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Oral ulcers- initial evaluation

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Oral ulcers- initial evaluation

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Diagnosis is often challenging One of the most common complaints of patients who attend with oral problems to the GP Estimated point prevalence 4 % world wide Causes are mostly local ( e.g trauma ) , but oral ulceration can be a manifestation of an underlying systemic problem e.g 
◘ GI dysfunction
◘ malignancy
◘ immunological abnormality
◘ cutaneous disease
 Oral mucosa has rich innervation – most ulcers are painful and can be debilitating
( other than early SCC ) also
most of the oral cavity mucosa is thin and delicate- ie prone to trauma , other than the mucosa of the hard palate and gingiva – which is keratinised and more resistant to injuries A single ulcer persisting for more than 3 weeks -which is not healing should be taken seriously Most common causes are
◘ trauma
◘ recurrent aphthous stomatitis
Most common cause and affects 5 to 25 % of the population
◘ microbial infections e.g herpes virus group infections
◘ dermatoses
◘ systemic disorders
◘ OSCC ( oral SCC )
◘ drug therapy

Ulcer- break in lining of or loss of the epithelium of the mucous membrane Erosion- superficial damage to / loss of epithelium Atrophy- thinning of epithelium Plaque – circumscribed raised area mostly > 20 mm in dia and usually white Macule- flat , circumscribed area of mucosa typically pigmented Papule – circumscribed raised lesion < 5 mm in dia Nodule – circumscribed raised lesion > 5 mm in dia Bulla – blister ( fluid filled swelling ) > 5 mm in dia involving mucosa or the skin Vesicle – blister ( fluid filled swelling ) < 5 mm in dia involving mucosa or the skin Cyst -sac like cavity containing fluid that may aris from a minor salivary gland or other submucosal structure

Classification of oral ulcers – Simple Complex Destroying , clinical features microscopic features pathogenesis clinical presence or absence of preceding fluid filled vesicles / bullae, Ulcers which persist for > 2 weeks are chronic , Primary
 recurrent apthous stomatitis trauma dermatoses malignancy infections orofacial granulomatosis neutropenic ulcers drugs

Secondary viral disease dermatoses angina bullosa haemorrhagica

RECURRENT APHTHOUS STOMATITIS ( RAS ) also
 known as Canker sore-Recurrent bouts of one or several shallow , rounded or ovoid painful ulcers 
that recur at intervals of a few days or up to 2-3 months. All forms of aphthous ulcers have yellow-gray pseudomembrane covering , rounded shape and a red ( erythematous ) halo. Minor ulcers – most common type-less than 1 cm buccal mucosa , labial mucosa , the floor of the mouth or the tongue can be single or multiple non-keratinised sites and heal within 10-14 days. major ulcers – 1to 3 ulcers at any one time > 1 cm take time to heal and often scar ( months in some cases ) can produce lesions through out the entire oral cavity , including the soft palate and tonsillar areas, and ulceration may extend to the oropharynx. Herpetiform – Unusually small variant – pinpoint ulcers occur in clusters less common- typpically women aged 29-30 yrs prefer lateral margins of the tongue and the floor of mouth very painful and resemble HSV infection

Aetiology is unknown . Several theories are proposed which include
 genetic factors haematological deficiencies immunological abnormalities trauma. Prevalent mainly in childhood and early adulthood natural resolution with age more common in women , non-smokers , high socioeconomic status ↑ in white people

starts usually in childhood family history is important – runs in families burning sensation of the oral mucosa 24-48 hrs before the ulcer appears but no antecedent vesicles or bullae pain is severe disproportionate to the size of the lesion localized area of erythema develops – small while papules within hrs forms – ulcerates and gradually enlarges over the next 48-72 hrs lesions are round symmetric ad shallow with fibrin covered mucosal defects and an erythematous border

treatment – tetracycline or doxycline mouth rinses 
( e . g 100 mg doxycyline capsule dissolved in 25 mls of water )
Chlorhexidine oral solution ( evidence of benefit in RAS ) topical corticosteroids e.g Adcortyl in Orabase , hydrocortisone buccal tablets , betamethasone soluble tablets , budesonide spray , betamethasone mouthwash topical analgesics e.g 2 % lidocaine HCl or benzydamine systemic therapy in severe cases – oral prednisolone for 1 week is one suggested regimen

Traumatic –Quite common- can be acute or chronic Physical , thermal or chemical trauma to the oral mucosa , tooth brushing Look for denture trauma , sharp broken teeth or accidents, mechanical friction Can happen any age and any sex Can happen after dental treatment from mucosal injury Usually resolves within 2 weeks

Infectious – Viruses e.g HSV ( common )-primary herpetic gingivostomatitis is the most common cause of viral ulcers
Varicella
HIV Bacterial infections as
Syphilis , TB , gonococcal stomatitis Fungal – candidiasis- angular cheilitis

