2. Course 341 MDS Dr Asma’a Faden http://faculty.ksu.edu.sa/Asmaa Faden

4. Ulcerative lesions Main causes of oral ulceration 1. Local Causes 2. Recurrent Aphthous Stomatitis 3. Infections 4. Drugs 5. Malignant disease 6. Systemic disease

5. Ulcerative lesions 4) Drugs - A wide range of drugs can give rise to ulcers of the oral mucosa. - Drugs may induce ulcers by producing a local burn, or by a variety of mechanisms such as the induction of lichenoid lesions. - A drug history is essential to elicit such uncommon reactions, and then the offending drug should be avoided.

6. Ulcerative lesions 4) Drugs Common drugs causing oral ulcerations: i)Drug-induced neutropenia/anaemia (cytotoxics, e.g, Chemotherapy) ii)Lichenoid drug reactions (e.g. β-blockers, NSAIDs) iii) Drug-induced mucositis (cyclophosphamide, e.g, Chemotherapy)

7. Ulcerative lesions 4) Drugs Clinically: - The mucosal reactions vary according to the causative agent, including localized stomatitis, or generalized in case of systemic drugs. Diagnosis rely on medical history, clinical examination and drugs used. Differential diagnosis: - Lichen planus, Stevens–Johnson syndrome, pemphigus vulgaris, severe and extensive burns. Management: - Elimination of any local cause, topical steroids and supportive therapy

8. Oral mucositis after chemotherapy (CT) and radiotherapy (RT)

9. Drug reaction oral ulceration

10. Ulcerative lesions Main causes of oral ulceration 1. Local Causes 2. Recurrent Aphthous Stomatitis 3. Infections 4. Drugs 5. Malignant disease 6. Systemic disease

11. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma ii)Kaposi’s sarcoma iii)Non-Hodgkin’s lymphoma

12. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma - Squamous-cell carcinoma represents about 90% of oral cancers, and accounts for 3–5% of all cancers. - The cause is multifactorial. The most important predisposing factors are tobacco smoke, alcohol, sun exposure, poor oral hygiene, dietary deficiencies, iron deficiency, liver cirrhosis, Candida infection, oncogenic viruses (e.g, HPV).

13. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma -Oral squamous-cell carcinoma occurs more frequently in men than in women (ratio 2 : 1), and usually in those over 40 years of age. -It has a varied clinical presentation, and may mimic several diseases. -Early carcinoma may appear as a white lesion, a red lesion, or both, or even as an exophytic mass. However, the most common clinical presentation is an erosion or an ulcer.

14. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma -Clinically: a carcinomatous ulcer has an irregular papillary surface, elevated borders, and a hard base on palpation. -The lesions are almost always chronic and indurated. The lateral border, the ventral surface of the tongue, and the lips are the most commonly affected areas followed by the floor of the mouth, the gingiva, the alveolar mucosa, the buccal mucosa, and the palate. -The prognosis depends on the tumor stage and the histopathological pattern.

15. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma - Laboratory tests Histopathological examination. - Differential diagnosis Traumatic ulcer, tuberculosis, syphilis, eosinophilic ulcer, minor salivary gland carcinomas. - Treatment Surgical excision, radiotherapy, or both, and chemotherapy.

16. Squamous Cell Carcinoma

17. 5- Malignant diseases Ulcerative lesions ii)Kaposi’s sarcoma (Discussed in viruses part)

18. 5- Malignant diseases Ulcerative lesions iii) Non-Hodgkin’s lymphoma -Non-Hodgkin lymphoma (also known as non-Hodgkin's lymphoma, NHL, or sometimes just lymphoma) is a cancer that starts in cells of the lymph system, which is part of the body's immune system. -Non-Hodgkin lymphoma may develop in any organ associated with the lymphatic system (e.g. spleen, lymph nodes, or tonsils). Most cases start with infiltration of lymph nodes, but some subtypes may be restricted to other lymphatic organs.spleenlymph nodestonsils

