1. Traumatic diseases of oral cavity. Infectious diseases of oral cavity.
Etiology, clinical picture, diagnostics, treatment and prevention.

2. Oral ulcers
How to diagnose?

3. What is an ulcer?
A mouth (or oral) ulcer   is an open sore in the mouth, or rarely a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. 

4. Epidemiology and frequency
Mouth ulcer is a very common oral lesion. Epidemiological studies show an average prevalence between 15% and 30%. Mouth ulcers tend to be more common in women and those under 45. 
The frequency of mouth ulcers varies from fewer than 4 episodes per year (85% of all cases) to more than one episode per month (10% of all cases) including people suffering from continuous recurrent aphthous stomatitis

5. What cause ulcers? Trauma (physical injuries) Chemical injuries
Smoking
Infection
- viral
- bacterial
- fungal
- protozoans
Immunodeficiency
Autoimmunity
Allergy
Dietary

6. Tools for diagnosis: History Examination Further investigation
Additional diagnostic methods – physical (VELscope, Visilite, Orascoptic DK)
Biopsy

7. Further investigation – questions you should ask:
How many ulcers do you have?
How long have you had that ulcer?
Is it painful?
Can you relate them to any trauma, hot food or another factors?
Is it the first time or you had them before?
Where are they located in the mouth?
Do they start as ulcer or as vesicle/bulla?
Do you get them anywhere else on the body?

8. Step by step guide to performing an oral cavity examination

9. Things you need to look for:
Place
Number
Size
Shape
Base
Edge

10. Differential diagnostic, based on history
How long have you had the ulcer?
Long time – chronic
Chronic trauma (single, can identify the cause, and should improve after removal)
Malignancy (single, painless)
TB (single ulcer in the tongue/palate, associated symptoms – chronic cough)
Mucous membrane pemphigoid (multiple ulcers affect mainly gingiva, blood filled blisters)
Primary or tetriary syphilis

11. Recent – acute
Acute trauma (single, can identify the cause, and should improve after removal)
Viral infection (multiple, associated symptoms – fever)
Immune mediated disease (Erythema multiforme, RAS)

12. How many ulcers do you have?
Single
Traumatic
Primary or tetriary syphilis TB
Malignancy
Multiple
Viral infection
Immune mediated disease

13. Is it painful? Yes Acute causes (trauma, viral, immune mediate) No
Chronic causes (trauma, TB)

14. Can you relate them to trauma or hot food?
Yes
Confirm traumatic ulcer
Remove the cause
Review after 1 week No
Look for other causes

15. Do you get them anywhere else on the body?No
Think or oral conditions
Yes – where?
Skin – mucocutanous disease (lichen planus, pemphigus)

16. So, just a few simple questions can help you to put diagnosis even before examination

17. Traumatic lesions Can be divided to:
Mechanical trauma (acute or chronic)
Chemical injury (acid, alcali)
Physical injury (thermal injury, electrical injury)

18. Traumatic lesion after teeth brush 2. White lesion caused by trauma.

19. White lesion caused by trauma (chemical injure - acetylsalicylic acid burn) 2. Leukoplakia of soft palatine

20. Hematoma after trauma 2. Hematoma after trauma – intraoral picture

21. Oral ulcers after long chemotherapy

22. Dental braces

23. Mechanical trauma
Can be:
Acute
Chronic

24. And caused by: A sharp edge of a tooth Accidental biting
Sharp, abrasive,or excessively salty food
 Poorly fitting dentures
Dental braces
Trauma from a tooth brush
Patients bad habits

25. Acute trauma Single, Can identify the cause
Should improve after removal

26. Traumatic ulcers:

27. Clinical features of traumatic ulcers:
•They are clinically diverse, but usually appear as a single, painful ulcer with a smooth red or whitish-yellow surface and a thin erythematous halo.
•They are usually soft on palpation, and heal without scarring within 6–10 days, spontaneously or after removal of the cause.
•However, chronic traumatic ulcers may clinically mimic a carcinoma.
•The tongue, lip, and buccal mucosa are the sites of predilection.
•The diagnosis is based on the history and clinical features.
•However, if an ulcer persists over 10–12 days a biopsy must be taken to rule out cancer.

28. Treatment Removing factors, caused trauma Good hygiene of oral cavity
Antiseptic for 7-10 days
Analgetics if it is necessary
Topical steroids may be used for a short time.
Biopsy

29. Leukoplakia
Etiology:  -​trauma from habitual biting, dental appliances -​tobacco use -​​alcohol consumption ​-oral sepsis -​local irritation ​-syphilis​ -vitamin deficiency -​endocrine disturbances​​ -dental galvanism ​-actinic radiation (in the case of lip involvement).
Symptoms - painless, fuzzy white patches on the side of the tongue or cheeks.

30. Clinical picture
-​located on the tongue, mandibular alveolar ridge and buccal mucosa in ~50%. -​palate, maxillary alveolar ridge, lower lip, floor of the mouth and the retromolar regions are somewhat less frequently involved. -​may vary from nonpalpable, faintly translucent white areas to thick, fissured, papillomatous, indurated lesions. -​surface is often wrinkled or shriveled in appearance and may feel rough on palpation. -​color may be white, gray, yellowish-white, or even brownish-gray in patients with heavy tobacco use. Physical: -​lesion cannot be wiped away with a gauze

32. Differential diagnosis:
Candidiasis and aspirin burn - can be wiped away with a gauze
Erythroplakia (a red plaque that does not rub off) is a dysplastic lesion (or worse) in 90 percent of cases.

33. Treatment
Treat dental causes such as rough teeth, irregular denture surface, or fillings as soon as possible.
Stopping tobacco or/and alcohol.
Removal of leukoplakic patches with using a scalpel, a laser or an extremely cold probe that freezes and destroys cancer cells (cryoprobe).

