1. Course 341 MDS Dr Asma’a Faden

3. Ulcerative lesions Facts ULCUS - Latin origin ULCUS means break in the skin. - Oral ulceration is a break in the oral epithelium, exposing nerve endings in the underlying connective tissue. - It results in pain and soreness of the mouth especially with spicy food and citrus fruits. - Patients vary in the degree to which they suffer and complain of the soreness.

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

5. Ulcerative lesions 1) Local Causes: i)Trauma (physical) - Appliances. - Self-inflicted. - Sharp teeth or restorations. - Iatrogenic. ii)Burns (chemical) - Chemical. - Electric. - Heat. - Radiation.

6. Ulcerative lesions 2) Recurrent aphthae i)Minor ulcers ii)Major ulcers iii) Herpetiform type

7. Ulcerative lesions 3) Infections i)Viral - Vesiculobullous diseases caused by viruses - Human herpesvirus 8 (HHV-8) - Human Immunodeficiency virus ii)Bacterial - Acute Necrotizing Ulcerative Gingivitis (ANUG) - Syphilis - Tubercelusosis iii) Fungal - Chronic Mucocutaneous Candidosis (CMC)

8. Ulcerative lesions 4) Drugs i)Drug-induced neutropenia/anaemia (cytotoxics) ii)Lichenoid drug reactions (e.g. β-blockers, NSAIDs) iii) Drug-induced mucositis (cyclophosphamide)

9. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma ii)Kaposi’s sarcoma iii)Non-Hodgkin’s lymphoma

10. Ulcerative lesions 6) Systemic diseases i)Mucocutaneous diseases ii)Haematological disorders iii)Gastrointistinal disorders

11. Ulcerative lesions 6) Systemic diseases i)Mucocutaneous disease - Behcet’s syndrome - Lichen planus - Vesiculobullous diseases

12. Ulcerative lesions 6) Systemic diseases ii)Haematological disorders - Anaemia - Leukemia

13. Ulcerative lesions 6) Systemic diseases iii) Gastrointestinal disorders - Coeliac disease (Gluten-sensitive entropathy) - Crohn’s disease -

14. - Are common oral lesions, most of them are caused by physical trauma. In addition, ulcers may arise with other traumatic causes as: 1- Physical (mechanical) 2- Chemical (Aspirin burn) Ulcerative lesions 1) Local Causes:

15. Traumatic ulcers Traumatic ulcers : 1- Physical Trauma: - Physical traumatic ulcers are common oral lesions. - Can be caused by a sharp or broken tooth, rough fillings, dental instruments, biting, denture irritation, sharp foreign bodies, etc. Ulcerative lesions 1) Local Causes:

16. 1- Physical Trauma: Clinical features: -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. Ulcerative lesions Traumatic ulcers 1) Local Causes:

17. 1- Physical Trauma: Clinical features: - 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. Ulcerative lesions Traumatic ulcers 1) Local Causes:

18. Physical traumatic Ulcer

19. Ulcerative lesions Traumatic ulcers 1- Physical Trauma: Differential diagnosis Squamous-cell carcinoma and other malignancies, aphthous ulcer, syphilis, tuberculosis. Treatment Removal of traumatic factors. Topical steroids may be used for a short time.

20. Ulcerative lesions Traumatic ulcers 2- Chemical trauma: -Oral ulcers may arise with local application of Aspirin (Salicylic Acid), cocaine or smoking crack cocaine (e.g., on the palate). Clinical features: - It appears as a red, painful erythema that may undergo desquamation, leaving erosions. -The lesions heal spontaneously in about a week. -The diagnosis is made exclusively on clinical grounds.

21. Chemical (Aspirin burn) ulceration: - The photos show a patient who placed an aspirin on her gums. Aspirin is an acid and burned the oral tissues (gums and cheek). - Fortunately the mouth heals quickly and within two weeks healing occurred.

22. Ulcerative lesions Traumatic ulcers 2- Chemical trauma: Differential diagnosis - Thermal burn, traumatic lesions, aphthous ulcers, drug reactions. Treatment - Discontinue the application of the causative agent.

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

24. 2-Recurrent Aphthous Stomatitis Ulcerative lesions - Recurrent aphthous ulcers are among the most common oral mucosal lesions, with a prevalence of 10–30% in the general population. -The cause remains unclear. Recent evidence supports the concept that cell- mediated immune responses play a primary role in the pathogenesis. - Several predisposing factors have been reported, such as trauma, allergy, genetic predisposition, endocrine disturbances, emotional stress, hematological deficiencies, and AIDS. -Three clinical variations have been recognized: minor, major and herpetiform ulcers. -They are very painful and cause the patient alot of discomfort.

