Examination of An Ulcer

EXAMINATION OF
ULCER
Guided by:
Dr. Munish
Kumar
Dr.Ravi Narula
Presented by:
Amritveer Kaur
An ulcer is the break in the continuity of

covering epithelium-skin or mucous
membrane
Follow the molecular death of the

covering epithelium or its traumatic
removal
S .DAS
PARTS OF ULCER
Margin
Edge
Floor
Base
S .DAS
CLASSIFICATION OF
ULCERS
TWO TYPES OF CLASSIFICATON OF ULCERS IS POSSIBLE:1.
CLINICAL:
2.
PATHOLOGICAL
S .DAS
Callous/ Chronic
S .DAS
Arterial, Traumatic,
S .DAS
HISTORY
Mode of onset
Duration
Pain
Discharge
Associated disease
S .DAS
1) Mode of onset
How ulcer developed ??
Traumatic- Eg.dental ulcer of the tongue
Spontaneously- may develop following a

swelling which may be matted tuberculous
lymph node or gumma or a rapidly growing
malignant tumour ( malignant melanoma)
S .DAS
Marjolins ulcer- on burn

scar
S .DAS
2) DURATION
How long??
Acute ulcer,chronic ulcer
Incubation period-time interval between

exposure and the onset
S .DAS
3) PAIN
IsInflammatory
the ulcer
painful??
ulcers
S .DAS
4) DISCHARGE
Does the ulcer discharge or not??
Nature of discharge-serum, pus or blood
S .DAS
5) ASSOCIATED DISEASE
Nervous diseases
Tuberculosis
Diabetes
syphillis
S .DAS
LOCAL EXAMINATION
Inspection
Palpation
Lymph Nodes
S .DAS
A ) Inspection
Size & Shape

Number
Position
Edge, Margin, Floor
Discharge
Surrounding area
S .DAS
1. Size & Shape

Tuberculous
S .DAS
2. Number
Tuberculous ,gummatous,varicose
ulcers and soft chancres may be more
than one in number
S .DAS
3. Position
RODENT ULCERS
S .DAS
Anywhere
Over
Where
subcutaneous
in the
bones such as
S .DAS
4.EDGE
Area between the margin and the floor
An ulcer has a margin or edge which takes

characteristic shape in a particular form of
ulcer
Gives clue to the diagnosis of ulcer also to

the condition of ulcer
S .DAS
TYPES OF EDGES
Undermined edges
Punched out edges
Sloping
Raised and pearly white beaded
Everted
S .DAS
UNDERMINED EDGES
Mostly seen in tuberculosis

Subcutaneous tissue destroyed faster than
skin
Overlying skin is thin friable ,reddish blue
and unhealthy
S .DAS
Undermining of edges
S .DAS
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
S .DAS
Punched out ulcers as seen in

vasculitis
S .DAS
SLOPING EDGE
Healing traumatic or venous ulcers

Reddish purple in color
Consists of new healthy epithelium
S .DAS
Healing traumatic ulcer
S .DAS
RAISED AND PEARLY WHITE

BEADED EDGE
Rodent ulcer
Develops in invasive cellular disease
and becomes necrotic at centre
S .DAS
BCC WITH TYPICAL ROLLED

PEARLY WHITE EDGES
S .DAS
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
S .DAS
SCC BUCCAL MUCOSA
S .DAS
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
When floor is covered with red granulation

tissue ulcer seems to be healthy and healing
Pale and smooth granulation tissue-slowely

healing ulcer
Wash leather slough-gummatous ulcer

S .DAS
Trophic ulcer penetrates down even to the

bone-which forms the floor in that case
A black mass at the floor suggests malignat

melanoma
S .DAS
A black mass at floor suggests malignant

melanoma
S .DAS
6.Discharge
Character
Its amount and smell
Healing ulcer-scanty serous discharge
Spreading and inflammed ulcer-purulent discharge
Malignant ulcer-sero-sanguineous discharge

S .DAS
7. Surrounding area
glossy ,red and oedematous Acutely

inflammed-
Scar or wrinkling old case of tuberculosis
Dark pigmentation & eczema varicose ulcer
Hypopigmentation non-healing ulcer
S .DAS
B. PALPATION
Tenderness
Edge and margin
Base
Depth
Bleeding
Relations to deeper structures
Surrounding skin
S .DAS
1. Tenderness
Acutely
S .DAS
2. Edge and margin
Marked Induration-squamous cell

carcinoma
Slight induration- chronic ulcer
S .DAS
3. Base
On which the ulcer rests

Better felt than seen
If an attempt is made to lift the ulcer between

the thumb and index finger, base will be felt
Slight induration at the base-chronic ulcer

Marked induration (hardness)-squamous cell
carcinoma
S .DAS
Relations to deeper structures
Gummatous ulcer over subcutaneous

bone (tibia,sternum) often fixed
Malignant also fixed
S .DAS
Surrounding skin
temperature & tenderness

