Diagnosis of ulcers

Plan 

Introduction 2

1. Definitions 2

2. DIAGNOSTIC APPROACH 3

2.1. Interrogation: 3

2.2. Exoral examination 4

2.3. Intraoral examination: 5

2.4. General examination 5

2.5. Additional examinations: 6

3. ETIOLOGICAL DIAGNOSIS 6

3.1. Single ulceration 6

3.2. Multiple ulceration 10

Conclusion 16

Decision trees 17

Bibliographic references: 18

Introduction 

         Ulcerations of the oral mucosa constitute a frequent reason for consultation in our daily practice.

Although these lesions are easily recognized by clinical examination, the etiological search, on the other hand, is not easy. It can reveal very diverse and sometimes serious local or general diseases.

        Additional tests often help with the diagnosis but their request must be justified. The treatment will depend on their etiology. 

Definitions  : 

• Erosion: is a loss of superficial substance affecting only the epithelium , which heals without scarring. It is painful. 
• The fissure : linear erosion of the epithelium and the upper part of the chorion. 
• Ulceration : is a deep loss of substance , affecting the entire height of the epithelium and extending to the chorion or even beyond.

    🡪 Clinically , the difference between the two stages of involvement of the oral mucosa; namely ulceration and erosion; is not always obvious. On the other hand, the anatomo-pathological examination distinguishes according to whether the epithelium alone is involved or whether the chorion and other elements are affected.

Diagnosis of ulcers

Fig1: Diagram illustrating the difference between erosion, ulceration and fissure

• Chancre: is reserved for an erosion or ulceration of an infectious nature caused by the penetration of a specific microorganism or bacillus (treponema).

1. DIAGNOSTIC APPROACH 

      When faced with a patient presenting with an ulceration, the diagnostic approach will be classic, starting with a detailed interview, an oral examination, a general examination and sometimes additional examinations. 

1. Questioning: he must specify:

• Age of the patient : 

• In the presence of an infant: lingual ulceration due to trauma by a neonatal tooth may be observed in Riga Fede syndrome.
• In a young patient: depending on the clinical context, we can focus on a traumatic origin or suspect celiac disease or chronic inflammatory bowel diseases.
• For a patient aged over 40  : we often observe neoplastic ulcers in this age group; especially in the presence of the alcohol-smoking factor. 

Age therefore has a diagnostic orientation value.

• Reason for consultation: 

• It is often translated as pain following the deep loss of the epithelium which makes the nerve fibers more vulnerable. 
• In some cases there is a semiological silence or a fortuitous discovery.
• The patient’s lifestyle can guide us towards an etiology:

• When the patient lives in a situation of poverty and precariousness, tuberculosis will be suspected.  
• The notion of prison or drug addict or risky sexual practices , leads to suspicion of syphilis and AIDS as the etiology of oral ulceration. 

• Identify addictions: tobacco, alcohol, drug addiction which constitute an etiology of ulceration.
• Note any personal history that may explain the presence of this ulceration:  

• Serological status: Viral, bacterial or fungal infection 
• Vaccination status: BCG vaccination
• Malignant hemopathy: leukemia, agranulocytosis 
• Chronic gastrointestinal disease: Crohn ‘s disease and Recto Hemorrhagic Colitis ( UC )    
• An autoimmune disease: Behcet 
• A history of cancer: upper aerodigestive tract or cervicofacial radiotherapy. 
• A dermatological disease: lichen planus, bullous dermatosis, lupus erythematosus.
• Previous or current medications : antibiotic therapy, corticosteroid therapy, immunosuppressants, psychotropic drugs, bisphosphonates, anti TNF Alpha, etc.

