Oral Ulcerative and Vesiculobullous Lesions

• Ulcerative and Vesiculobullous Lesions of the Oral Mucosa

Terminology

• An ulcer is a break in the skin or epithelium due to tissue death, resulting in total loss of the surface epithelium and exposing the underlying connective tissue
• An erosion is a partial loss of surface epithelium that appears clinically as a red lesion
• A vesicle is an elevated lesion containing clear fluid and is less than one cm in diameter
• A bulla is an elevated lesion containing clear fluid and is more than one cm in diameter

Classification of Oral Ulcers

• Oral ulcers classification is based on the history of the ulcer
• Oral ulcers classifications are according to whether they are preceded by vesicles or bullae or not
• Etiological classification of oral ulcers

Classification Based on History

• First classification is based on the history of the ulcer
• Recording the history of an oral ulcer includes main points such as duration, which is how long the ulcer has been present, this helps determine if the ulcer is acute or chronic
• Past history of similar lesions, this helps determine if the ulcer is primary or recurrent
• Number of ulcers, helps determine if the ulcer is single, few, or multiple ulcers
• Other points to include in the history of an oral ulcer includes pain, causative factors, systemic diseases, skin lesions, and infections

Types of Ulcers

• Acute multiple ulcers
• Chronic multiple ulcers
• Recurrent ulcers
• Single (Solitary) ulcers
• This is the first step in decision tree for diagnoses

Acute Multiple Ulcers

• Oral ulcers due to viral infection (Viral stomatitis)
  • Herpes Simplex virus infection
  • Varicella Zoster virus infection
  • Coxsackie virus infection
• Erythema multiforme
• Oral ulcers secondary to cancer chemotherapy
• NG
• Oral ulcers secondary to blood diseases

Chronic Multiple Ulcers

• Pemphigus vulgaris
• Mucous membrane pemphigoid
• Bullous Lichen planus
• Herpes simplex virus infection in immune compromised patients

Recurrent Oral Ulcers

• Recurrent aphthous ulcer
• Behcet's syndrome
• Reiter's syndrome
• Recurrent HSV infection
  • Recurrent herpes labialis
  • Recurrent intraoral herpes

Single Oral Ulcers

• Traumatic ulcer
• Malignant ulcer squamous cell carcinoma
• Single oral ulcer due to infection
  • Tuberculous ulcer
  • Syphilitic ulcer
  • Deep fungal infection e.g. histoplasmosis

Classification By Preceding Vesicles or Bullae

• Primary Ulcers: NOT preceded by vesicles or bullae
• Secondary Ulcers: preceded by vesicles or bulla
• Intraepithelial Bulla
  • Acantholytic Lesions
  • Non Acantholytic Lesions
• Subepithelial Bulla

Primary Ulcers

• Ulcers which are NOT preceded by vesicles or bullae
  • Traumatic ulcer
  • Recurrent aphthous ulcer
  • Malignant ulcer
  • Ulcers due to systemic disease e.g. blood diseases
  • Ulcers due to bacterial and fungal infection

Secondary Ulcers

• Preceded by vesicles or bulla
• Intraepithelial Bulla
  • Acantholytic lesions: due to destruction of intercellular attachment e.g Pemphigus vulgaris
  • Non acantholytic lesions: due to the death and rupture of groups of epithelial cells e.g. Herpes simplex virus infections, Herpes zoster, Herpangina, Hand, foot and mouth disease
• Subepithelial Bulla
  • Mucous membrane pemphigoid
  • Bullous lichen planus

Etiological Classification

• Trauma example is a traumatic ulcer
• Viral infection example is viral stomatitis
• Bacterial infection example is tuberculous ulcer
• Fungal infection example is histoplasmosis
• Immune mediated example is Erythema multiform
• Drug induced oral ulcers example is oral ulcers secondary to cancer chemotherapy

Intraoral Clinical Examination

• Intraoral clinical examination includes, site, size, shape, single or multiple, shallow or deep, Surrounding oral mucosa (margin), Scar formation (Scars of old ulcers), Floor, Edge, and Base, this helps describe an oral ulcer
• Edge is the area between the margin and the floor
• Different types of edges include: undermined edge which is tuberculous ulcer, raised everted edge which is squamous cell carcinoma
• Margin
  • Surrounded by red halo e.g. recurrent aphthous ulcer
  • Not surrounded by red halo e.g. ulcers secondary to cancer chemotherapy
• Floor is seen by inspection
  • Covered or not
  • Covered by fibrinous exudate: mass of fibrin and dead PMNs
• Base: felt by palpation
  • Induration is the feel of hardness in the base of an ulcer
  • Indurated base: Squamous cell carcinoma, Major recurrent aphthous ulcer, Chancre, Long standing traumatic ulcer
  • Non indurated base: Minor aphthous ulcer
• Size
  • Pin head size ulcers
  • Small ulcer
  • Large ulcer
• Number
  • Single ulcer
  • Few ulcers
  • Multiple ulcers
• Depth
  • Shallow
  • Deep where the floor is covered by fibrinous exudate
• Regular/ well defined outline
• Irregular outline
• Healing:
  • Without scar formation
  • With scar formation e.g major RAU