Mobility
Fixity to deeper structure malignant lesion
For nerve lesion
S .DAS
C.EXAMINATION OF LYMPH
NODES
Acute ulcers regional lymph nodes enlarged

tender
Tuberculous ulcers-enlarged ,matted ,slightly

tender
Malignant ulcers-stony hard and fixed
S .DAS
SPECIAL
INVESTIGATIONS
Routine blood examination

Bacteriological examination of the
discharge
Chest X-Ray
Biopsy
S .DAS
ORAL ULCERS
Erosion / Ulcer
Erosion shallow crater in the epithelial

surface , erythematous area, implies only
superficial damage
Ulcer deeper crater that extends trough the

entire thickness of the surface epithelium and
involves the underlying connective tissue
WOOD AND GOAZ
Oral ulcers may be divided into 2

groupsShort term (those that usually disappear
within 3 weeks)
Persistent (last longer than 3 weeks)
WOOD AND GOAZ
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
Seldom are multiple or

recurrent
On
tongue,lips,mucobucc
al fold,gingivae and
palate
WOOD AND GOAZ
Borders are raised and reddish
Bases may have yellowish white necrotic

surface that may be readily removed
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
Occur on movable
mucosa (non
keratinized) lips,
buccal mucosa,
tongue floor of mouth,
mucobuccal fold , soft
palate
WOOD AND GOAZ
Yellow necrotic
centre,smooth
contoured border,
red halo,symmetric
and circular
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
WOOD AND GOAZ
Lesion occurs on fixed mucosa , it is

tightly bound to periosteum (keratinized)
hard palate, gingivae, alveolar ridge
Lesion often returns to same location
WOOD AND GOAZ
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
WOOD AND GOAZ
Syphillis
Primary(chancre)-
Develop approximately 3
weeks after inoculation
single, indurated
nonpainful ulcer at the
site of sprirochete entry,
spontaneously heals in
4-6 weeks.
WOOD AND GOAZ
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
WOOD AND GOAZ
Secondarymaculopapular rash on
skin
oral ulcers covered

by mucous
membrane(mucous
patches)
WOOD AND GOAZ
Snail track ulcers-multiple small

,rounded superficial erosions which
coalesce to form narrow curved shallow
ulcers
Lymph nodes enlarged and painless
S .DAS
3 Stage- gumma
Occur most often In palate
or tongue starting at small
firm nodular masses
Necrosis commences
within nodules and
produces ulceration of
surface epi
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
Slightly Indurated, chronic

ulcer that may be painfulon any mucosal surface
Reddish blue Undermined

edges
WOOD AND GOAZ
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
Pressure on adjacent soft tissues causes pus to

exude from ulcer , Identifies the condition
S .DAS
A gutta percha point may be

placed in the ulcer and
passed 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

Examination of An Ulcer

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What are the different parts of an ulcer?

What are the different parts of an ulcer?

How are ulcers classified clinically and pathologically?

How are ulcers classified clinically and pathologically?

EXAMINATION OF

An ulcer is the break in the continuity of

Follow the molecular death of the

How ulcer developed ??

Traumatic- Eg.dental ulcer of the tongue

Spontaneously- may develop following a

Marjolins ulcer- on burn

Acute ulcer,chronic ulcer

Incubation period-time interval between

Does the ulcer discharge or not??

Nature of discharge-serum, pus or blood

Size & Shape

1. Size & Shape

Area between the margin and the floor

An ulcer has a margin or edge which takes

Gives clue to the diagnosis of ulcer also to

Mostly seen in tuberculosis

PUNCHED OUT EDGE

Gummatus ulcer or in deep trophic ulcer

Punched out ulcers as seen in

Healing traumatic or venous ulcers

Healing traumatic ulcer

RAISED AND PEARLY WHITE

BCC WITH TYPICAL ROLLED

ROLLED OUT EVERTED

SCC BUCCAL MUCOSA

Healing ulcer- blue zone (growing

Exposed surface of the ulcer

When floor is covered with red granulation

Pale and smooth granulation tissue-slowely

Wash leather slough-gummatous ulcer

Trophic ulcer penetrates down even to the

A black mass at the floor suggests malignat

A black mass at floor suggests malignant

Its amount and smell

Healing ulcer-scanty serous discharge

Spreading and inflammed ulcer-purulent discharge

Malignant ulcer-sero-sanguineous discharge

glossy ,red and oedematous Acutely

Scar or wrinkling old case of tuberculosis

Dark pigmentation & eczema varicose ulcer

Hypopigmentation non-healing ulcer

2. Edge and margin

Marked Induration-squamous cell

Slight induration- chronic ulcer

On which the ulcer rests

If an attempt is made to lift the ulcer between

Slight induration at the base-chronic ulcer

Relations to deeper structures

Gummatous ulcer over subcutaneous

temperature & tenderness

Acute ulcers regional lymph nodes enlarged

Tuberculous ulcers-enlarged ,matted ,slightly

Malignant ulcers-stony hard and fixed