• The family history will look for a notion of familial aphthosis, systemic conditions (Behçet’s disease, systemic lupus erythematosus, etc.) or a notion of tuberculous contagion.
• History of the injury:
  • Date of appearance : it can be recent or old.
  • The circumstances in which the ulceration appears and the notion of triggering factors (food, trauma, bites, burns, stress, medication, menstrual period in women, etc.).
  • Mode of development : either progressive or by recurrences. Canker sores can have a recurrent or cyclical development.
  • Accompanying signs: these are the warning signs which indicate the extent of the lesion:

• Local: Spontaneous or provoked pain, bleeding, burning sensation.
• Locoregional : look for swallowing disorders, dysphagia, salivation disorders (sialorrhea) or sensitivity disorders (hypoesthesia).
• General: look for signs of deterioration in general condition: asthenia, anorexia, weight loss, cough, fever, etc.
• The treatments undertaken : local or general and their effects.
• Look for other associated lesions:  

• Lesions of other mucous membranes: digestive, ocular and genital are found in certain ulcerations such as lichen planus, Behcet’s disease.
• Skin lesions can be found in Erythema multiforme and in lupus.

2. Exorbital examination  : (search according to the data from the interview)

• Existence or absence of facial asymmetry related to swelling
• Look for neurological signs (lipo-mental hypoesthesia)
• Examination of the lymph node areas in search of adenopathy for which it is necessary to specify: The location, number, volume, consistency and mobility. Neoplastic lesions are most often accompanied by one or more fixed and hard adenopathies.
• Measuring the Amplitude of Mouth Opening
• Note the presence of other associated lesions: cutaneous, peri-orificial (oral, ocular, nasal) or digital (felon in the case of herpes for example).

3. Intraoral examination: it is often difficult to do or even impossible in certain situations. It must be done under good lighting, it appreciates:

• Oral hygiene 
• Dental condition, presence of a traumatic element (prosthesis, root)
• Examination of the mucous membranes, region by region (particular attention to the folds)
• Examination of the lesion itself :

🡪 Upon inspection: note the following characters: 

• Number: single or multiple ulceration.
• The location: either on a keratinized mucosa, non-keratinized mucosa (the canker sore affects non-keratinized mucosa exclusively), or both.  
• The Diameter
• Borders: flat or raised, regular or irregular, healthy, erythematous or keratotic. Uneven borders are often found in malignant ulceration and erythematous halo is found in aphtha. 

• The bottom: smooth or necrotic, fresh butter, hemorrhagic or not, infected (presence of oozing or pus).
• The surrounding mucosa: a background of erythema (post-bullous lesions), a background of white lesions, a cracked background (chancre). 

🡪 On palpation: always protected with a finger cot, assess: 

• The limits of the lesion
• Consistency: soft or hard, 
• Sensitivity: preserved or not.
• Bleeding on contact
• If the ulceration is lingual, the degree of lingual protraction must be assessed, 
• If the ulceration is gingival, test the mobility of the adjacent teeth. 

4. The general examination 

 Will be performed or requested if a general origin is suspected following the anamnesis and the lesion appearance: the general examination will concern the other mucous membranes (nasal, ocular, genital) and the skin covering or any associated symptomatology suggestive of an infectious or syndromic picture. The dentist can examine the exposed parts of the body: hands, forearms, feet.

Clinical examination is sufficient to establish the diagnosis of ulceration. The supposed etiology 

(by questioning and clinical examination) can be confirmed by additional tests.

5. Additional examinations:   

They vary according to each suspected etiology and will be requested according to the guidelines:

• Blood count, leukocyte balance 

• Serology (HIV, VDRL, TPHA, etc.) 
• Tuberculin IDR
  • Local samples: bacteriological, virological or mycotic in an infectious hypothesis
• A cytological examination (cyto-diagnosis) 

• Biopsy with conventional histology and possibly direct immunofluorescence: IFD (post-bullous ulcerative lesions)
• Radiological examinations: for the extension of tumor processes:

• Standard X-rays to look for underlying bone lysis, 
• CT scan in case of tumor lesion to assess its extension and its relationships with neighboring structures,
• MRI especially for lingual and floor lesions.
• Opinions of the different specialties: Gastrology, dermatology, ophthalmology, hematology, gynecology, etc. 

