8: Oral Ulcerative Diseases

Oral Ulcerative Diseases

An ulcer may be described as breach in the continuity of the surface epithelium of the skin or mucous membrane to involve the underlying connective tissue as a result of micro molecular cell death of the surface epithelium or its traumatic removal.

Classification Of Oral Ulcers

Ulcerative lesions affecting the oral cavity can be categorized based on the etiology or based on the mode of onset and clinical presentation.

Classification based on mode of onset and clinical presentation

image Single ulcers

image Multiple ulcers

image Recurring oral ulcers

Flowcharts 1 and 2 summarize acute ulcers that are recurring in nature and those that occur as an isolated episode.

Traumatic Ulcers

Traumatic injuries involving the oral cavity may lead to the formation of surface ulcerations. Although the exact incidence of these ulcerations is not known they are one of the most common ulcers seen affecting the oral cavity.

Types of Trauma

The oral cavity is prone to injuries from events such as accidentally biting oneself while talking, sleeping, mastication or as a result of an epileptic seizure. Fractured, malposed, or malformed teeth, as well as the premature eruption of teeth, can contribute to the formation of surface ulceration.

Nocturnal parafunctional habits, such as bruxism may be associated with the development of traumatic ulcers of the buccal mucosa, the labial mucosa and the lateral borders of the tongue. Ulcerations may be the result of voluntary, selfinduced, and deliberate acts by patients with physical or psychological symptoms who suffer from attention seeking behavior. These ulcers are characteristically present over visible surfaces such as the lips, corner of mouth and facial aspects of gingiva (ulcers caused by gingival picking). Bulimic individuals may present with nail marks or minute pinpoint red spots and/or ulcerations over the palate which is brought about by the frequent efforts to vomit.

Newborns and infants may present with sublingual ulcerations (Riga-Fede disease). These ulcers may occur as a result of chronic mucosal trauma due to adjacent anterior natal or neonatal teeth. The trauma is often associated with breast feeding. The lingual frenum may be ulcerated by repeated trauma because of the frenum rubbing against the mandibular incisors teeth in cunnilingus and in recurrent coughing episodes.

Young children are commonly susceptible to electrical and/or thermal burns of the lips and commissure areas. Extensive ulcerations with necrosis may develop. Children in this age group have a tendency to chew their lips immediately after surgical removal of teeth under the influence of local anesthesia.

Clinical features

In most cases, the source of the injury is identified. The patient’s usual complaint is pain or a painful ulceration. Individual lesions usually appear as shallow or deep ulcers associated with areas of erythema. The ulcer may reveal the presence of a central yellowish purulent exudate. Occasionally the border of the ulcer is indurated.

Ulcerations can occur throughout the oral cavity. Ulcers associated with mechanical trauma are often found on the buccal mucosa, the labial mucosa of the upper and lower lips, and the lateral border of the tongue (Figure 2). The mucobuccal folds, gingiva, and palatal mucosa may also be involved. Most lesions associated with electrical burns occur in children and involve the lips and commissural areas. Ulcers formed due to thermal injuries are generally seen to occur on the posterior regions of the buccal mucosa and the palate.

Caustic chemical agents can damage any area of the oral mucous membrane. However, they are commonly seen on the gingival margins and buccal vestibular regions of the oral cavity. Very frequently these ulcers are covered by a whitish pseudomembrane which when peeled leaves behind a raw ulcerated surface (Figure 3). Some patients in the Indian subcontinent use cloves and topical pain balms meant for extraoral application over the gingiva to relieve tooth pain. Hence, most of the chemical burns are generally seen adjacent to carious teeth.


image Consumption of a soft and bland diet.

image Removal of traumatic factor (extraction of root stumps, supraerupted teeth and malposed third molars, sharp cuspal edges of teeth may be grounded, irritating dentures may be corrected, restoration of fractured teeth and orthodontic correction of malposed teeth) will cause the resolution of the ulcer in 10–14 days.

image Patient may be advised to rinse his/her mouth with warm saline.

image Topical application of antiseptic and analgesic/anesthetic medication (choline salicylate 8.7%, benzylkonium 0.01% and lignocaine hydrochloride 2%—patient can be asked to apply the agent over the ulcers 10 minutes prior to food intake, 3–4 times a day).

image In case of multiple ulcers—analgesic/antiseptic mouth-wash (chlorhexidine gluconate 0.2% or benzydamine hydrochloride 0.15% mouthrinse—one teaspoon of the agent can be dissolved into 50 ml of water. This prepared solution is swished in the mouth for 1 minute. The patient is advised to rinse the mouth 3 times a day, 30 minutes after food intake).

image Application of topical corticosteroids (triamcinolone acetonide oral paste 0.1%). Patient can be advised to apply the paste 30 minutes prior to food intake, 3 times a day for 2 weeks.

image For extremely large and deep seated ulcers, penicillin may be administered (Capsule Amoxicillin, 500 mg, 3 times a day for 5 days) to prevent secondary infections.

image Patients presenting with ulcers secondary to self-inflicted injuries may be referred to a psychiatrist or psychologist after symptomatically managing the ulcer.

