{"id":14115,"date":"2017-03-25T10:24:13","date_gmt":"2017-03-25T10:24:13","guid":{"rendered":"http:\/\/biomedpharmajournal.org\/?p=14115"},"modified":"2017-03-28T07:21:49","modified_gmt":"2017-03-28T07:21:49","slug":"ulcerative-lesions-of-the-oral-cavity-an-overview","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol10no1\/ulcerative-lesions-of-the-oral-cavity-an-overview\/","title":{"rendered":"Ulcerative Lesions of the Oral Cavity\u2013an Overview"},"content":{"rendered":"

Introduction<\/strong><\/p>\n

Oral ulcers are one of the most common complaints of the oral mucosa.A loss or break in the continuation of surface epithelium or mucous membrane that extends into lamina propria. Oral ulcers are confirmed by the underlying systemic condition such as the nature, site, duration and frequency.<\/p>\n

Classification<\/strong><\/p>\n

Local Factors<\/p>\n

Traumatic<\/p>\n

Sharp teeth\/ill fitting dental prosthesis<\/p>\n

Radiation\/chemotherapy<\/p>\n

Chemical and\u00a0thermal injury<\/p>\n

Infections<\/p>\n

Bacterial<\/p>\n

Tuberculosis<\/p>\n

Syphilis<\/p>\n

Viral<\/p>\n

Herpes simplex infection<\/p>\n

Chicken pox<\/p>\n

Hand,foot & mouth disease<\/p>\n

HIV Infection<\/p>\n

Fungal<\/p>\n

Mucormycosis<\/p>\n

Systemic Factors<\/p>\n

Gastrointestinal disease<\/p>\n

Crohns disease<\/p>\n

Ulcerative colitis<\/p>\n

Mucocutaneous disease:<\/p>\n

Lichen planus<\/p>\n

Erythema multiforme<\/p>\n

Systemic erythematosus<\/p>\n

Malignancy<\/p>\n

Squamous cell carcinoma<\/p>\n

Miscellaneous<\/p>\n

Necrotizing sialometaplasia<\/p>\n

Recurrent aphthous stomatitis<\/p>\n

Local Factors<\/p>\n

Traumatic ulcer<\/strong><\/p>\n

Physical traumatic ulcers are more common in oral cavity. Mainly due to sharp tooth,ill- fitting dentures,rough fillings ,fractured restoration,orthodontic appliance,sharp foreign body,bitting1<\/sup>.Appears as yellow base with erythematous borders & heals in 7 -14 days if cause is removed.<\/p>\n

Radiation \/ Chemotherapy<\/strong><\/p>\n

Chemotherapy and radiation therapy overthrough the healthy balance of bacteria\u00a0in the mouth and may lead to changes in the lining of the mouth and the salivary glands, which make\u00a0saliva. This affects the healthy balance of bacteria. These changes may cause mucositis manifest as multiple areas of painful mucosal erythema,ulcers & sloughing.These complications can lead to other problems such as\u00a0dehydration\u00a0and\u00a0malnutrition2<\/sup>.<\/p>\n

Chemical and Thermal Injury\u00a0\u00a0\u00a0\u00a0\u00a0 <\/strong><\/p>\n

Ulcer is due to aspirin , sodium perborate, cocaine or smoking crack cocaine (e.g., on the palate).Hydrogen peroxide, Chlorhexidine, Listerine, are the commonly used dental medicaments by patients that can cause mucosal damage.Chemical injury usually manifests as, superficial white, wrinkled appearance.Exposure time increases,cause necrosis and the affected epithelium becomes separated from the underlying tissue and can be desquamated and leaving erosions. \u00a0Histopathological examination shows features of coagulative necrosis3<\/sup>. If the chemical injury is involved with a salivary gland duct, it might end up with transient obstructive sialadinitis4<\/sup> and end up with permanent obstruction, chronic sialadinitis and may require surgical excision of duct\/gland5<\/sup>Thermal injury is. most commonly on the palate & tongue.Arise due to hot foods or liquids which shows an erythematous area of vesicles which can later transform into an ulcer.<\/p>\n