25. Herpetiform recurrent Aphthous Stomatitis -The herpetiform variation is characterized by small, painful, shallow ulcers, 1– 2 mm in diameter, with a tendency to coalesce into larger irregular ulcers. - Characteristically, the lesions are multiple (10–100), persist for one or two weeks, and heal without scarring. - usually in old age group, common in females. Ulcerative lesions 2-Recurrent Aphthous Stomatitis

26. Herpetiform aphthae

27. Minor recurrent Aphthous Stomatitis -Minor aphthae are the most common form, and they present clinically as small, painful, round ulcers 3–6 mm in diameter, covered by a whitish-yellow membrane and surrounded by a thin red halo. -The lesions may be single or multiple (two to six), and they heal without scarring in 7–12 days. - Mainly found in on the non-keratinized mobile mucosa, lips cheeks, floot of the mouth. Ulcerative lesions 2-Recurrent Aphthous Stomatitis

28. Minor aphthous ulcer

29. Major recurrent Aphthous Stomatitis -The major form is characterized by deep painful ulcers, 1–2 cm in diameter, that persist for 3–6 weeks and may cause scarring. - The number of lesions varies from one to five. - Found in any area of the mucosa, including keratinized dorsum of the tongue, palate. Ulcerative lesions 2-Recurrent Aphthous Stomatitis

30. Major aphthous ulcer

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

32. Ulcerative lesions 3) Infections i)Viral - Vesiculobullous diseases caused by viruses - Human herpesvirus 8 (HHV-8) - Human Immunodeficiency virus ii)Bacterial - Acute Necrotizing Ulcerative Gingivitis (ANUG) - Syphilis - Tubercelusosis iii) Fungal - Chronic Mucocutaneous Candidosis (CMC)

33. Ulcerative lesions Infectious causes of oral mucosal ulcers 1- Viral - Vesiculobullous diseases caused by viruses - Human herpesvirus 8 (HHV-8) - Human Immunodeficiency virus

34. Human Herpes virus-8 (HHV-8) -The causative microbe for Kaposi’s sarcoma (KS). -Kaposi sarcoma is a malignant neoplasm of endothelial cell origin. -Four forms of KS are recognized: Classic, African (endemic), Immunosuppression-associated (iatrogenic) and AIDS-related (epidemic): This has a high incidence among AIDS patients, primarily involves the skin, lymph nodes, viscera, and frequently the oral mucosa. Ulcerative lesions Infectious causes of oral mucosal ulcers 1- Viral

35. Kaposi’s sarcoma starts as a spot or erythematous or violet plaque which appears flat. Its habitual location is the palate or the gingiva, but have been observed it on the tongue.

36. Human Herpes virus-8 (HHV-8) -Clinically: the oral lesions present as multiple or solitary red or brownish-red patches or elevated plaques or tumors. - The palate and gingiva are the most common sites affected, followed by buccal mucosa, tongue, and lips. - Differential diagnosis: Pyogenic granuloma, peripheral giant-cell granuloma, hemangioma. - Treatment: Interferon, chemotherapy, radiotherapy, or surgical excision in small, localized lesions. Ulcerative lesions Infectious causes of oral mucosal ulcers 1- Viral

37. Human Immunodeficiency Virus (HIV) - A minority of patients with severe HIV disease will develop deep, necrotic ulcers of unknown aetiology. - These ulcers are painful, cause profound dysphagia and can arise on any oral mucosal surface, although the buccal and pharyngeal mucosa ate the more commonly affected sites. Ulcerative lesions Infectious causes of oral mucosal ulcers 1- Viral

38. Human Immunodeficiency Virus (HIV) -The ulcers typically resolve with systemic thalidomide (e.g. 200 mg daily) - Small number of patients with HIV disease may have ulcers similar to that of recurrent aphthous stomatitis (RAS), although whether the frequency of RAS in HIV is truly increased remains unclear. Ulcerative lesions Infectious causes of oral mucosal ulcers 1- Viral

39. HIV-associated ulceration

40. Ulcerative lesions 3) Infections i)Viral - Vesiculobullous diseases caused by viruses - Human herpesvirus 8 (HHV-8) - Human Immunodeficiency virus ii)Bacterial - Acute Necrotizing Ulcerative Gingivitis (ANUG) - Syphilis - Tubercelusosis iii) Fungal - Chronic Mucocutaneous Candidosis (CMC)

41. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial i) Acute Necrotizing Ulcerative Gingivitis (ANUG) ii) Syphilis iii) Tubercelusosis

42. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial i) Acute Necrotizing Ulcerative Gingivitis (ANUG) -This entity used to be called "Trench Mouth" because of its prevalence in soldiers fighting in the trenches during world war I. - Etiology: Fusobacterium nucleatum, Treponema vincentii, and probably other bacteria play an important role. - Predisposing factors are emotional stress, smoking, poor oral hygiene, local trauma, and mainly HIV infection.

43. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial i) Acute Necrotizing Ulcerative Gingivitis (ANUG) -Clinical features The characteristic clinical feature is painful necrosis of the interdental papillae and the gingival margins, and the formation of craters covered with a gray pseudomembrane. - Spontaneous gingival bleeding, halitosis, and intense salivation are common. Fever, malaise, and lymphadenopathy are less common. -Rarely, the lesions may extend beyond the gingiva (necrotizing ulcerative stomatitis). -The diagnosis is made at the clinical level.