2. ETIOLOGICAL DIAGNOSIS     

Once the diagnosis of ulceration has been made, the diagnostic approach is essentially etiological. Schematically, we can be faced with 2 cases:

• Single ulceration 
• Multiple ulceration

1. Single ulceration:
   1. Traumatic Ulceration: 

• It is relatively common, evolving in an acute mode.
• It is very painful, with regular edges , without erythematous halo, smooth bottom, flexible base, generally molded on a causal agent ( poorly adapted prosthesis, dilapidated root or tooth). 
• The most common location is the lateral edge of the tongue.
• Treatment consists of removing the etiology and prescribing antiseptic mouthwashes. 

• It should heal within 7 to 14 days after the cause is removed. 
• Persistence beyond 14 days should lead to a biopsy to reorient the diagnosis. Ulceration will be suspicious of neoplastic until proven otherwise.

2. Isolated canker sore:

• Common aphthous ulcer:

     The diagnosis of common aphthous ulcer will be made in the presence of a round or oval ulcer , painful, 2 to 10 mm (<1 cm) in diameter, with regular edges and surrounded by an erythematous inflammatory halo. The base is yellow in color like fresh butter, resting on a soft base. Its usual location is the mobile mucosa. There is no adenopathy.

     The progression is towards healing without scarring in 7 to 10 days.

• Giant canker sore:

      Giant aphthae is distinguished from common aphthae by several clinical characteristics:

• The size of the ulceration is significantly larger , from 1 to 5 cm, as is its depth.
• The ulceration is irregular , surrounded by a large erythematous areola with a necrotic background . 
• The ulceration is extremely painful , interfering with chewing, and can lead to dysphagia and hypersalivation. 
• The evolution is long (more than a month) and the healing leaves more or less mutilating fibrous scars. 
• Their prevalence is markedly increased in HIV infection . 

Diagnosis of ulcers

Fig3: Giant canker sore on the inner side of the lower lip

• The treatment:

• Motivation for Hygiene, prescription of Antiseptic (Chlorexidine®) in Mouthwash applied 4 to 5 times per day. 
• Application of 2% Xylocaine gel 15 to 30 minutes before meals. 
• Cauterization by Touch with trichloroacetic acid is reserved for professional use because there is a risk of burns and necrosis.
• Application of mouthwashes based on corticosteroids or Aspégic® in sachets  
• Gastric dressing application: Maalox® mouthwash. 

3. Malignant ulceration:

• Squamous cell carcinoma of the oral mucosa accounts for about 94% of all malignant tumors of the oral cavity. Observed in patients over 50 years of age with alcohol and tobacco intoxication, it affects two to three times more men than women.

• This diagnosis should be considered in the presence of any unique, chronic oral ulceration . 
• The ulceration is painful, variable in size, irregular in shape , the edges are raised and everted . The base is more or less granular , vegetating , or budding , with necrotic and/or hemorrhagic areas . On palpation, an indurated base is detected , which goes well beyond the limits of the ulceration and extends in depth. 
• The tongue, floor of the mouth, and soft palate are the structures most commonly affected.
• It may be accompanied by dental mobility when it is gingival, or by discomfort when protracting the tongue, or by dysphagia.
• Submandibular adenopathy is almost constant.  
• A deterioration in the general condition may be observed (fever, weight loss, asthenia).                                                                                                  
• The clinical diagnosis will be confirmed by histopathological examination.
• A biopsy is performed: 

4. Infectious Ulceration:
5. Ulceration of tuberculous origin: due to Koch’s bacillus.

       The oral manifestations of tuberculosis are of two types: either: 

• Primary mucocutaneous tuberculosis: the oral mucosa is the site of initial inoculation and the lesion is a tuberculous chancre (rare) in the form of gingival ulceration, particularly lower, simulating gingivitis or pseudo-pericoronitis with unilateral satellite adenopathies. 
• Secondary mucocutaneous tuberculosis : the oral lesion is then due to autoinoculation on a pre-existing erosion of the oral mucosa by the tuberculosis bacillus present in the patient’s bronchial secretions: painful, irregular ulceration with a necrotic yellow base (tongue++, lips) with satellite adenopathy.

Diagnosis of ulcers

Diagnosis:   

• Positive tuberculin IDR 
• Histology: Giant cell epithelial granuloma with caseous necrosis.
• ECB of sputum can isolate BK (specialized service)

    Treatment :   

• Refer the patient to the specialist service (the anti-tuberculosis dispensary “DAT”). 