Infections<\/strong><\/p>\n

Bacterial<\/strong><\/p>\n

Tuberculosis<\/strong><\/p>\n

Tuberculosis (TB) is a chronic granulomatous infectious disease due to Mycobacterium tuberculosis6<\/sup>.Tuberculosis can either be primary or secondary and can involve any part of the body. The oral cavity is an unusual site\u00a0 and almost due to secondary infection. These lesions manifest as non\u2011healing ulcers, nodules, fissures, verrucous proliferation, erythematous patches or plaques, indurated lesions, or as jaw lesions7<\/sup>.The dorsal surface of the tongue is more commonly involved8<\/sup>and appears as undermined edges and a yellow granular base with minimal induration is seen.oral lesions follow lung lesions.Other sites such as gingiva, floor of the mouth, palate, lips, buccal folds, tooth sockets, and jaw bones9,10<\/sup>.<\/p>\n

Syphilis<\/strong><\/p>\n

Syphilis is an infectious venereal disease caused by the spirochete Treponema palladium<\/em>, whicharevirulenttohumans,andwhicharemembersoftheorderSpirochaetale.Syphilis may be acquired (common) or congenital (rare).\u00a0 Acquired syphilis is classified as primary, secondary and tertiary.Primary and secondary cause ulcer.<\/p>\n

Table 1<\/strong><\/p>\n\n\n\n\n\n\n\n\n
Primary Syphilis – Chancre<\/strong><\/td>\nSecondary Syphilis \u2013 Mucous patch<\/strong><\/td>\n<\/tr>\n
Appears 3 wks after the infection<\/td>\nAppears after the primary infection<\/td>\n<\/tr>\n
Lips, tongue,gingiva ,tonsils<\/td>\nHighly contagious<\/td>\n<\/tr>\n
Single,indurated ,non painful ulcer<\/td>\nMultiple, painless,greyish white plaque overlying an ulcerated surface surrounded by erythematous zone<\/td>\n<\/tr>\n
Spontaneously heals in 4-6 wks<\/td>\nTongue,gingiva ,buccal mucosa<\/td>\n<\/tr>\n
–<\/td>\nNeighbouring ulcer fuse \u2013 Snail track ulcer<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Viral<\/strong><\/p>\n

Herpes Simplex Infection<\/strong><\/p>\n

Herpes simplex ,an acute infectious disease commonly affecting man,with exception of viral respiratory infections.Two types of HSV: HSV -1 & HSV \u2013 2 . HSV-1 infections affect the face and mouth ; HSV-2 infections occur genitally. Both viruses may cause recurrent disease Transmitted directly by contact with body fluids. Seen in immovable mucosa. Within few days ,the mouth becomes painful and the gingival is intensely inflamed appears as edematous and erythematous Mainly affects lips,tongue,buccal mucosa,palate,pharynx and tonsils.\u00a0 Lesion appears as small vesicles,which are thin walled,surrounded by inflammatory base are formed .These vesicles rupture and form shallow,oval shaped discrete ulcers and covered by with grayish white or yellow plaque and surrounded by an\u00a0 erythematous halo and cause extremely painful ulcers.The ulcers may vary in size measuring millimetres or centimetre in diameter.They heal spontaneously within 7 \u2013 14 days and leave no scar.<\/p>\n

\u00a0Chicken Pox<\/strong><\/p>\n

An acute viral disease\u00a0 caused by Varicella \u2013 Zoster virus is similar to herpes simplex virus,occurring in children. Most common in winter and spring months. Transmission is by air-borne droplet or direct contact with active lesions .Most common sites are vermillion border of the lips and palate followed by buccal mucosa resembles aphthous ulcers.Lasts 7-10 days .The lesion begins as 3- 4 mm,white ,opaque vesicles that rupture to form 1 to 3 cm ulcerations.<\/p>\n