34. Chemical injures: Chemicals such as aspirin or alcohol
 that are held or that come in contact with the oral mucosa may cause tissues to become necrotic and slough off creating an ulcerated surface.

35. Treatment: Wash a mouth with lot of water Analgetics (for 3-5 days )
Antiseptics ( for 7 – 10 days)
Keratolytics (after 5-7 days)
Keratoplastics (after 7-10 days)

36. Physical injures:
Electric Burns to the Mouth -are most commonly caused when a child bites into a cord, touches the male ends of a "live" but improperly connected cord, or sucks on the female end of an extension cord that is plugged into the wall. The vast majority of the patients is younger than three years.

37. Treatment: Conservative Antiseptics Antibiotics Analgetic
2. Surgical (after the healing was completed and after the degree of functional and/or aesthetic deformity was established (usually 6 months post-injury)).

38. Stomatitis Description
Stomatitis is an inflammation of the lining of any of the soft-tissue structures of the mouth. Stomatitis is usually a painful condition, associated with redness, swelling, and occasional bleeding from the affected area. Bad breath (halitosis) may also accompany the condition. Stomatitis affects all age groups, from the infant to the elderly.

39. Definition
Inflammation of the mucous lining of any of the structures in the mouth, which may involve the cheeks, gums, tongue, lips, and roof or floor of the mouth. The word "stomatitis" literally means inflammation of the mouth. The inflammation can be caused by conditions in the mouth itself, such as poor oral hygiene, poorly fitted dentures, or from mouth burns from hot food or drinks, or by conditions that affect the entire body, such as medications, allergic reactions, or infections.

40. Herpetic stomatitis
Herpetic stomatitis is a viral infection of the mouth that causes ulcers and inflammation. These mouth ulcers are not the same as canker sores, which are caused by a different virus.

41. Symptoms:
Blisters in the mouth, often on the tongue, cheeks, palate, gums, and a border between the lip (red colored) and the normal skin next to it
Decrease in food intake, even if the patient is hungry
Difficulty swallowing (dysphagia)
Fever (often as high as 104 °Fahrenheit) may occur days before blisters and ulcers appear
Irritability
Pain in mouth
Swollen gums
Ulcers in the mouth, often on the tongue or cheeks -- these form after the blisters pop

42. Causes
Herpetic stomatitis is a contagious viral illness caused by Herpes virus hominis (also herpes simplex virus, HSV). It is seen mainly in young children. This condition is probably a child's first exposure to the herpes virus.
An adult member of the family may have a cold sore at the time the child develops herpetic stomatitis. More likely, no source for the infection will be discovered.

43. Herpetic stomatitis – intraoral and extraoral picture

44. 1. Herpes recurrent 2. Herpes recurrent in AIDS patient

45. Differential diagnostics:
Streptococcal pharyngitis –does not involve the lips or perioral tissues and vesicles do not precede the ulcers
Erythema multiforme – ulcers are larger, usually without a vesicular stage and are less likely to affect the gingiva.
Aphthous stomatitis – the multiply lesions, palatal and gingival location are indicative to herpesvirus infection. Additionally, aphthae usually localized only on nonceratinized mucoza, such as the floor of the mouth, alveolar mucosa and buccal mucosae.

46. Treatment: Good oral hygiene
Acyclovir family of antiviral medications – non later than 48 hours!
Analgetic ( or oral topical anesthetic )
Diet (no hot or pepper food)
Antiseptics

47. Aphthous Ulcers
Of all the type of nontraumatic ulceration that affect oral mucosa that is the most common.

48. Aphthous ulcers are also known as canker sores
Aphthous ulcers are also known as canker sores. They are painful, temporary sores that may occur anywhere in the mouth. Usually, they show up in several places:
On the inside of the lips
Inside the cheeks
On the tongue
At the base of the gums

49. Canker sores on tongue:

50. Etiology: Immune system disorders
Other conditions cause similar sores:
Blood and immune system diseases, including HIV
Vitamin and mineral deficiencies
Allergies
Trauma
Crohn's disease
Lupus

51. Clinical features:
Three forms of aphthous ulcers have been recognized: minor, major and herpetiform.

52. §  Major Ulcerations (> 0,5cm)—10% of lesions
o   extremely painful (odynophagia)... typically heal with scar formation
o   Appearance- deeply cratered ulcers
o   Duration-    > 1 month for healing.
o   Location- posterior oral cavity.
0 Number – 1- 10
o   NOTE- THINK OF HIV DISEASE PROGRESSION OR IMMUNOSUPPRESION
§  Minor Ulceration (1-5 mm)—85% of lesions
o   painful… heal without scar formation
o   Duration days
o   Location- anterior oral cavity
0 Number – 1-5
§  Herpetiform Ulceration (1-3mm lesions that form clusters)—5% of lesions.
o   Number –
o   Locational – any intraoral site

53. Minor ulcers: Are the most commonly encountered form
Single, painful oval ulcer less than 0,6 mm, covered by a yellow fibrinous membrane
Last 7 to 10 days
Periods of freedom from disease – 2-3 weeks to year

54. Major ulcers: Lesions are larger: more than 6-10 mm More painful
Persist longer that minor aphthae
One ulcer disappears, another one starts
Healing generally occurs in 6 weeks and longer
Chronic stress, common disease can cause

55. Herpetiform ulcers Recurrent crops of small ulcers
Healing generally occurs in 1 to 2 weeks
Not preceded by vesicle and exhibit no virus-infected cells

56. Treatment: Oral hygiene Avoiding spicy food
Oral rising with sodium bicarbonate
Analgesics
Antiseptics
Anti – inflammatory agents
Antimicrobial and corticosteroids