Primary Herpetic Gingivostomatitis

Primary herpetic gingivostomatitis is caused by herpes simplex virus (double-stranded DNA virus which is a member of the human herpes virus family). Most orofacial and ocular infections are caused by HSV-1. Infections involving the genitalia and the skin surface of the lower part of the body are caused by HSV-2. It has been reported that HSV-2 has a greater virulence. Almost 95% of the cases have a subclinical infection, only about 5% manifest symptoms. The infection confers resistance against another primary infection for lifetime.

Clinical features

image Primary herpetic gingivostomatitis has an acute onset.

image Typically affects children (generally below 6 years of age), but this infection also occurs in adults (immunocompromised).

image Males and females are equally affected.

image Prodromal systemic symptoms (fever, malaise, myalgia) precede oral lesions by 2–3 days.

image The skin, mucous membranes, eyes and central nervous system are the most commonly affected sites.

image Multiple oral ulcers affecting all parts of the mouth.

image Generalized erythema of gingiva usually associated with multiple vesicles or ulcers (Figure 4).

image Cervical lymphadenopathy occurs as a rule.

image Food intake becomes difficult and dehydration may ensue.

image Self-limiting condition in normal children. However, it may become disseminated in immunocompromised children or adults.


Recurrent Herpes Infection

Recurrent infections of herpes can manifest in two forms:

Precipitating Factors

Clinical presentation

image Patients present with cluster of tiny fluid filled vesicles (Figure 5A–C) which rupture to form pinpoint ulcers. These ulcers may coalesce to form larger areas of ulceration.

image Lesions may be preceded by burning, itching, tingling sensation or pain in the region.

image The lesions last for 5–7 days and subside and subsequently recur. Now the frequency of recurrence may be varied.

image Occasionally associated with fever and pharyngitis.

image As a consequence to healing an area of pigmentation is noticed at the site of the lesion (however this pigmented area is readily visualized only in fair skinned individuals).

Varicella Zoster Infection

Varicella zoster virus causes two distinct clinical entities. The primary infection by varicella zoster causes chicken pox, while the reactivated virus causes a secondary infection termed herpes zoster or shingles.

Chicken Pox

The primary infection by varicella zoster virus usually affects children. It is characterized by the sudden onset of generalized pruritic vesicular rashes affecting the skin. The incubation period of the virus varies from 10 to 21 days. Approximately 50% of the affected children present with prodromal symptoms of fever, malaise, headache, and abdominal pain, which last for about 1–2 days before the appearance of the dermal lesions.

Dermal lesions

On an average 100–300 new lesions are found at any given point of time. Lesions heal generally without scarring. Occasionally crusting of the lesions may be seen. However, an area of hypopigmentation may be appreciated at the site of the healed lesion. These hypopigmented areas fade away with time.

Herpes Zoster

Herpes zoster is caused by reactivation of varicella zoster virus that is inactive in dorsal root or cranial nerve ganglion, after primary infection.

It is estimated that only in about 0.3–0.5% of the population, the virus is reactivated after the primary infection.

Clinical features

image The clinical features depend on the dermatome involved.

image The nerves that are commonly affected are C-3, T-5, L-1 and L-2.

image Manifests in middle age.

image When the trigeminal nerve is involved, the ophthalmic division of the nerve is most commonly involved. About 15–20% of the affected individuals show involvement of the maxillary or mandibular division.

image Painful vesicles and/or ulcers seen both inside and outside the oral cavity, which stop abruptly at the midline (i.e. lesions do not cross midline) (Figure 7).

image Bilateral lesions may indicate severely immunocompromised state. Literature review reveals reports of necrosis of alveolar bone exfoliation of teeth in immunocompromised individuals.

image Occasionally pain may be present along the course of the affected nerve in the absence of vesicles. Such a manifestation is termed zoster sine herpete or zoster sine eruption.

image Ramsay Hunt syndrome is a symptom complex associated with herpes zoster. It is characterized by varicella zoster infection affecting the geniculate ganglion of the facial nerve, unilateral facial paralysis and unilateral vesicular eruptions involving the oral mucosa and external ear.

Post-herpetic neuralgia is one of the relatively common sequelae of varicella zoster infection that results from scarring of the involved nerve.

Jan 12, 2015 | Posted by in Oral and Maxillofacial Radiology | Comments Off on 8: Oral Ulcerative Diseases
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