Hand,Foot and Mouth Disease<\/strong><\/p>\n

It is an epidemic infection caused by the enterovirus 71 and by A16,A5,A9,A10,echovirus 9.Smal ,multiple ulcers preceded by vesicles,commonly seen in children,highly contagious\u00a0 which is self limited.lesion might be scary &recovery is less than a week. In add to that patient may develop\u00a0 ulcer in cutaneous region.Mainly affects\u00a0 hard palate,tongue and buccal mucosa. The lesions of the disease are raised,discrete,whitish or yellowish to dark pink solid papules or nodules,surrounded by a narrow zone of erythema.\u00a0 A sore mouth with refusal to eat\u00a0 and the tongue may become red and edematous.<\/p>\n

HIV Infection<\/strong><\/p>\n

Acquired immunodeficiency syndrome is caused by the human immunodeficiency virus ( HIV ). Characterised by immuno suppression.Caused by HIV -1 and HIV \u2013 2.\u00a0 It is a nononcogenic human retrovirus and it belongs to a lentivirus group type III.Mode of transmission is by sexual,infected body fluids such as blood and blood products and breast milk. Saliva is not a significant route of transmission of HIV. Infection can be transmitted vertically from mother to child.Wide spectrum of oral ulcerative lesions.Develop deep necrotic ulcers of unknown etiology .HHV-8 DNA – detected within such ulcers.HIV disease may have ulcers similar to those\u00a0 of recurrent apthous stomatitis.<\/p>\n

Fungal<\/strong><\/p>\n

Mucormycosis<\/strong><\/p>\n

Mucormycosis (zygomycosis) is a rare, aggressive, invasive fungal infection that usually afflicts immunosuppressed patients11<\/sup>.Most common 3rd <\/sup>invasive fungal infection,following aspergillosis and candiadiasis and also found in autopsies of hematologic patients.occur in soil & manure,Which is very common in diabetic pts & it\u00a0 represents a necrotic lesion of the palate.Mode of spread throughdirect extension or through blood vessels and lymph vessels.other sites involved are buccal mucosa,upper and lower lip,mandible.Rhinocerebral mucormycosis is the most common type and its extension to the orbit and brain is quite usual12<\/sup>. Intraorally,ulcer with raised erythematous borders with surface of the ulcer appearing black and necrotic with areas of denudation is seen.\u00a0Often associated with traid of symptoms,Uncontrolled diabetes mellitus,periorbital infection,meningoencephalitis.<\/p>\n

Systemic Factors<\/strong><\/p>\n

Gastrointestinal Disease<\/strong><\/p>\n

Crohns Disease<\/strong><\/p>\n

Crohns disease is a granulomatous inflammation of the intestine & aiso involves the oral cavity of unknown etiology.Present as linear ulcers & hyperplastic folds of the buccal and labial vestibules which may mimic denture induced hyperplasia. Fissuring of the tongue . extremely rare, pyostomatitis vegetans is an oral type of Crohn’s disease that results in multiple abscesses, pustules, and ulcers in the oral cavity. Crohn’s sufferers will develop painful sores in the mouth, known as aphthous ulcers. These oral ulcers usually appear during a flare-up of intestinal inflammation13<\/sup>.<\/p>\n

Ulcerative Colitis<\/strong><\/p>\n

Pyostomatitis vegetans is an uncommon inflammatory disease of the oral cavity.Occurs in upper & lower\u00a0 anterior vestibule.Sometimes hard &\u00a0 soft palate ,tongue involvement is uncommon.Many small projections show tiny pustules beneath the epithelium,which liberate purulent material when ruptured.These leaves areas of ulceration,which may coalesce into form an large areas of necrosis known as snail track ulcerations.Palatal lesion appeared as multiple\u00a0 apthous ulcers14<\/sup>.<\/p>\n

