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| IMC Wiki | Ulcers of oral mucosa

Ulcers of oral mucosa

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Specified lesions and diseases

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Introduction

Ulcers of oral mucosa can be caused by numerous aetiological factors. They arise predominantly on previously injured mucosa as secondary efflorescence, expose the lamina propria and heal with scarring. All disorders discussed in the vesiculo-bullous diseases chapter may appear in severe cases also in form of ulcers, therefore a definitive separation of the two groups of diseases is not possible. In the following articles, such disorders will be demonstrated in which ulcer the leading symptom is

Traumatic- and radiation-induced ulcerations

Synonym: decubital ulcer, radiation mucositi

Definition and clinical features

Mechanical injuries or radiation-, e.g. X-rays-induced ulceration of oral mucosa are common disorders. Injury can result from trauma, including cheek chewing, contact with orthodontic devices, dentures or interdental wire ligature, etc. Other causes include: pterygoidal palate ulcerations in babies (Bednar’s aphthae), thermal-, electrical- or chemical burns.
The ulcer presents usually as a single lesion in close association with its causing agent (e.g. sharp margin of a denture). Most common locations are: lateral tongue, buccal and labial mucosa. The radiation-induced ulcer after irradiation therapy of cancer may appear everywhere within the mouth. Chronic irritation may induce hyperplasia or hyperkeratosis, as well.

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Diagnosis/ Histopathological features

Microscopically, a deep epithelial defect can be seen which is covered by a fibrino-purulent membrane. The ulcer bed consists of granulation tissue, if foreign body is present, it induces formation of foreign-body granulomas. Deep, radiation-induced ulcers may cause osteoradionecrosis with sequestration of necrotic bone tisse and secondary development of painful fistulas, on occasion. A characteristic feature of radiation-induced tissue damage is: the so-called radiation vasculopathy with fibrous thickening of vessel walls and lumen obliteration accompanied by very mild inflammatory reaction in surrounding tissues.

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Differential diagnosis

Intraoral ulcers of different aetiology:
  • Malignant tumours
  • Recurring aphthae
  • Systemic diseases (haematologic; gastrointestinal, like celiac disease, Chron’s disease and ulcerative colitis; mucocutaneus, like lichen planus, pemphigus, erythema multiforme, epidermolysis bullosa, lupus erythematodes; infections, medications

Treatment and prognosis

Elimination of causative factors. Topical treatment. The healing process of traumatic ulceration is either rapid or slow, whereas healing of radiation-induced ulcers is generally prolonged, some of them don’t heal at all.

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Acute necrotising ulcerative gingivitis (ANUG)

Synonym: Vincent’s infection, trench mout

Definition and clinical features

Acute, necrotising, non-contagious inflammation of the gingiva and tonsils caused by an anaerobic fusiform bacterium (Bacillus fusiformis=fusobacterium nucleatum) and a spirochete, Borrelia vincentii. Main predisposing factors are: poor oral hygiene, smoking, immunodeficiency, especially in HIV-infections, and diabetes mellitus. The infection frequently occurs in the presence of phsychologic stress, it affects predominantly young male adults in residential schools, asylums and military service. Clinical features consist of: blunted interdental papillae with mucosal necrosis, fetid odor, significant pain, and spontaneous haemorrhage of gingival margin. Uncommon ancillary clinical features include: fever, malaise, lymph node enlargement (in contrast to herpetic stomatitis).

In severe cases, the infection spread out to the entire oral mucosa and affects tonsils (Plaut-Vincent’s angina=acute necrotising ulcerative mucositis =ANUM)

A particularly severe form of the disease (noma =cancrum oris) occurs in underfed and immunocompromised small children in Africa and South-East Asia with buccal perforation, tooth loosening, bone necrosis and, not infrequently, lethal outcome.

Diagnosis/ Histopathological features

Smears for detection of fusobacteria and spirochete; only diagnostic in large numbers, since small numbers are components of the normal oral flora.
Histologically, predominant tissue necrosis with uncharacteristic ulcer covered by pseudomembrane.

Differential diagnosis

Acute leukaemia, herpetic stomatitis, chronic metal intoxicatio

Treatment and prognosis

Professional tooth cleaning, oral hygiene, metronidasol (during pregnancy: penicillin).
Usually benign course, often recurrent.

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Tuberculosis

Definition and clinical features

Tuberculosis is a chronic infectious disease caused by Mycobacteria: predominantly by M. tuberculosis, rarely also by atypical Mycobacteria, such as M. avium-intracellulare, M. scrofulaceum, M. kansasii. Tuberculosis is most commonly localised in the respiratory system, but all other organs can be affected. Tuberculosis is a notifiable disease!