2. Syphilis  : Sexually transmitted infection (STI) caused by Treponema pallidum.

• Syphilitic chancre is located in the mouth in about 8% of cases, mainly on the lips, tongue and tonsils. It appears about 3 weeks after contact with the pathogen (Treponema Pallidum).
• The ulceration, which can reach up to 2 cm in diameter, is painless , round or oval, well-defined, with regular, flat, sharp edges .
• The background is red , called “muscle flesh” with a smooth and varnished appearance.
• The base is cardboard on the surface without exceeding the margins of the lesion.
• Ulceration is highly contagious
• Accompanied by one or more unilateral, large, hard, mobile, painless satellite adenopathies. 
• The chancre will heal spontaneously in 5 to 6 weeks (leaving a round, white or pigmented, indelible scar), but the lymphadenopathy may persist for another 2 years. 
• Syphilis is diagnosed by serological tests: non-treponemal test: VDRL (Venereal Disease Research Laboratory) and specific test for treponemal antibodies: TPHA (Treponema Pallidum Haemagglutination Assay)
• Treatment consists of penicillotherapy.

3. Other infectious ulcers:

• Cytomegalovirus

Cytomegalovirus infection of the oral cavity may be suspected in cases of large, deep, irregularly shaped, single, and painful ulcers. Typically, these ulcers lack an erythematous border and occur particularly in immunocompromised patients (on immunosuppressants, on corticosteroids, such as transplant patients). 

• Mycotic infections: 

• Candidiasis  : the erosions are painful and covered with a whitish coating over a large inflammatory area.
• Histoplasmosis: oral ulcers are crateriform, very painful. Jagged, they have abrupt, non-detached edges and a red, slightly fibrinous base.

2. Multiple ulceration (see Decision tree for multiple ulcerations)
   1. Oral aphthosis:
3. Idiopathic recurrent oral aphthosis: ABRI:

• It is the repetition of outbreaks within the year that leads to the diagnosis of recurrent aphthous ulcers retrospectively. In fact, the diagnosis of aphthous ulcers is made in the presence of at least 4 outbreaks of aphthous ulcers per year . 
• In the face of a recurring aphthous lesion, Behcet’s disease must be ruled out to speak of ABRI.
• Three clinical forms of ABR are described:
• Minor aphthosis:

• 1 to 5 common canker sores with a diameter of < 1 cm
• Spontaneous Healing in 10 Days
• Miliary aphthosis:
• In the presence of multiple small ulcerations (10 to 100 elements), with a diameter < 2 mm, occurring in clusters, very painful. 
• Giant aphthosis

• 1 to 5 giant canker sores with a diameter >1cm
• Very Painful
• Deep ulceration with necrotic base
• Soft base
• Evolution: 1 month with retraction healing 

2. Behçet’s disease: Touraine aphthosis

                Behçet’s disease is named after a Turkish dermatologist who described it in 1937. It is a chronic, recurring inflammatory multisystem disease of unknown cause. It is a chronic vasculitis clinically dominated by:

• Recurrent mouth ulcers 98%,  
• Genital ulcers 87%, 
• Eye damage 73%,
• Skin lesions 69%
• Minor lesions: Arthritis 57%, gastrointestinal lesions 16%, neurological signs 11%, vascular lesions 9%.
• Diagnosis: In 2013, new international criteria for Behçet’s disease were established. The diagnosis is made when the patient has a score ≥ 4 points.

Diagnosis of ulcers

Recurrent mouth ulcers	2 points
Recurrent genital ulcers	2 points
Eye injuries	2 points
Skin lesions	1 point
Hypersensitivity test	1 point
Vascular lesions	1 point
Central nervous system damage	1 point

Table  : New international criteria for Behçet’s disease (2013)

• The treatment: is based on:

• Dental care: Restoration of the oral cavity, possibly with corticosteroid-based mouthwashes.
• Internal medicine management using Colchicine as first-line treatment: 1.5 mg/day in adults, to prevent recurrences.