Mucocutaneous<\/strong><\/p>\n

Lichen Planus<\/strong><\/p>\n

It is a common mucocutaneous disease.Oral lesions may accompany or even precede the appearance of skin and genital lesions.Seen in\u00a0adulthood, and children are rarely affected. usually observed in nervous, `highly strung’ people (Shaler 1983). Mainly due to stress and T cell mediated condition and other causes includes trauma, malnutrition and infection. It can occur anywhere in the oral cavity. The buccal mucosa. tongue, and gingiva are the most common sites, whereas palatal lesions are uncommon. They are usually symmetrical and bilateral lesions or multiple lesions in the mouth. Andreasen (1968) histopathologically divided oral lichen planus into six types: reticular, papular, plaque-like, erosive, atrophic, and bullous. The reticular, papular, and plaque-like forms are usually painless and appear clinically as white keratolic lesions. The bullous , atrophic, and erosive forms are often associated with a burning sensation and in many cases can cause severe pain15<\/sup>.<\/p>\n

Erythema Multiforme <\/strong><\/p>\n

Caused by mycoplasma pneumonia,herpes simplex virus,drugs like sulphonamides & penicillin . Severe form of EM \u2013 stevens johnson syndrome which is characterized by crusted ulcers on vermillion border of \u00a0lip followed by buccal mucosa ,tongue,lips,palate & extremities .<\/p>\n

Systemic Erythematosus<\/strong><\/p>\n

Lupus erythematosus is an autoimmune disease involving both humoral & cell mediated immune system.2 forms \u2013 Discoid & Systemic of which SLE present as ulcer on palate. Erythematous rash,seen over malar processes & the bridge of the nose.This Butterfly distribution is associated with\u00a0 SLE.<\/p>\n

Malignancy<\/strong><\/p>\n

Squamous Cell Carcinoma<\/strong><\/p>\n

90% of all cases caused by tobacco.Due to pipe smoking,present on the vermillion border of lip to 1 side of the midline.Ulcer due to chronic irritation on the lateral & ventral border of tongue.Indurated ulcer with raised borders. smoking,alcohol indurated ulcer of varying size present on 1 side of midline .Due to chewing of tobacco & betal nut,dental irri &cheek biting.Present as induration & infiltration of deeper tissues.<\/p>\n

Miscellaneous<\/strong><\/p>\n

Necrotizing Sialometaplasi<\/strong><\/p>\n

It is a rare, self limiting, variably ulcerated, benign, inflammatory process, predominantly affecting salivary tissue. The importance of the lesion is that it may be mistaken for a malignancy and lead to inappropriately radical surgery. The vast majority (80%) of cases affect the minor salivary glands of the palate, while other sites include retro-molar pad, gingiva, lip, tongue and cheek. The condition has also been reported in major salivary glands. A sub-acute variant has also been described. association with other tumours, specifically: Warthin\u2019s tumour, Abrisokov\u2019s tumour, carcinoma of the lip, rapidly growing mesenchymal malignancy and salivary gland tumours. The lesions may 1 occur bilaterally and metachronously. When ulceration occurs, it usually remains superficial, but a single case of full-thickness necrosis of the palate has been reported. The lesion heals spontaneously over a period of two to twelve weeks. Drug therapy with intra-lesional steroids appears to offer no benefit on recovery time of the lesion or associated anaesthesia16<\/sup>.<\/p>\n

Recurrent Aphthous Stomatitis<\/strong><\/p>\n

The term \u201caphthous\u201d is derived from a Greek word \u201caphtha\u201d which means ulceration. Recurrent aphthous stomatitis (RAS) is one of the most common painful oral mucosal conditions seen among patients. These present as recurrent, multiple, small, round, or ovoid ulcers, with circumscribed margins, having yellow or gray floors and are surrounded by erythematous haloes, present first in childhood or adolescence17<\/sup>.Due to genetics,trauma,tobacco,drugs,hemantinic acid, Sodium lauryl sulfate – containing toothpaste18.<\/sup><\/p>\n