Morbidity increases worldwide, mainly in alcoholics, AIDS patients, drug addicts and diabetics. Tuberculosis is characterised by the formation of specific, epitheloid granulomas (tubercles) as morphological correlatives of cell-mediated, delayed hypersensitivity reaction type IV against antigens of the bacterial wall. The clinical course is determined by the virulence of Mycobacteria and the resistance of the organism to disease. Two forms are distinguished pathogenetically: primary tuberculosis following infection in previously unexposed people and secondary (postprimary) tuberculosis after endogenous reactivation or secondary infection in a previously sensitised host. Clinically, tuberculosis is classified in three stages: primary stage, stage of haematogenous dissemination (miliary tbc) and isolated-organ tuberculosis.

Oral manifestation of primary tuberculosis is rare (1-4%), with most cases presenting as a crater-shaped, coated, painless ulcer that heals spontaneously. Regional lymph nodes are always massively enlarged, soft and coalesce with each other and occasionally with the skin; sometimes caseous discharge is drained off by fistulas. Healing occurs with scarring and calcification.

During the course of early haematogenous dissemination (miliary tuberculosis), the oral mucosa and the skin can also become affected (1-3 mm caseating granulomas); almost exclusively in small children.

Diagnosis/Histopathological features



  • The safest diagnostic test is the detection of Mycobacteria in culture (negative result does not exclude tbc)
  • Biopsy; identification of tubercle bacilli in tissue by Ziehl-Neelsen staining; caseating granulomas are characteristic but not pathognomonic.
  • Thorax rtg
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Differential diagnosis

  • Clinically: intraoral ulcers of different aetiology, particularly syphilis and carcinoma
  • Histologically: other granulomatous inflammations, e.g. sarcoidosis, systemic mycoses, syphilis stage III, foreign-body granulomas (beryllium granuloma), etc.

Treatment and prognosis

Long-term, multiagent chemotherapy in sufficient dosage. The mycobacteria causing lupous skin tuberculosis are less virulent and less therapy resistant, than other strains. The prognosis is determined by the overall clinical condition of the patient.

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Syphilis

Synonym: Lue
Syphilis is a chronic, sexually transmitted infection caused by Treponema pallidum. The disease has been discussed in details in the article „White lesions (Syphilis)”. With regard to ulcerative mucosal lesions, the first and second stages of disease are of importance.

First stage (primary syphilis): Most common sites of inoculation: genital, perianal and rarely intraoral (lips, tip of the tongue, tonsils); development of hard, painless papule or nodule (chancre), which can develop a central ulceration. Important signs are the hardness and painlessness of the papule and ulcers. Accompanying painless regional lymphadenopathy. Highly infectious; the initial lesion heals within 6-8 weeks.

Second stage (secondary syphilis): 8-10 weeks after the infection, haematogenically spreaded, highly infectious papules with erosions occur mainly in the oral mucosa, accompanied by influenza-type signs and a general lymph knode swelling. Intraoral manifestations: erythema and so called plaques opalines/muqueuses (mucous patches), degenerated papules or clean-based ulcers on the gums and tongue. They evolve from small red papules, which undergo erosion and present with whitish covering. Highly infectious, commonly accompanied by a diffuse maculo-papulous cutaneous rash affecting the palms and plantar areas, condyloma lata and generalised lymphadenopathy.

Diagnosis/ Histopathological features

Smear for detection of Treponema pallidum, dark-field microscopy.
Histologically, both lesions are characterised by unspecific granulation tissue rich in plasma cells.

Differential diagnosis

Lues I
other primary lesions in tularaemia, cat-scratch disease, soft ulcer, inguinal lymphogranuloma, traumatic ulcer, solitary aphtha (painful!), tuberculosis, early carcinoma, etc.

Lues II
drug allergy, virus-induced enanthema or exanthema, infectious mononucleosis

Treatment and prognosis

Penicillin (or erythromycin, doxycyclin, tetracycline in patients with penicillin allergy).
With timely and high dose application of antibiotics curable. Poor prognosis in cases with AIDS.

