Examination Of An Ulcer o41f

EXAMINATION OF ULCER

Guided by: Dr. Munish Kumar Dr.Ravi Narula

Presented by: Amritveer Kaur

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An ulcer is the break in the continuity of covering epithelium-skin or mucous membrane

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Follow the molecular death of the covering epithelium or its traumatic removal

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PARTS OF ULCER    

Margin Edge Floor Base

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CLASSIFICATION OF ULCERS • TWO TYPES OF CLASSIFICATON OF ULCERS IS POSSIBLE:1.

CLINICAL:

2.

PATHOLOGICAL

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Callous/ Chronic

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Arterial, Traumatic,

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HISTORY     

Mode of onset Duration Pain Discharge Associated disease

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1) Mode of onset 

How ulcer developed ??

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Traumatic- Eg.dental ulcer of the tongue

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Spontaneously- may develop following a swelling which may be matted tuberculous lymph node or gumma or a rapidly growing malignant tumour ( malignant melanoma)

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Marjolins ulcer- on burn scar

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2) DURATION 

How long??

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Acute ulcer,chronic ulcer

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Incubation period-time interval between exposure and the onset

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3) PAIN 

IsInflammatory the ulcer painful?? ulcers

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4) DISCHARGE 

Does the ulcer discharge or not??

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Nature of discharge-serum, pus or blood

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5) ASSOCIATED DISEASE    

Nervous diseases Tuberculosis Diabetes syphillis

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LOCAL EXAMINATION   

Inspection Palpation Lymph Nodes

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A ) Inspection      

Size & Shape Number Position Edge, Margin, Floor Discharge Surrounding area

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1. Size & Shape Tuberculous

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2. Number 

Tuberculous ,gummatous,varicose ulcers and soft chancres may be more than one in number

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3. Position RODENT ULCERS

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Anywhere Over Where subcutaneous in the bones such as

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4.EDGE 

Area between the margin and the floor

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An ulcer has a margin or edge which takes characteristic shape in a particular form of ulcer

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Gives clue to the diagnosis of ulcer also to the condition of ulcer

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TYPES OF EDGES     

Undermined edges Punched out edges Sloping Raised and pearly white beaded Everted

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UNDERMINED EDGES   

Mostly seen in tuberculosis Subcutaneous tissue destroyed faster than skin Overlying skin is thin friable ,reddish blue and unhealthy

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Undermining of edges

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PUNCHED OUT EDGE   

Gummatus ulcer or in deep trophic ulcer Edge drops down at right angles to skin surface Disease which causes the ulcer itself do not tend to spread to the surrounding tissue

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Punched out ulcers as seen in vasculitis

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SLOPING EDGE   

Healing traumatic or venous ulcers Reddish purple in color Consists of new healthy epithelium

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Healing traumatic ulcer

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RAISED AND PEARLY WHITE BEADED EDGE  

Rodent ulcer Develops in invasive cellular disease and becomes necrotic at centre

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BCC WITH TYPICAL ROLLED PEARLY WHITE EDGES

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ROLLED OUT EVERTED EDGE Squamous cell carcinoma or an ulcerated adenocarcinoma Caused by fast growing cellular disease , growing portion at the edge of ulcer heaps up and spills over normal skin to produce an everted edge

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SCC BUCCAL MUCOSA

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Healing ulcer- blue zone (growing spreading ulcer- edge is inflammed and oedematous epi) and a white zone (fibrosis) S .DAS

5.FLOOR 

Exposed surface of the ulcer

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When floor is covered with red granulation tissue ulcer seems to be healthy and healing

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Pale and smooth granulation tissue-slowely healing ulcer

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Wash leather slough-gummatous ulcer S .DAS

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Trophic ulcer penetrates down even to the bone-which forms the floor in that case

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A black mass at the floor suggests malignat melanoma

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A black mass at floor suggests malignant melanoma S .DAS

6.Discharge 

Character

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Its amount and smell

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Healing ulcer-scanty serous discharge

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Spreading and inflammed ulcer-purulent discharge

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Malignant ulcer-sero-sanguineous discharge S .DAS

7. Surrounding area 

glossy ,red and oedematous Acutely inflammed-

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Scar or wrinkling – old case of tuberculosis

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Dark pigmentation & eczema → varicose ulcer

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Hypopigmentation → non-healing ulcer

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B. PALPATION       

Tenderness Edge and margin Base Depth Bleeding Relations to deeper structures Surrounding skin

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1. Tenderness Acutely

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2. Edge and margin 

Marked Induration-squamous cell carcinoma

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Slight induration- chronic ulcer

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3. Base  

On which the ulcer rests Better felt than seen

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If an attempt is made to lift the ulcer between the thumb and index finger, base will be felt

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Slight induration at the base-chronic ulcer Marked induration (hardness)-squamous cell carcinoma