44. ِAcute Necrotizing Ulcerative Gingivitis

45. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial i) Acute Necrotizing Ulcerative Gingivitis (ANUG) - Differential diagnosis Herpetic gingivitis, Desquamative gingivitis, Agranulocytosis, leukemia. -Treatment Systemic metronidazole and oxygen-releasing agents topically are the best therapy in the acute phase, followed by a mechanical gingival treatment.

46. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial ii) Syphilis - Syphilis is a relatively common sexually transmitted disease. - Etiology Treponema pallidum. -Clinical features: Syphilis may be acquired (common) or congenital (rare). - Acquired syphilis is classified as primary, secondary and tertiary.

47. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial ii) Syphilis -Clinical features: -The characteristic lesion in the primary stage is the chancre that appears at the site of inoculation, usually three weeks after the infection. - Oral chancre appears in about 5–10% of cases, and clinically presents as a painless ulcer with a smooth surface, raised borders, and an indurated base. - Regional lymphadenopathy is a constant finding.

48. Solitary chancre on the ventral surface of the tongue Two chancres on the tongue

49. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial ii) Syphilis - Differential diagnosis Traumatic ulcer, aphthous ulcer, tuberculosis, herpes simplex, candidiasis, erythema multiforme, lichen planus. -Treatment Penicillin is the antibiotic of choice. Erythromycin or ephalosporins are good alternatives.

50. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial iii) Tuberculosis - Tuberculosis is a chronic, granulomatous, infectious disease that primarily affects the lungs. - Etiology Mycobacterium tuberculosis. -Clinical features The oral lesions are rare, and usually secondary to pulmonary tuberculosis. -The tuberculosis ulcer is the most common feature. - Clinically, the ulcer is painless and irregular, with a thin undermined border and a vegetating surface, usually covered by a gray-yellowish exudate. - The dorsum of the tongue is the most commonly affected site, followed by the lip, buccal mucosa, and palate.

51. Ulcerative lesions Infectious causes of oral mucosal ulcers 2- Bacterial iii) Tuberculosis - Clinically, the ulcer is painless and irregular, with a thin undermined border and a vegetating surface, usually covered by a gray-yellowish exudate. - The dorsum of the tongue is the most commonly affected site, followed by the lip, buccal mucosa, and palate. - Differential diagnosis: carcinomas, syphilis, eosinophilic ulcer, necrotizing sialadenometaplasia, malignant granuloma, major aphthous ulcer. - Treatment Antituberculous drugs.

52. Tuberculosis: typical ulcer on the dorsal surface of the tongue

53. Ulcerative lesions 3) Infections i)Viral - Vesiculobullous diseases caused by viruses - Human herpesvirus 8 (HHV-8) - Human Immunodeficiency virus ii)Bacterial - Acute Necrotizing Ulcerative Gingivitis (ANUG) - Syphilis - Tubercelusosis iii) Fungal - Chronic Mucocutaneous Candidosis (CMC)

54. Ulcerative lesions Infectious causes of oral mucosal ulcers 3- Fungal Chronic Mucocutaneous Candidosis (CMC) Chronic Mucocutaneous Candidosis (CMC) -Chronic mucocutaneous candidiasis (CMC) is the label given to a group of overlapping syndromes that have in common a clinical pattern of persistent, severe, and diffuse cutaneous candidal infections. -These infections affect the skin, nails and mucous membranes Chronic oral candidiasis Chronic oral candidiasis - Chronic oral candidiasisChronic oral candidiasis -Related to denture stomatitis -HIV-associated candidiasis -Related to inhaled corticosteroid use

55. CMC

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

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

59. 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.

60. 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)

61. 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

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

63. Drug reaction oral ulceration

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

65. 5- Malignant diseases Ulcerative lesions i)Oral squamous cell carcinoma ii)Kaposi’s sarcoma iii)Non-Hodgkin’s lymphoma

66. 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).

67. 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.

68. 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.

69. 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.

70. Squamous Cell Carcinoma

71. 5- Malignant diseases Ulcerative lesions ii)Kaposi’s sarcoma (Discussed in viruses part)

72. 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

73. 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

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

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

76. 6- Oral ulcers related to systemic diseases Ulcerative lesions i)Mucocutaneous. ii)Haematological. iii)Gastroentrological.

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

78. 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.

79. 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)

80. 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.

81. 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.

82. Behcets Disease Ulcerative lesions

83. Behçet Disease

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

85. 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.

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

87. 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.

88. 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.

89. 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.

90. Chronic lymphocytic leukemia: ulcer on the palate

91. Chronic lymphocytic leukemia: severe gingival enlargement and ulcerations

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

93. 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

94. 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.

95. 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.

96. Aphthous ulcer-like in Gluten entropathy patient

97. 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

98. 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

99. 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

100. 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

101. Crohn’s disease

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

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