3. ABR and HIV

         The prevalence of oral aphthous ulcers is increased in HIV infection. HIV-infected patients may present with aphthous lesions in any of the three clinical forms of ABR (giant and miliary aphthous ulcers are most common). These ulcers heal slowly and may persist for several months, leaving mucosal scars.

2. Chronic Inflammatory Bowel Diseases “IBD”:

         Chronic inflammatory bowel diseases (IBD) are of unknown etiology, including Crohn’s disease (CD) and ulcerative colitis (UC).

• Crohn’s disease is characterized by transmural, asymmetric, segmental granulomatous inflammation that can affect the entire digestive tract, from the mouth to the anus.
• Ulcerative colitis is characterized by inflammation that can extend from the rectum to the entire colon, including the small intestine and anus, characterized by a continuous arrangement of lesions. 
• Their evolution is characterized by the alternation of flare-ups and remissions , and can be punctuated by the occurrence of various digestive manifestations  (diarrhea, abdominal pain, etc.) and extra-digestive manifestations (articular, ocular, cutaneous, hematological, vascular, etc.).
• Recurrent oral ulcers can sometimes precede gastrointestinal manifestations by several years and thus represent the only presenting symptom. They are more frequent in Crohn’s disease . 
• These ulcerations associated with IBD are often not clinically distinguishable from primary aphthosis . However, they can take on different aspects:

• In Crohn ‘s disease , lesions may present as linear ulcers with hyperplastic edges at the level of the gingivo-jugal grooves , sometimes associated with fissured macrocheilitis (lip edema).
• Ulcerations occurring during UC may be hemorrhagic .
• These patients are treated with: non-steroidal anti-inflammatory drugs, steroidal anti-inflammatory drugs, immunosuppressants, anti-TNF-alpha.

3. Celiac disease: Gluten-sensitive enteropathy:

           It is an autoimmune disease characterized by chronic inflammation of the small intestine, induced by the ingestion of gliadin (present in certain varieties of cereals, wheat, rye, barley and uncertainly, oats) in genetically predisposed subjects.

• The classic signs of the condition are related to malabsorption of the small intestine: diarrhea, steatorrhea, weight loss , malnutrition, asthenia, abdominal pain, biological signs of malabsorption: iron deficiency anemia , etc.
• Regarding oral manifestations, recent scientific publications link intestinal inflammation with recurrent oral aphthosis . These studies demonstrate the more frequent, but far from systematic, coexistence between aphthosis and celiac disease. 
• For the treatment of celiac disease, it is sufficient to permanently eliminate the triggering agent to obtain complete remission with disappearance of oral lesions ( a gluten-free diet for life ).

Diagnosis of ulcers

4. Blood diseases:

Some blood diseases such as neutropenia, agranulocytosis, leukemia and anemia may present with mouth ulcers. 

1. Two types of anemia contribute largely to these recurrent oral ulcers , iron deficiency anemia and macrocytic anemia , the latter being attributable to a deficiency in folic acid (vitamin B9) or vitamin B12 ( pernicious anemia (or Biermer’s)) .
2. All forms of leukemia can be accompanied by oral manifestations, the main ones being ulcerations, spontaneous gingival hemorrhages , gingival hyperplasia, petechiae , and delayed healing.
3. Neutropenia is a decrease in the level of neutrophils in the blood. 

• All etiologies of neutropenia can be responsible for oral ulcers, which vary according to the severity of the neutropenia. They are frequent , early and sometimes reveal neutropenia.
• Clinically, these ulcers are deep and wide , necrotic with a grayish fibrinous base, and extremely painful. They are rarely surrounded by a perilesional inflammatory red halo like aphthoid ulcers. 

5. Dermatological diseases:
6. Disseminated or discoid lupus erythematosus:

It is a systemic autoimmune      disease , characterized mainly by rheumatological, dermatological (a butterfly-shaped rash on the face), hematological and nephrological signs.

Oral ulcers     indicate a flare-up of the disease. They are superficial , with an erythematous edge and poorly defined , sometimes surrounded by a striated honeycomb                                          keratosis .

Treatment: corticosteroid therapy or immunosuppressants (severe forms).

