands,
liver, lymph nodes, GIT, CNS, kidneys and oral mucosa
Common sites – tongue, palate, buccal
mucosa
It appears as a solitary, painful ulceration of
several weeks duration
Some lesions appear erythematous or white
with an irregular surface
Ulcerated lesions have firm, rolled margins
ORAL FINDINGS
Oral lesion begin as an area of erythema ,
becomes papule & forms Painful ,
granulomatous –appearing ulcer
Cervical lymph nodes are enlarged and firm
Patients with HIV has an ulcer with indurated
border, seen on gingiva , palate , tongue
DIFFERENTIAL DIAGNOSIS
Traumatic ulcerative granuloma
Squamous cell carcinoma
Lymphoma
LABORATORY FINDINGS
Biopsy – stained with PAS OR methanamine
silver – reveal presence of fungi
MANAGEMENT
Immunocompromised patients -IV amphotericin B
AIDS – itraconazole & maintenance therapy
Immunocompetent – itraconazole or ketoconazole for 6
to 12 months
BLASTOMYCOSIS
ETIOLOGY AND PATHOGENESIS
Caused by Blastomyces dermatitidis
Infection results from inhalation and is found
in agricultural and construction workers
CLINICAL MANIFESTATIONS
It is acquired by inhalation of spores , particularly after
rain
The spores reach the alveoli of lungs, where they begin
to grow as yeasts
The infection is halted and contained in the lungs
The sites of dissemination include skin, bone, prostate,
meninges, oropharyngeal mucosa and abdominal organs
Types
Acute blastomycosis
Resembles pneumonia, characterised by high
fever, chest pain, malaise, night sweats and
productive cough with mucopurulent sputum
Rarely, the infection may precipitate life-
threatening adult respiratory distress syndrome
Chronic blastomycosis
More common
Characterisezd by low grade fever, night sweats, weight
loss and productive cough
Chest radiographs shows diffuse infiltrates or pulmonary
or hilar masses
Calcification is not typically present
Lesion begins as erythematous nodules that enlarge ,
becoming verrucous or ulcerated
ORAL FINDINGS
It may result from either extrapulmonary
dissemination or local inoculation with the
organism
Lesions have an irregular, erythematous or white
intact surface
Appear as ulcerations with irregular rolled borders
and varying degree of pain
LABORATORY FINDINGS
Diagnosis by biopsy and culture demonstrates presence
of multinucleated yeast cells with dark cytoplasm &
colorless cell walls with characteristic of B.dematitidis
TREATMENT
Disseminated or progressive – ketoconazole ,
fluconazole , itraconazole for mild to moderate
Amphotericin B – sever disease
MUCORMYCOSIS
ZYGOMYCOSIS/ PHYCOMYCOSIS
ETIOLOGY AND PATHOGENESIS
Caused by saprophytic fungi
Occurs in soil or as a mold on decaying food
Fungus is nonpathogenic
CLINICAL MANIFESTATIONS
Rhinocerebral zygomycosis
Patient experiences nasal obstruction, bloody nasal
discharge, facial pain or headache, facial swelling or
cellulitis and visual disturbances with concurrent proptosis
With progression of disease into the cranial vault,
blindness, lethargy and seizures may develop followed by
death
If maxillary sinus is involved, the initial
presentation may seen as intraoral swelling
of maxillary alveolar process & palate
If the condition is untreated, palatal
ulceration, appears as black and necrotic and
massive destruction
ORAL FINDINGS
Ulceration of the palate
Lesion is large & deep, causing denudation of
underlying bone
Other sites- gingiva, lip , alveolar ridge
Initial manifestation confused with dental pain or
bacterial maxillary sinusitis caused by invasion of
maxillary sinus
LABORATORY FINDINGS
Biopsy is split into culture & histopathology
Histopathologic findings- necrosis &
nonseptate hyphae
Necrosis & occlusion of vessels is present
MANAGEMENT
Combination of surgical debridement of the
infected area
Amphotericin B for 3 months
Observed for renal toxicity
Posaconazole , antifungal agent is used for patients
unable to tolerate toxicity of amphotericin
SYPHILITIC ULCER
Syphilis is a sexually transmitted disease ,
caused by Treponema pallidumCHANCRESeen in genital region Other sites- lips , tongue, palate, tonsillar regionsIn initial stage- papule seen which subsequently
erodesTypical syphilitic ulcer is punched-out, non tender,
indurated and associated with yellowish discharge
Associated nodes are firm & non tender on palpation
Self-limiting & last for 2 weeksHeal with minimum scar formation MUCOUS PATCHESAppears after a latency period of 6 months Patient complains of fever, headache, bodyache & sore
throatCutaneous maculopapular rashes associated with
lymphadenopathy
Oral lesions are characterised by appearance of oval red macules (palate) or papules (buccal mucosa & commissures) and mucous patches
Mucous patches are seen as raised erosive areas covered by a grayish white pseudomembraneous and surrpunded by an erythematous halo
Measure about 1 cm in diameterSmall lesions join together to give rise to snail
track ulcers severe & generalised form – lues maligna, also
termed ulceronodular disease
Oral mucosa reveals shallow crater like ulcers
Common sites – palate , buccal mucosa, tongue, lower lip, and gingiva
GUMMAIt is a highly destructive lesion It occurs 8 to 10 years after initial infectionCommon sites – hard palate , tongue
MANAGEMENT
Parenteral pencillin G
Allergic to pencillin, treated with
doxycycline , tetracycline , erythromycin