Clinical Features of Recurrent Apthous Stomatitis<\/strong><\/p>\n

Table 2<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\u00a0<\/strong><\/td>\nMinor<\/strong><\/td>\nMajor<\/strong><\/td>\nHerpetiform<\/strong><\/td>\n<\/tr>\n
Age of onset<\/td>\n10-19<\/td>\n10- 19<\/td>\n20- 29<\/td>\n<\/tr>\n
Numbers of ulcer<\/td>\n1-5<\/td>\n1-10<\/td>\n10 \u2013 100<\/td>\n<\/tr>\n
Sites<\/td>\nLip,cheek ,tongue<\/td>\nPalate,pharynx<\/td>\nFloor of the mouth,pharynx,palate,gingiva<\/td>\n<\/tr>\n
Size of ulcers ( mm)<\/td>\n<10<\/td>\n>10<\/td>\n1-2 but often coalse<\/td>\n<\/tr>\n
Duration in days<\/td>\n10-14<\/td>\n\u00d8 30<\/td>\n10-30<\/td>\n<\/tr>\n
<\/td>\nSmall yellowbase surrounded by erythematous border and heals without scarring<\/td>\nSingle large ulcer,heals with scarring<\/td>\nMultiple shallow ulcers,pin head shaped,painful ulcerS<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

Conclusion<\/strong><\/p>\n

The diversity in causes of oral ulceration can\u00a0 be a challenging to task .Hence through knowledge of presentation of the ulcer together with the signs and symptoms of the disease can help the clinician to provide a proper management<\/p>\n

References<\/strong><\/p>\n

    \n
  1. Crispian Scully and Rosemary Shotts;Mouth ulcers and other causes of orofacial soreness and painWest J Med. 2001 Jun; 174(6): 421\u2013424 .<\/li>\n
  2. Oral Complications of Chemotherapy and Head\/Neck Radiation (PDQ\u00ae).<\/li>\n
  3. Physical and chemical injuries. In: Neville B W, Damm D, Allen C M, Bouquot J. Oral and maxillofacial pathology. 3 rd ed. Philadelphia: W B Saunders; 2009:285-329.<\/li>\n
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  11. Kyrmizakis DE1<\/sup>,Doxas PG,\u00a0Hajiioannou JK,\u00a0Papadakis CE.Palate ulcer due to mucormycosis.J Laryngol Otol.\u00a02002 Feb;116(2):146-7.<\/li>\n
  12. Odessey E1<\/sup>,Cohn A,\u00a0Beaman K,\u00a0Schechter L, Invasive mucormycosis of the maxillary sinus: extensive destruction with an indolent presentation.Surg Infect (Larchmt).\u00a02008 Feb;9(1):91-8.<\/li>\n
  13. Michael KerrUlcers and Crohn\u2019s Disease,\u00a0Published on\u00a0March 1, 2012.<\/li>\n
  14. Shafer\u2019s Textbook of oral pathology ,R.Rajendran,B.Sivapathasundharamseventh edition,2012.<\/li>\n
  15. Rajendran R. Oral lichen planus. J Oral Maxillofac Pathol 2005;9:3-5.<\/li>\n
  16. Abrams AM, Melrose RJ, Howell FV. Necrotizing sialometaplasia. A disease simulating malignancy. Cancer 1973; 32:130-5.<\/li>\n
  17. Jurge S, Kuffer R, Scully C, Porter SR. Recurrent aphthous stomatitis. Oral Dis 2006;12:1\u201121. 2. Scully C, Porter S. Oral mucosal disease: Recurrent aphthous stomatitis. Br J Oral Maxillofac Surg 2008;46:198\u2011206.<\/li>\n
  18. Preeti L et all Recurrent aphthous stomatitis Journal of Oral and Maxillofacial Pathology Vol. 15 Issue 3 Sep – Dec 2011 252.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    Introduction Oral ulcers are one of the most common complaints […]<\/p>\n","protected":false},"author":9,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[46],"tags":[],"class_list":["post-14115","post","type-post","status-publish","format-standard","hentry","category-vol10no1"],"_links":{"self":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/14115","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/comments?post=14115"}],"version-history":[{"count":9,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/14115\/revisions"}],"predecessor-version":[{"id":14433,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/posts\/14115\/revisions\/14433"}],"wp:attachment":[{"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/media?parent=14115"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/categories?post=14115"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/biomedpharmajournal.org\/staging\/wp-json\/wp\/v2\/tags?post=14115"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}