2. Erosive lichen planus

    Oral lichen planus is a chronic inflammatory disease , characterized by keratinization disorders , affecting the skin and oral mucosa (the elective site of the lesions is the posterior-inferior jugal mucosa). The etiopathogenesis is poorly understood.

The clinical forms are multiple and the symptoms are varied.                                                                                   

• The erosive form is manifested by the association of painful erosive lesions and white keratotic lesions on the periphery.
• The bullous form precedes the erosive form. 

      Treatment: – Local corticosteroid therapy in case of symptoms.

                                  – General corticosteroid therapy in severe forms

6. Ulcerations associated with bullous conditions:
7. Pemphigus  :

     Pemphigus are autoimmune bullous dermatoses , secondary to the production of pathogenic autoantibodies directed against the interkeratinocyte junction systems , causing acantholysis that affects the skin and mucous membranes . The disease mainly affects adults.

      There are several types of pemphigus: pemphigus vulgaris is the most common, revealed in most cases by oral erosions .

     Clinically, the blisters are only very rarely visible, due to their thinness and their low resistance to chewing trauma, their rupture causes very painful erosions , with a red base and an opalescent edge, sometimes raised. There is no erythematous border , which avoids confusion with canker sores. 

• Treatment :  

• General corticosteroid therapy.
• Combination of immunosuppressants in case of resistance to corticosteroids.

2. Pemphigoid 

      Pemphigoid preferentially affects the mucous membranes with a cicatricial and synechiaeous evolution . It is due to an autoantibody directed against a protein of the anchoring filament .

      Rare, it mainly affects elderly people (70 years old) and is characterized by selective involvement of the oral, ocular, genital, and sometimes ENT or esophageal mucosa. 

       The oral mucosa is most frequently affected: erosive gingivitis , associated or not with blisters or erosions of the palate. The mobile mucosa is rarely affected . 

       The clinical diagnosis is made on the forceps sign (the forceps without claws detach the epithelium in very large flaps on the periphery of the gingival erosions). 

3. Erythema multiforme 

        Erythema multiforme (EP) is an acute disease of the skin and mucous membranes , of uncertain etiology, which can be triggered by taking medication (NSAID drug eruption, antibiotics, etc.), but also by recurrent herpes .

        PE is characterized by small oral vesicles that rupture, leaving multiple , very painful erosions covered with a pseudomembranous coating . These lesions affect the entire oral cavity with a predominance of labial involvement .

        The most characteristic difference from aphthosis is the presence of red papulomacular lesions, arranged in a “cockade” , on the extremities or face . 

Diagnosis of ulcers

• Treatment : 

• In the case of isolated oral involvement, the first-line treatment is Disulone (100 mg/day) combined with topical corticosteroids (Diprolène® or Dermoval® in Orabase® in equal quantities). 
• In case of ocular involvement, the use of immunosuppressants is imperative (especially cyclophosphamide). 

7. Post-vesicular ulcers:
8. Primary herpes infection:

       Herpetic gingivostomatitis is characterized by numerous coalescing , erythematous vesicles , accompanied by hyperthermia, sialorrhea, and dysphagia. The presence of painful satellite adenopathies is constant.

• The vesicles rupture rapidly, leaving small , painful fibrinous erosions which, when merging, become polycyclic . Perinarine , perioral and extrafacial (fingers, etc.)    cluster vesicles can also be found .
• Small clear vesicles can be found at the level of the labial half-mucosa which persist for 48 to 72 hours, giving rise to brownish crusts .
• Treatment : 

• Mixed feed
• Compound mouthwashes
• Xylocaine gel 5%
• Painkiller 
• Antiviral treatment should be initiated as soon as the clinical diagnosis is suspected (within the first 3 days). Acyclovir has proven efficacy. Acyclovir (ZoviraxR), orally whenever possible, (200 mg tablet, 5 times daily) is the treatment of choice for 10 days. 

2. Chickenpox and shingles

These are vesicular cutaneous and mucous membrane          eruptive infections , grouped in clusters, caused by the same herpes virus HHV3 . 