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Recurrent aphthous stomatitis (RAS)

Synonym: recurrent aphthous ulceration (RAU), canker sore

Definition clinical features

Recurrent aphthous stomatitis presents with solitary or multiple, non-contagious, painful, inflammatory epithelial defects (ulcers) on oral mucosa. It is one of the most common oral mucosal diseases, prevalence varies between 10-65%; women are more frequently affected than men, it is more common in non-smokers than smokers. Definitive cause is unknown; the disease has a tendency to occur along family lines. Changes in immunological reactions are detectable, but non-specific. Ulceration can be induced by mechanical trauma and certain foods (allergy possible). In a subgroup of patients the following predisposing factors have been found to play a role: nutritional deficiencies (iron, folate, vitamin B12), stress, luteal phase of menstruation cycle and AIDS (severe form). First presentation of the disease usually occurs in childhood or puberty. Afterwards, patients may develop painful recurrent ulcerations in yearly, monthly or weekly intervals or they suffer from the symptoms continuously. Individual ulcers are flat, covered by a yellowish-white fibrino-purulent membrane and surrounded by an erythematous margin. Ulceration may also occur in multiple pattern; systemic symptoms of a disease fail. The most commonly involved locations are: lips, cheeks, soft palate, and ventral tongue surface.

Three clinical variants are distinguished:
  1. Minor aphthous ulceration (Mikulitz’s-aphthe) – common; small ulcers (< 1cm, less than 5) on mobile, non-keratinising mucosa. Healing without scarring within 14 days.
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  2. Major aphthous ulceration (Sutton’ disease; Periadenitis mucosae necrotisans recurrens) – rare; solitary large ulcers (up to 3 cm), any localisation incl. Tongue dorsum and hard palate can be involved; healing with scarring within 1-3 months.
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  3. Herpetiform aphthous ulceration – multiple (up to 100), small ulcerations (1-3 mm), which coalesce into larger, irregularly demarcated ulcers.

Diagnosis/ Histopathological features

History of recurrence and clinical appearance. No laboratory test provides definitive diagnosis. Blood counts appropriate, to exclude haematological deficiencies.
Histological features are non-specific with infiltration of mononuclear inflammatory cells (lymphocytes, monocytes, mast cells, plasma cells) at early stage followed by epithelial necrosis. After rejection of necrotic tissue, the ulcer ground will be covered by a fibro-purulent pseudomembrane (granulocytes). Common association with dilated and inflamed excretory ducts of small salivary glands.

Treatment and prognosis

Treatment of underlying predisposing conditions; topical treatment with chlorhexidine rinsing, or corticosteroids (hydrocortisone 2.5 mg pellets or 0.1% triamcinolone ointment). Sometimes stronger topical steroids (e.g. betamethasone or beclomethasone) may be indicated. In resistant cases systemic corticosteroids may be required.

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Behçet’s disease

Synonyms: Behçet’s syndrome, grande aphthosis Touraine, pernicious aphthosis, Morbus Behçet-Adamantiade

Definition and clinical features

It is a particularly severe and sometimes lethal form of aphthous ulceration; a systemic disease of systemic vasculitis type with involvement of various organs. Rare disease, the highest prevalence occurs in the Middle East and Japan, predominantly in men. Aetiology unknown, numerous immunological disordes, as with aphthous stomatits, has been reported. Immune complexes, possibly with herpes simplex viruses may be of significance. It is a systemic disease; the oral lesions cannot be differentiated from those in aphthous ulcerations.

Clinical triad:
  • Oral aphthous stomatitis of any type in almost all cases
  • Recurrent genital ulcerations
  • Ocular involvement (reduced visual acuity, uveitis, retinitis)
Further clinical symptoms:
  • Dermatosis: erythema nodosum
  • Arthritis of large joints
  • Central nervous system involvements: diverse symptoms
  • Other disorders: thrombosis-related colitis, renal diseases, aorta aneurysm, etc.

Diagnosis/ Histopathological features

Diagnostic criteria of the International Study group for Behçet’s disease (1990)

Obligatory: recurrent oral aphthous ulcerations (≥ three times/year)

Plus two of the following:
  • Recurrent genital ulcerations
  • Uveitis anterior/posterior, retinitis
  • Skin lesions (erythema nodosum, pseudofolliculitis, sterile papulo-pustular lesions, acneiform nodules in post adolescent patients not receiving corticosteroids)
  • Positive pathergy test after i.c. injection of saline (development of a sterile pustule 24-48 hours after injection)

Differential diagnosis

Other muco-cutaneous syndromes, particularly ulcerative colitis, erythema multiforme, syphilis and Reiter’s diseas

Treatment and prognosis

Oral ulcerations: as with oral aphthous
ulcerationsSystemic disease: immunosuppression
Long-term prognosis is dubious, intensive monitoring of patients for recurrences is mandatory, can have a lethal outcome.