19. 5- Malignant diseases Ulcerative lesions iii) Non-Hodgkin’s lymphoma - Clinically: NHL may manifest as a solitary area of necrotic ulcers typically affecting the gingiva, palate and fauces. - Laboratory tests Histopathological and immunohistochemical examination. - Differential diagnosis Eosinophilic ulcer, necrotizing sialadenometaplasia, tuberculosis, squamous cell carcinoma. - Treatment Radiotherapy and chemotherapy

20. Non-Hodgkin lymphoma: large ulcer on the soft palate

21. Ulcerative lesions Main causes of oral ulceration 1. Local Causes 2. Recurrent Aphthous Stomatitis 3. Infections 4. Drugs 5. Malignant disease 6. Systemic disease

22. 6- Oral ulcers related to systemic diseases Ulcerative lesions i)Mucocutaneous. ii)Haematological. iii)Gastroentrological.

23. Oral ulcers related to systemic diseases Ulcerative lesions i) Mucocutaneous: 1- Behcet’s syndrome 2- Lichen Planus. 3- Vesiculobullous diseases

24. Oral ulcers related to systemic diseases Ulcerative lesions i) Mucocutaneous: 1- Behcet’s syndrome - Behçet disease is a chronic multisystemic inflammatory disorder. -The exact cause is unclear, although an immunogenetic basis is suggested. - It is more common in males (5–10 times), and the onset is usually in the 20– 30 years age group.

25. Oral ulcers related to systemic diseases Ulcerative lesions i) Mucocutaneous: 1- Behcet’s syndrome Clinical features - The major clinical diagnostic criteria for the disease are: (a) recurrent oral ulcerations (aphthae) (b) recurrent genital ulcerations (c) ocular lesions (conjunctivitis, reduced visual acuity (d) skin lesions (papules, pustules,ulcers)

26. Oral ulcers related to systemic diseases Ulcerative lesions i) Mucocutaneous: 1- Behcet’s syndrome Clinical features -Minor clinical features may also be present, e. g., arthritis, arthralgia, vein thrombosis, arterial occlusion and aneurysms, central nervous system involvement, pulmonary, renal, and gastrointestinal manifestations. -The diagnosis is mainly made on clinical grounds. For accurate diagnosis, recurrent oral ulcerations plus two of the other four major criteria must be present.

27. Oral ulcers related to systemic diseases Ulcerative lesions 1- Behcet’s syndrome - Differential diagnosis Recurrent aphthous ulcers, erythema multiforme, Stevens–Johnson syndrome. -Treatment Topical steroids in mild cases. Systemic steroids in severe cases.

28. Behcets Disease Ulcerative lesions

29. Behçet Disease

30. Oral ulcers related to systemic diseases Ulcerative lesions ii) Haematological: 1- Anemia. 2- Leukemia.

31. Oral ulcers related to systemic diseases Ulcerative lesions ii) Haematological: 1- Anemia -Pernicious anemia, iron deficiency anemia usually affect the oral mucosa. Clinical features: The oral manifestations are early and common, and are characterized by an atrophic, smooth and red tongue. A burning sensation, taste loss, angular cheilitis may be present. Differential diagnosis includes atrophic lichen planus and malnutrition disorders. -The diagnosis is based on hematological laboratory tests. - Management : treat the cause by supplements or good nutrition.

32. Pernicious anemia: red and smooth dorsum of the tongue with areas of ulcerations.

33. Oral ulcers related to systemic diseases Ulcerative lesions ii) Haematological: 2- Leukemia - Leukemias are a group of malignant disorders of the blood-forming tissues, characterized by defects in the maturation and proliferation of leukocytes. Etiology These conditions are probably caused by a combination of genetic and environmental factors (viruses, chemicals, radiation). - Leukemias are classified as acute and chronic, depending on the clinical course, and myeloid or lymphocytic, according to the histogenetic origin.

34. Oral ulcers related to systemic diseases Ulcerative lesions ii) Haematological: 2- Leukemia Clinical features: All forms of leukemia can have oral manifestations. -The most common oral lesions are ulcerations, spontaneous gingival hemorrhage, petechiae, ecchymoses, tooth loosening, and delayed wound healing. Gingival enlargement is a characteristic pattern, frequently seen in patients with myelomonocytic leukemia. - Candidiasis and herpetic infections are relatively common oral complications of leukemia.

