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Oral Pathology:  Soft Tissue Case #22

 

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Patient: Young woman.

Chief Complaint:
The patient complains of oral discomfort. She has had multiple oral ulcers constantly for the past three years. Individual ulcers heal in seven to ten days. Treatment of the ulcers with silver nitrate made them worse. No treatment has helped the lesions. The patient reports that the ulcers have occurred in various locations in the oral cavity, but have not involved the gingiva, hard palate or dorsum of the tongue. Her mother, sister and brother have had similar oral lesions.

Medical History:
No abnormalities are identified.

Dental History:
Routine care.

Clinical Findings:
The lesions consist of flat ulcers, approximately 4 mm in diameter, surrounded by an erythematous zone, located on the ventral surface of the tongue, floor of the mouth and soft palate. The ulcers are tender to palpation and are fixed to the surface mucosa but not to underlying structures.

Clinical Images
ulcer on left lateral and ventral tongue ulcer on floor of mouth
Ulcer on Left Lateral and Ventral Tongue Ulcer on Floor of Mouth
ulcer on soft palate  
Ulcer on Soft Palate  

 

There are no radiographs available for this case.

There are no lab reports available for this case.

There are no charts available for this case.

Summary:
The ulcers in this patient are characterized by abrupt (acute) onset, healing of ulcers in a predictable period of time, and continued formation of new ulcers.
The ulcers involve multiple nonkeratinized oral mucosal sites.
No skin, eye, or genital lesions or cervical lymphadenopathy are reported.

Lesions to Exclude from the Differential Diagnosis:
Epidermolysis Bullosa
  ~The onset of blisters and ulcers almost always begins at birth or early childhood.
  ~Lesions of the skin are present.
  ~Lesions do not heal in a consistent period of time.
Viral Infections          
  ~Do not recur and heal in a consistent amount of time, except for recurrent herpes. 
  ~Recurrent herpes involves keratinized mucosal surfaces.
Mycotic Infections (candidosis)
  ~Candidosis is not predominantly an ulcerative disease.        
  ~Lesions do not heal in a consistent amount of time.
Autoimmune Diseases
  ~Chronic and persistent with a more gradual onset
  ~Lesions do not heal in a consistent amount of time.
Idiopathic
  ~Erythema multiforme
*Lesions occur on both keratinized and nonkeratinized mucosal surfaces.
*Each ulcer does not heal in a consistent amount of time.
*Skin lesions (target lesions) are sometimes present but do not occur in all patients.
  ~Epithelial Dysplasia, Carcinoma-in-situ, and Squamous cell carcinoma
*Clinical appearance is erythroplakia and/or leukoplakia with minimal formation of ulcers
*Lesions are persistent, and each lesion does not heal completely. 
~Lichen Planus, Medication-induced mucositis, and Contact stomatitis
*Lesions are persistent and chronic.
*Lesions do not recur and then heal in a consistent amount of time

Lesions to Include in the Differential Diagnosis:
Aphthous Ulcers
  ~Ulcers have an abrupt or acute onset, and each ulcer heals in a predictable amount of time.
  ~Ulcers occur on non-keratinized mucosal surfaces.
  ~Skin lesions and cervical lymphadenopathy are not present.

Management:
Explain to the patient the nature of the disease, that there is no cure, and that the goal of treatment is to control the ulcers.
Most commonly treated initially with topical corticosteriods (example: triamcinolone acetonide, 0.1% or 0.2% mouthrinse).
For patients with constantly forming new lesions (as in this case), a short burst of systemic corticosteroids may be necessary but must be followed by topical steroids.

Final Diagnosis:
Aphthous Ulcers