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Lichen planus

Definition and clinical features

This immune-related muco-cutaneous disease is predominantly characterised by white lesions, therefore it will be discussed in details in the chapter: „White lesions (Lichen planus)“. However, oral lichen planus may also appear with erosions, ulcers (erosive form), as well as with bullae (bullous form). Particularly the erosive form is considered as a praeneoplastic condition.

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Lupus erythematosus

Definition and clinical features

Lupus erythematosus, the prototypical autoimmune disease, occurs in discoid (DLE) and systemic (SLE) forms, usually in women. Both variants can affect the oral cavity.

The discoid lupus erythematosus has been discussed in details in the article: „White lesions (Discoid lupus erythematosus)."

The lesions in systemic lupus erythematosus resemble those in DLE, however ulcers are usually more severe. SLA can be associated with Sjögren’s syndrome and with arthritis of the temporomandibular joint. It may also occur in form of a paraneoplastic syndrom, especially in visceral malignancies.

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Differential diagnosis

Drug-induced enanthemas, immunocomplex vasculitis, syphilis stage II, lichen planus

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Crohn’s disease

Synonyms: regional ileitis, regional enteritis

Definition and clinical features

About 10% of patients with Crohn’s disease of the intestines present with oral mucosal lesions in form of aphthous-like ulceration, recurrent diffuse or nodular swelling of the lips and, most commonly, cobblestone-like swelling of oral mucosa and deep, granulomatous-appearing, linear ulcers. The most common intraoral locations include: buccal and posterior vestibule, lower lip and corner of mouth. Men are more commonly affected than women.
Oral lesions develop prior to intestinal manifestation in about 60% of cases! Possible early diagnosis by dental professionals!

Diagnosis/ Histopathological features

Biopsy, complete blood count, gastrointestinal examinations, if necessary.

Histologically, granulomatous inflammation within the submucosal connective tissue with formation of characteristic, non-necrotizing epithelioid granulomas, without detection of acid-fast bacilli (Mycobacteria) in Ziehl-Neelsen stain.
Differentiation from sarcoidosis is not possible on the basis of histology alone.

Differential diagnosis

Clinically, intraoral ulcers of other aetiology, particularly malignant tumours, chronic bacterial infections, Melkersson-Rosenthal syndrome.
Histologically, other chronic, granulomatous inflammations.

Treatment and prognosis

Topical or intralesional corticosteroids; systemic or eventually topical administration of sulfasalazine.
Oral lesions disappear with treatment of the gastrointestinal process in many cases

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Ulcerative colitis

Definition and clinical features

Aphthous ulcerations may be associated with ulcerative colitis, however, there is no direct causal connection; ulcers may also develop secondary to anaemia caused by chronic intestinal bleeding. General symptoms include: persistent diarrhoea, in severe cases with haemorrhagic and mucous content, iron deficiency anaemia, weight loss.
Oral manifestation: yellowish-white pustules on oral mucosa (pyostomatitis vegetans) or ragged, chronic ulcers.

Diagnosis/ Histopathological features

Biopsy, complete blood count, gastrointestinal examinations, if necessary

Differential diagnosis

Intraoral ulcers of other causes; particularly Crohn’s disease

Treatment and prognosis

Topical or intralesional corticosteroids, sulfasalazine.

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Haematological disorders

Definition and clinical features

Ulcerous-narcotising oral mucosal lesions may also occur in haematological disorders, such as:
  • Non-Hodgkin lymphomas
  • Agranulocytosis
  • Leukaemia
Aetiology unknown: irradiation, chromosomal defects, chemotherapeutics and viruses may play a role. The intraoral manifestations mainly comprise ulcers, petechiae, gingival hyperplasia (acute myelogeneous leukaemia) with formation of green-coloured tumors (chloroma) of immature myeloid cells and infections by candida albicans or herpes viruses. The predominant locations of ulcers are: gingiva, tongue, and tonsils. Other features: labial anaesthesia, facial nerve palsy. General symptoms include: lymph node enlargement (usually generalised), paleness, hepato-splenomegaly, purpura.

Severe leukopenias, caused by viral infections (in particular, HIV), drugs, irradiation, or of idiopathic aetiology may induce intraoral ulcerations. Characteristically, they appear as persistent mucosal ulcers without surrounding inflammatory margin.

