3- Oral Mucosal Ulceration.pdf

Oral Mucosal Ulceration Dr.NOOR QASIM F.K.H.C.M.S (PhD ) OMFM The First & The Only Franchise in the Iraq 1 ulcers A...

Oral Mucosal Ulceration Dr.NOOR QASIM F.K.H.C.M.S (PhD ) OMFM The First & The Only Franchise in the Iraq 1 ulcers An ulcer is a break in the continuity of the epithelium, exposing the connective tissue to the oral environment. Ulcers may have sharp well-defined borders or ragged margins, but all are covered by a grey- yellow fibrin slough. Ulcers have a superficial bacterial contamination by oral flora, but the tissue below very rarely becomes infected. The rapid turnover of oral epithelium allows uncomplicated ulcers to heal rapidly. The First & The Only Franchise in the Iraq 2  Main causes of mucosal ulcers 1- Systemic disease (bigs) incudes: A- blood disorders (anemia –haematinic deficiency-leukemia) B- infections(viral-bacterial –fungal ) C- gastrointestinal disease(crohn disease-celiac disease-ulcerative colitis) D-skin diseases(lichen planus-immune blistering disease) 2- Malignant neoplasms 3- Local causes and trauma(mechanical-chemical –thermal-radiation) 4- Aphthae(RAS) 5- Drugs The First & The Only Franchise in the Iraq 3 Although histological examination and specific laboratory tests are often mandatory, a careful clinical examination, associated with thorough history taking, can provide insights into the nature of an oral ulcer. Important clinical features in investigating a patient affected by ulcer(s) of the mouth range from: Number of ulcers, single as for oral cancer or multiple as for herpetic infection Specific localization, as for aphthae which prefer non keratinized mucosa or chronic traumatic ulcer, in relation with rough surface. Duration, acute ulceration usually due to viral infection or chronic as neoplasm, traumatic or tuberculosis. The First & The Only Franchise in the Iraq 4  Presence of a blister preceding the ulcer, a feature of immune-mediated conditions(bulla) or viral infection (vesicle) Presence of other mucosal or cutaneous changes, as for lichen planus, blistering lesions on skin. Gastrointestinal symptoms as pain ,diarrhoea or constipation. Ulcers should always be examined for induration (firmness on palpation), which may be indicative of malignancy. Unless the cause is undoubtedly local, general physical examination is also indicated, looking especially for mucocutaneous lesions, lymphadenopathy or fever. The First & The Only Franchise in the Iraq 5 Systemic disease associated with ulceration (Aphthous like ulcer ALU) A-Blood disorder Anemia and haematinic deficiency The role of iron metabolism in the maintenance of the structure of the oral mucosa has been the subject of much investigation. It is certainly the case that iron deficiency, even when relatively mild in clinical terms, can result in generalized oral epithelial atrophy and loss of the papillary pattern of the tongue mucosa. It seems that other deficiencies that might affect iron metabolism and erythrocyte production, such as folate and vitamin B12 deficiencies, may also contribute to this destabilization of the oral epithelium. The First & The Only Franchise in the Iraq 6  Oral ulcers in cases of leukemia are secondary to anemia ,haematinic deficiency or due to chemotherapy and radiotherapy (mucositis). In leukemia the patient also will complain from malaise, generalized weakness,pallor,purpura and lymphadenopathy. Investigation required include: Complete blood count (CBC) Haematinics (ferritin,folate,vit B12 )and zinc Blood film in suspected cases of leukemia The First & The Only Franchise in the Iraq 7 B-infections(viral-bacterial –fungal ) Viral infection :Human herpes virus infections include (HSV-1,varicella virus –EBV –CMV) and HIV infection. Bacterial infections like Syphilis and Tuberculosis. Fungal infections like deep mycosis Herpes infection Syphilis ulcer T.B ulcer The First & The Only Franchise in the Iraq 8  C- gastrointestinal disease(inflammatory bowel disease IBD and celiac disease): -Inflammatory bowel disease (IBD) The inflammatory bowel diseases are lifelong conditions resulting from aberrant inflammation of the mucosal lining of the gastrointestinal tract. The two main categories are Crohn's disease, which may affect the gut anywhere from mouth to anus, and ulcerative colitis, which is predominantly within the colon. The First & The Only Franchise in the Iraq 9 Crohn’s disease is an inflammatory bowel disease of unknown etiology Granulomatous inflammation affects the ileocaecal region, causing thickening and ulceration(non caseating granuloma). Oral ulceration caused by malabsorption anemia and haematinic deficiency. The First & The Only Franchise in the Iraq 10  Typical orofacial features of Oral Crohn’s disease Diffuse soft or tense swelling of the lips, or mucosal thickening Cobblestone thickening of the buccal mucosa Gingivae may be erythematous and swollen Sometimes, painful mucosal ulcers, linear in sulci or resembling aphthae Mucosal tags in sulcuses Glossitis due to iron, folate or vitamin B12 deficiency can result from malabsorption Orofacial granulomatosis (OFG)shares many features The First & The Only Franchise in the Iraq 11 ULCERATIVE COLITIS Ulcerative colitis is an inflammatory disease of the large intestine causing ulceration and fibrosis There is no direct oral involvement, but the oral condition of pyostomatitis vegetans is closely associated. Oral ulcers caused