• Chickenpox:

          This is the primary infection , generally occurring during childhood between 1 and 14 years of age. The entire oral mucosa can be affected, most often in the form of yellowish vesicles which quickly ulcerate leaving rounded and painful erosions . The course is spontaneously favorable in 10 to 15 days.

• Shingles:

           Shingles is the recurrent form due to the reactivation of the HHV3 virus remaining latent in the sensory ganglia, most often triggered by advanced age, leukemia, lymphoma or other cancers.

Oral manifestations in the form of group vesicular eruptions appear when the trigeminal branches V2 and V3 are affected. The vesicles develop into pustules and ulcers covered with a yellowish-white fibrin-leukocyte coating on the mucous membranes, and into crusts on the skin . The involvement is unilateral and painful . The lesions persist for 2 to 3 weeks.

8. Ulcers related to medication  :    

     A multitude of drugs can cause aphthous toxidermia or induced aphthae. This diagnosis of ^”  drug-induced aphthosis  ^“ will be confirmed by healing upon stopping the incriminated substance , without response to local corticosteroids.

      The most incriminated medicinal substances are: Alendronate (antiosteoclastic), certain NSAIDs (Piroxicam, ibuprofen), hexachlorophene in mouthwashes, anticoagulants (Phenindione), antihypertensives (Nicorandil, Captopril), barbiturates (Phenobarbital), sodium hypochloride, niflumic acid, gold salts, etc.

Conclusion 

       Les ulcérations et érosions de la muqueuse buccale peuvent être l’expression de nombreuses affections locales ou générales. Dans certains cas, elles peuvent même être révélatrices d’une pathologie jusqu’alors inconnue du patient.

      Savoir détecter les lésions suspectes est primordial pour la santé du patient ; cela demande aux médecins dentistes une bonne connaissance de l’aspect et de l’évolution dans le temps des lésions élémentaires. Il ne faut jamais hésiter à revoir un patient présentant une lésion pour en objectiver la guérison. 

     L’histoire de la maladie et l’anamnèse permettront d’orienter le diagnostic et de réaliser, si besoin, des examens complémentaires. Dans certains cas, seul l’examen histopathologique des prélèvements établira le diagnostic définitif.

Arbres décisionnels 

Arbre décisionnel des ulcérations multiples

Arbre décisionnel des ulcérations uniques

Références bibliographiques :

1. A. Peglion ; Classification clinique des érosions et ulcérations : quand le chirurgien-dentiste doit-il s’inquiéter ? Human health and pathology. 2013.
2. G. GUILLET, J.-M. BONNETBLANC, L. VAILLANT, P. SAIAG, E. GROSSHANS ; Orientation diagnostique devant : Ulcération ou érosion des muqueuses orales et/ou génitales ; Ann Dermatol Venereol 2002 ;129 :2S224-2S227.
3. J. Billet, L. Ben Slama et collaborateurs ; PATHOLOGIE DE LA MUQUEUSE BUCCALE – Claude Beauvillain de Montreuil ; © Société Française d’Oto-rhino-laryngologie et de Chirurgie de la Face et du Cou, Editeur, 2009.
4. J.-P. Coulon, E. Piette ; Aphtes banals, aphtose buccale récidivante et maladie de Behçet ; ; EMC Stomatologie, 22-050-N-10 © 2007 Elsevier Masson SAS.
5. K. Zinelabidine, I. Rhizlane, M. Meziane, et F/Z Mernissi ; aphtose buccale récidivante, et si c’était une maladie coeliaque ; Pan Afr Med J. 2012; 12: 88..
6. L. Vaillant – D. Goga ; Dermatologie buccale ; © 1997 Doin Editeurs, Paris.
7. S. OURAD, S. CHBICHEB, W. ELWADY ; Aphtoses buccales ; Service Pathologie Chirurgicale ; Faculté de Médecine Dentaire de Rabat ; Web J Dent 2013,vol :7,n°1.
8. L. Vaillant, M. Samimi  Aphtes et ulcérations buccales Presse Med. 2016 ; 45 : 215–226

http://dx.doi.org/10.1016/j.lpm.2016.01.005

Diagnostic des ulcérations

  Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.
 

Diagnosis of ulcers