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Relations to deeper structures  

Gummatous ulcer over subcutaneous bone (tibia,sternum) –often fixed Malignant also fixed

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Surrounding skin    

temperature & tenderness Mobility Fixity to deeper structure –malignant lesion For nerve lesion

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C.EXAMINATION OF LYMPH NODES 

Acute ulcers –regional lymph nodes enlarged tender

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Tuberculous ulcers-enlarged ,matted ,slightly tender

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Malignant ulcers-stony hard and fixed

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SPECIAL INVESTIGATIONS    

Routine blood examination Bacteriological examination of the discharge Chest X-Ray Biopsy

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ORAL ULCERS 

Erosion / Ulcer

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Erosion –shallow crater in the epithelial surface , erythematous area, implies only superficial damage

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Ulcer –deeper crater that extends trough the entire thickness of the surface epithelium and involves the underlying connective tissue WOOD AND GOAZ

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Oral ulcers may be divided into 2 groupsShort term (those that usually disappear within 3 weeks) Persistent (last longer than 3 weeks)

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Differential list of short term ulcers      

Traumatic ulcer Recurrent aphthous ulcers-minor Recurrent intraoral herpes simplex Ulcer occurring as a result of odontogenic infection Ulcers occurring as a result of vesiculobullous diseases Ulcers secondary to infectious diseases WOOD AND GOAZ

Differential list of persistent ulcers        

Traumatic ulcer Major aphthous ulcer Squamous cell carcinoma Ulcers in human immunodeficiency virus disease Low grade mucoepidermoid tumour Systemic mucosis Chancre Gumma WOOD AND GOAZ

Traumatic ulcer 

Vary greatly in size and shape

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Seldom are multiple or recurrent

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On tongue,lips,mucobucc al fold,gingivae and palate WOOD AND GOAZ

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Borders are raised and reddish

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Bases may have yellowish white necrotic surface that may be readily removed

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Frequently tender or regional lymphadenitis occurs as a result of contamination of the ulcer by oral flora WOOD AND GOAZ

Recurrent aphthous ulcer-minor 

Shallow ulcer 0.5 to 2 cm in dia

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Occur on movable mucosa (non keratinized) lips, buccal mucosa, tongue floor of mouth, mucobuccal fold , soft palate WOOD AND GOAZ

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Yellow necrotic centre,smooth contoured border, red halo,symmetric and circular

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Lesions occur singly , occasionally two or three and are widely distributed WOOD AND GOAZ

Recurrent intra oral herpes simplex Shallow ulcer,not more than 0.5 cm in dia with red halo,number of vesicles may occur in tight clusters,rupture to form lager ulcer upto 1.5 cm in dia  Sclloped border 

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Lesion occurs on fixed mucosa , it is tightly bound to periosteum (keratinized) hard palate, gingivae, alveolar ridge

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Lesion often returns to same location

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Major aphthous ulcer Severe form of the minor RAU  Usually single or at the most there are three  Larger than 2 cm,deep very painful occur in the posterior of the mouth  Heal with scar formation 

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Syphillis 

Primary(chancre)-

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Develop approximately 3 weeks after inoculation

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single, indurated nonpainful ulcer at the site of sprirochete entry, spontaneously heals in 4-6 weeks. WOOD AND GOAZ

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Oral lesions occur most often on lips, tip of tongue or gingiva

Measures 0.5 to 2 cm in dia,shallow ,oval or round in shape, have a narrow copper colored slightly raised borders with reddish brown base or centre  regional lymph nodes are enlarged, firm discrete and painless 

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Secondarymaculopapular rash on skin

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oral ulcers covered by mucous membrane(mucous patches)

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Snail track ulcers-multiple small ,rounded superficial erosions which coalesce to form narrow curved shallow ulcers

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Lymph nodes –enlarged and painless

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3 Stage- gumma Occur most often In palate or tongue starting at small firm nodular masses

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Necrosis commences within nodules and produces ulceration of surface epi

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Necrotic tissue at the base of ulcer sloughs awaypunched out lesion is seen WOOD AND GOAZ

T.B  

Oval in shape with irregular cresentric border Often multile

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Slightly Indurated, chronic ulcer that may be painfulon any mucosal surface

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Reddish blue Undermined edges

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Ulcers from odontogenic infections 

In most cases of chronic alveolar abscess, ulcer is seen on alveolar ridge on buccal or lingual surface near mucobuccal fold, seldom on palate

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Pressure on adjacent soft tissues causes pus to exude from ulcer , Identifies the condition

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A gutta percha point may be placed in the ulcer and ed into the tract as far as it will go without undue force radiograph is taken If the point is seen to reach the apex infected tooth diagnosis is ensured WOOD AND GOAZ

U O Y K THAN