by anemia and haematinic deficiency secondary to malabsorption. The First & The Only Franchise in the Iraq 12  Coeliac disease (gluten-sensitive enteropathy) Coeliac disease is a permanent intolerance to gliadin—the protein component of wheat. It is a lifelong inflammatory condition of the gastrointestinal tract that affects the small intestine causing villous atrophy. Malabsorption, as a result of coeliac disease, may result in a haematinic deficiency, particularly of iron and folic acid. The First & The Only Franchise in the Iraq 13 Oral manifestations of coeliac disease Oral ulceration—RAS Glossitis Angular cheilitis Enamel hypoplasia of permeant teeth ,short stature and failure to thrive in children IgA anti-gliadin, IgA anti-reticulin, and IgA endomysial autoantibodies are blood tests that can be used as a first-line investigation in those people suspected of having coeliac disease in addition to CBC and haematinics. The First & The Only Franchise in the Iraq 14  If history of the patient revealed any gastrointestinal symptoms investigation includes : Complete blood count Haematinics (folate , ferritin , serum Vit B12 ) and zinc Referral of the patient to Gastroenterologist for further evaluation The First & The Only Franchise in the Iraq 15 D-skin diseases(lichen planus-immune blistering disease) Lichen planus Lichen planus is a very common chronic inflammatory disease of skin and mucous membranes. Immune blistering disease includes mainly pemphigus vulgaris – pemphigoid-Epidermolysis bullosa. The First & The Only Franchise in the Iraq 16  2- Malignant Ulcer A single, indurated ulcer is a common presentation of oral cancer and must be carefully differentiated from traumatic or tuberculous ulcers. A range of neoplasms may present with ulcers, most commonly these are carcinomas, but Kaposi sarcoma, lymphomas and other neoplasms may be seen. *carcinoma is cancer that forms in epithelial tissue. *Sarcoma is cancer that develop in mesenchymal cells(muscles,tendons.blood vessels, bone). The First & The Only Franchise in the Iraq 17 3-Local causes and trauma(mechanical-chemical –thermal-radiation-self induced) Traumatic ulcers are usually caused by biting, denture trauma ,hot food, chemical trauma by dental materials or by aspirin(aspirin burn) ,chemotherapy and radiotherapy and arise at trauma-prone sites such as lip, buccal mucosa or adjacent to a denture flange. They are tender, have a yellowish-grey floor of fibrin slough and red irregular margins. Traumatic ulcers heal in days after elimination of the cause. If they persist for more than 10 days without reduction in size and symptoms, or there is any other cause for suspicion as to the cause, biopsy should be carried out to exclude other diseases. The First & The Only Franchise in the Iraq 18  4-Aphthae(Recurrent aphthous stomatitis RAS): Recurrent aphthous stomatitis (RAS), or “canker sores,” is a common oral mucosal disease affecting 10–20% of the general population. characterized by recurring ulcers of the oral mucosa usually manifesting first in childhood or adolescence in patients with no other systemic diseases. RAS may present in three main forms based on its clinical appearance: Minor, major,herpetiform. The First & The Only Franchise in the Iraq 19 Possible etiological factors for recurrent aphthae Genetic predisposition Exaggerated response to trauma Infections Immunological abnormalities Gastrointestinal disorders Haematological deficiencies Hormonal disturbances Stress The First & The Only Franchise in the Iraq 20  Minor aphthae: The most common type Non-keratinized mucosa affected Ulcers are shallow, rounded, 3–7 mm across, with an erythematous margin and yellowish floor One or several ulcers may be present Individual minor aphthae persist for 7–10 days, then heal without scarring. The First & The Only Franchise in the Iraq 21 Major aphthae Uncommon Ulcers frequently several centimetres across Sometimes mimic a malignant ulcer Ulcers persist for several weeks Masticatory mucosa, such as the dorsum of the tongue or occasionally the gingivae, may be involved Scarring may follow healing The First & The Only Franchise in the Iraq 22  Herpetiform aphthae Uncommon Non-keratinized mucosa affected Ulcers are 1–2 mm across Dozens or hundreds may be present May coalesce to form irregular ulcers Widespread bright erythema round the ulcers ulcers may last for approximately 7–14 days, The First & The Only Franchise in the Iraq 23 5-Drugs Drugs may induce ulcers by producing a local burn or by a variety of mechanisms. Cytotoxic drugs (e.g. methotrexate), NSAIDs and nicorandil (a potassium channel activator used in cardiac disorders) or others may be the cause. The First & The Only Franchise in the Iraq 24  Management Treat the underlying cause. Remove etiological factors. Ensure any possible traumatic element is removed (e.g. a denture flange). Prescribe a chlorhexidine 0.2% aqueous mouthwash. Maintain good oral hygiene. A benzydamine mouthwash or spray, as topical analgesic. Corticosteroid creams, gels and inhalers. Patients should not eat or drink for 30 min after using the corticosteroid, in order to prolong contact with the lesion. Systemic corticosteroids in sever cases( In patients using potent topical corticosteroids for more than a month it is prudent to add an antifungal, since candidosis may arise) The First & The Only Franchise in the Iraq 25 The First & The Only Franchise in the Iraq 26