Transcript Oral ulcers related to systemic diseases Ulcerative lesions

Course 341 MDS
Dr AsmA’A FADen
http://faculty.ksu.edu.sa/Asmaa Faden
Ulcerative lesions
Main causes of oral ulceration
1. Local Causes
2. Recurrent Aphthous Stomatitis
3. Infections
4. Drugs
5. Malignant disease
6. Systemic disease
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.
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)
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
Oral mucositis after chemotherapy (CT) and radiotherapy (RT)
Drug reaction oral ulceration
Ulcerative lesions
Main causes of oral ulceration
1. Local Causes
2. Recurrent Aphthous Stomatitis
3. Infections
4. Drugs
5. Malignant disease
6. Systemic disease
Ulcerative lesions
5- Malignant diseases
i) Oral squamous cell carcinoma
ii) Kaposi’s sarcoma
iii) Non-Hodgkin’s lymphoma
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5- Malignant diseases
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).
Ulcerative lesions
5- Malignant diseases
i) Oral squamous cell carcinoma
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Oral squamous-cell carcinoma occurs more frequently in men than in
women (ratio 2 : 1), and usually in those over 40 years of age.
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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.
Ulcerative lesions
5- Malignant diseases
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.
Ulcerative lesions
5- Malignant diseases
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.
Squamous Cell Carcinoma
Ulcerative lesions
5- Malignant diseases
ii) Kaposi’s sarcoma
(Discussed in viruses part)
Ulcerative lesions
5- Malignant diseases
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.
Ulcerative lesions
5- Malignant diseases
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
Non-Hodgkin lymphoma: large ulcer on the soft palate
Ulcerative lesions
Main causes of oral ulceration
1. Local Causes
2. Recurrent Aphthous Stomatitis
3. Infections
4. Drugs
5. Malignant disease
6. Systemic disease
Ulcerative lesions
6- Oral ulcers related to systemic diseases
i) Mucocutaneous.
ii) Haematological.
iii) Gastroentrological.
Ulcerative lesions
Oral ulcers related to systemic diseases
i) Mucocutaneous:
1- Behcet’s syndrome
2- Lichen Planus.
3- Vesiculobullous diseases
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Ulcerative lesions
Oral ulcers related to systemic diseases
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)
Ulcerative lesions
Oral ulcers related to systemic diseases
i) Mucocutaneous:
1- Behcet’s syndrome
Clinical features
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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.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Ulcerative lesions
Behcets Disease
Behçet Disease
Ulcerative lesions
Oral ulcers related to systemic diseases
ii) Haematological:
1- Anemia.
2- Leukemia.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Pernicious anemia: red and smooth dorsum of the tongue
with areas of ulcerations.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Chronic lymphocytic leukemia: ulcer on the palate
Chronic lymphocytic leukemia: severe gingival enlargement and ulcerations
Ulcerative lesions
Oral ulcers related to systemic diseases
iii) Gastroentrological diseases:
1- Coeliac diseases (Gluten-sensitive entropathy)
2- Crohn’s disease.
Ulcerative lesions
Oral ulcers related to systemic diseases
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
Ulcerative lesions
Oral ulcers related to systemic diseases
1- Coeliac Disease
-Clinical features: Typical 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.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Aphthous ulcer-like in Gluten entropathy patient
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
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Oral ulcers related to systemic diseases
2- Crohn’s Disease
Clinical features:
-Presents clinically with abdominal pain, nausea, diarrhea, weight loss, lowgrade fever, and rectal bleeding.
- Extra-abdominal involvement includes arthritis,uveitis, and oral lesions.
Ulcerative lesions
Oral ulcers related to systemic diseases
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.
Ulcerative lesions
Oral ulcers related to systemic diseases
2- Crohn’s Disease
Laboratory tests: Histopathological examination.
Differential diagnosis Orofacial granulomatosis, epulis fissuratum, pyogenic
granuloma.
Treatment Topical steroids, systemic steroids, sulfasalazine
Crohn’s disease
Crohn’s disease: cobblestone appearance of the buccal mucosa
Irregular superficial ulcers on ventral surface of tongue in Crohn’s disease