Other associations – Autoimmune conditions e.g
SLE , Behcet’s syndrome Dermatological causes
lichen planus
erythema multiforme
blistering dermatoses – pemphigus , pemphigoid , linear IgA disease , epidermolyis bullosa acquisita and dermatitis herpertiformis Gastrointestinal conditions e.g
Inflammatory bowel diseases- Crohn’s and ulcerative colitis
Coeliac disease Haematological conditions
Anaemia-iron , b12 or folic acid deficiency may predispose to aphthous stomatitis 
Myeloproliferative disorders


Drugs –Drugs can cause oral ulceration in several ways Drug related chronic ulcers can mimic NSAIDs and antihypertensives 
( Captopril ) can cause oral ulcers
Aspirin – acid burn to mucosa Bisphosphonates
directly and via osteonecrosis of the jaw Cytotoxic drugs Nicorandil – dose related localised usually on inner aspect of cheek or on the tongue Peicillamine , gold & methotrexate


Features suggestive of malignancy –Non healing painless ulcer of > 3 wks duration Ulcer – rolled thickened edges White patch with firm consistency Red lesions or lesion with erythematous appearance Risk factors as
age ( + 85 % cases in people > 50 )
smoking , tobacco , alcohol , male sex , HPV infection , immunosuppression , genetic mutations and diets low in fruit and vegetable No h/o previous ulceration No local factors responsible for ulceration previous h/o pre-malignant lesions previous h/o OSCC lack of a systemic cause for ulceration

OSCC -oral squamous cell carcinoma –red or white painless indurated non healing ulcer with elevated and ill defined margins often manifests as a solitary oral mucosal ulceration painless until it involves the periosteum- often presents late with poor prognosis common sites is lateral border of the tongue followed by floor of the mouth L node enlargement may be seen early in the course of the disease Advanced dis can present as bleeding , loosening of teeth , difficulty wearing dentures , dysphagia , dysarthria , odynophagia and neck mass

Examination – Appearance
○ round or oval in shape
○ colour – pale yellow , or grey
○ inflammation
○ ulcer is localised or widespread
○ how many
○ blister preceding the ulcer Location – use easily understandable terms and check these regions
○ inside of lips
○ inside of cheeks
○ floor of mouth
○ mucosa
○ under the surface of the tongue
○ teeth and gums
○ hard palate Feel for induration of the ulcer and surrounding tissue- exclude fixation of mobile tissues as tongue
 Note – prosthesis , sharp teeth , dental restorations Examine for swelling , lymphadenopathy in head and neck region and any extra-oral lesions

history-is it painful , burning sensation how many how long for area affected pain when eating , drinking or brushing teeth associated symptoms recent dental intervention , dental prosthesis full medication / drug use previous h/o ulcerations – pattern , healing time smoking , betel leaves ( paan ) , tobacco chewing

Suspicious lesions -Do not investigate in primary care refer promptly if the ulcer does not respond as anticipated within 2 weeks Histopathological examination of all ulcerated red , white or mixed oral lesions that have persisted is mandatory Clinical diagnosis of oral lesions can be very challenging – wide differential diagnosis Patients can present to a GP or dentist for a diagnosis OSCC- early diagnosis and prompt surgical treatment is the key Incidence of oral cancer is increasing Also refer if the patient requests a 2nd opinion

NICE USC guidance oral cancers-Unexplained ulceration in the oral cavity lasting for more than 3 weeks OR a persistent and unexplained lump in the neck -a lump on the lip or in the oral cavity OR a red or red and white patch in the oral cavity consistent with erythroplakia or erythro
leukoplakia-a lump on the lip or in the oral cavity consistent with oral cancer OR a red or red and white patch in the oral cavity consistent with erythroplakia or erythro
leukoplakia

References Differential diagnosis and management of oral ulcers Amanda Siu et al Vol 34 , December 2015 , Seminars in Cutaneous Medicine and Surgery Oral ulceration : GP guide to diagnosis and treatment Stephen Flint MA , PhD , MB BS , BDS , FDSRCP , FFDRCSI , FICS Prescriber 5 March 2006 Oral mucosal ulceration- a clinician’s guide to diagnosis and treatment J Fourie, SC Boy SADJ November 2016 , Vol 71 no 10 p500-p508 BMJ Best Practice – Assessment of oral ulceration Evaluation of oral ulceration in primary care BMJ 2010 ; 340: c2639 Warning Signs and Symptoms of Oral Cancer and its Differential Diagnosis Kavitha Muthu et al Journal of Young Pharmacists 10 (2) : 138-143 April 2018 Oral Ulcers- A Review Sivapathasundharam B et al J Dent & Oral Disord- Volume 4 Issue 4- 2018 BMJ Best Practice Oral aphthous ulcers Review article : oral ulceration – aetiopayhogenesis , clinical diagnosis and management on the gastrointestinal clinic E A Field et al Ailment Pharmacol Ther 2003 ; 18 : 949-962 Oral Medicine Full Referral Guide Yorkshire & the Humber Feb 2017

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