Diagnosis/ Histopathology

Complete blood count and bone marrow biopsy, if indicated

Differential diagnosis

Intraoral ulcers of different aetiology

Treatment and prognosis

Chemotherapy of leukaemia; supportive care – oral hygiene and local analgesics; acyclovir against herpes viruses, antimycotics agains candidosis.

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Oral cancer

Definition and clinical features

The majority of malignant oral tumours are squamous cell carcinomas, which represents one of the ten most common cancers worldwide. In women, it is the seventh, in men the fifth most common malignancy. The incidence varies significantly according to geographic regions. In India, it is the commonest cancer (in particular in women), in Europe, the most cases are reported in Northern France and Eastern European countries (with male predominance). In Germany, oral cancer accounts for about 5% of all malignancies, the peak incidence is between 60-70 years, in both sexes. Incidence- and mortality rates are increasing in several countries, also in younger age groups.

The most important risk factors of oral carcinoma are:
  • tobacco smoking
  • chronic alcohol abuse
  • poor oral hygiene
Betel quid chewing has a significant aetiological role in India and Southeast Asia. In the carcinogenesis of oral cancer, preneoplastic conditions and lesions (e.g. dysplastic leukoplakias) play a significant role, as well (see: Preneoplastic disorders)“.

Other primary malignant tumours (mainly adenocarcinomas) are rare, they may involve the maxillary sinus or salivary glands; other examples are malignant lymphomas, Kaposi’s sarcoma (particularly in AIDS), or metastases from other primary sites.

Clinical features are variable. Carcinoma may appear as red or white mucosal lesions, ulcers, clefting defects or nodes. The most common clinical manifestation is a depressed, irregularly shaped ulcer with granulating bed and surrounding rolled borders.

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Diagnosis/ Histopathological features



  • The majority of oral cancer can be diagnosed by inspection!
  • As a general rule, all suspicious lesions on oral mucosa, which cannot be unequivocally classified as benign, must be examined histologically!
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Differential diagnosis

  • Intraoral ulcers of different aetiology
  • Frequently, oral carcinomas will be falsely interpreted as pressure induced lesions under ill-fitting denture and treated inadequately over a long period of time.

Treatment and prognosis

The treatment is dependent on the TNM-stage and localisation of primary tumour. Small tumours (pT1, N0) can be treated by complete excision with wide tumour-free surgical margins, whereas advanced tumours are treated by combined modalities: surgery, irradiation, and chemotherapy.
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The prognosis of oral cancer is unfavourable; 5-year survival rate is about 40%. This is mainly due to late tumour detection, only in advanced stage, in many patients. This situation can only be improved by consistent implementation of prevention stategies and early detection! It is a matter of common knowledge that despite of similar size, location and therapy oral carcinomas may have completely different clinical course. The underlying causes are target of intensive research.


sources

  • Bankfalvi A, Piffko J (2000)   Prognostic and predictive factors in oral cancer: the role of the invasive tumour front   J Oral Pathol Med. 2000 Aug;29(7):291-8
  • Hornstein OP (Mohr W, Gorz E) (1996)   Erkrankungen des Mundes. Ein interdisziplinäres Handbuch und Atlas   Kohlhammer, Stuttgart - Berlin - Köln
  • Lopez R, Fernandez O, Jara G, Baelum V (2002)   Epidemiology of necrotizing ulcerative gingival lesions in adolescents   J Periodontal Res. 2002 Dec;37(6):439-44
  • Mittermayer C (1993)   Oralpathologie. Erkrankungen der Mundregion 3. Auflage   Schattauer, Stuttgart-New York
  • Muhlmeier G, Tisch M, Bredlich RO, Peter RU, Maier H (1993)   Erosions of the mouth mucosa   HNO. 2002 Aug;50(8):762-3
  • Neville BW, Damm DD, Allen CM, Bouqout JE (2002)   Oral & Maxillofacial Pathology   2nd Ed. 2002, W.B. Saunders Company: Philadelphia, London, New York, St Louis, Sydney, Toronto.
  • Reichart PA, Philipsen HP (1999)   Oralpathologie. Farbatlanten der Zahnmedizin 14   Georg Thieme Verlag, Stuttgart, New York
  • Scully C, Cawson RA (1996)   Taschenatlas Oralpathologie   Heidelberg: Hüthing, 1996
  • Sistig S, Cekic-Arambasin A, Rabatic S, Vucicevic-Boras V, Kleinheinz J, Piffko J (2001)   Natural immunity in recurrent aphthous ulceration   J Oral Pathol Med. 2001 May;30(5):275-80