35. Oral ulcers related to systemic diseases Ulcerative lesions ii) Haematological: 2- Leukemia Laboratory tests Peripheral blood counts, bone-marrow examination. Differential diagnosis Agranulocytosis, cyclic neutropenia, thrombocytopenic purpura, acute necrotizing ulcerative gingivitis, gingival overgrowth due to drugs. Treatment Chemotherapy, bone-marrow transplantation, supportive therapy.

36. Chronic lymphocytic leukemia: ulcer on the palate

37. Chronic lymphocytic leukemia: severe gingival enlargement and ulcerations

38. Oral ulcers related to systemic diseases Ulcerative lesions iii) Gastroentrological diseases: 1- Coeliac diseases (Gluten-sensitive entropathy) 2- Crohn’s disease.

39. Oral ulcers related to systemic diseases Ulcerative lesions 1- Coeliac Disease -Also known as gluten-sensitive enteropathy, celiac disease occurs in people who have a susceptibility to gluten intolerance. -Celiac disease results in damage to the villi. Without villi, the inner surface of the small intestine becomes less like a plush carpet and more like a tile floor, and the body is unable to absorb nutrients necessary for health and growth. - Instead, nutrients such as fat, protein, vitamins and minerals are eliminated with your stool. -The exact cause of celiac disease is unknown, but it’s often inherited

40. Oral ulcers related to systemic diseases Ulcerative lesions 1- Coeliac Disease -Clinical features: Typica l cases of CD present at the age of 6-24 months with symptoms of intestinal malabsorption, impaired growth, abnormal stools, abdominal distension, muscle wasting, hypotonia, poor appetite or unhappy behaviour. - In adults, the symptoms of CD may be highly varied and range from severe weight loss and diarrhoea with bulky offensive stools, to subtle complaints of cramps, abdominal bloating, flatulence and even constipation. - These individuals are often mistakenly diagnosed as having an irritable bowel syndrome.

41. Oral ulcers related to systemic diseases Ulcerative lesions 1- Coeliac Disease - Differential diagnosis : Recurrent oral aphthous ulcers-like are common and should arouse suspicion of the condition. --There are a range of blood tests that have been introduced internationally over the past few years that can be used to support the diagnosis of CD. - Management : The first line of treatment is the complete removal of gluten from the diet. This usually entails life-long avoidance of all cereals containing gluten, including wheat, oats, rye and barley.

42. Aphthous ulcer-like in Gluten entropathy patient

43. Ulcerative lesions 2- Crohn’s Disease Definition Crohn’s disease or regional ileitis is a chronic inflammatory disease that primarily affects the ileum and other parts of the gastrointestinal tract. - The disease usually affects young individual Etiology Unknown; probably immunologically mediated. Oral ulcers related to systemic diseases

44. Ulcerative lesions 2- Crohn’s Disease Clinical features : -Presents clinically with abdominal pain, nausea, diarrhea, weight loss, low- grade fever, and rectal bleeding. - Extra-abdominal involvement includes arthritis,uveitis, and oral lesions. Oral ulcers related to systemic diseases

45. Ulcerative lesions 2- Crohn’s Disease Clinical features : Oral lesions occur in 10–20% of patients and are characterized by nodular swelling, which may be ulcerated. -Diffuse raised nodules resulting in a cobblestone appearance of the mucosa or mucosal tag lesions may occur. - Granulomatous lip swelling, angular cheilitis, gingival swelling, and atypical ulcerations may be seen. Oral ulcers related to systemic diseases

46. Ulcerative lesions 2- Crohn’s Disease Laboratory tests : Histopathological examination. Differential diagnosis Orofacial granulomatosis, epulis fissuratum, pyogenic granuloma. Treatment Topical steroids, systemic steroids, sulfasalazine Oral ulcers related to systemic diseases

47. Crohn’s disease

48. Crohn’s disease: cobblestone appearance of the buccal mucosa

49. Irregular superficial ulcers on ventral surface of tongue in Crohn’s disease