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Oral ulcers- initial evaluation

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

  1. Differential diagnosis and management of oral ulcers Amanda Siu et al Vol 34 , December 2015 , Seminars in Cutaneous Medicine and Surgery Oral ulceration :
  2. GP guide to diagnosis and treatment Stephen Flint MA , PhD , MB BS , BDS , FDSRCP , FFDRCSI , FICS Prescriber 5 March 2006
  3. Oral mucosal ulceration- a clinician’s guide to diagnosis and treatment J Fourie, SC Boy SADJ November 2016 , Vol 71 no 10 p500-p508
  4. BMJ Best Practice –Assessment of oral ulceration
  5. Evaluation of oral ulceration in primary care  BMJ 2010 ; 340: c2639
  6. 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
  7. Oral Ulcers- A Review Sivapathasundharam B et al J Dent & Oral Disord- Volume 4 Issue 4- 2018
  8. BMJ Best Practice Oral aphthous ulcers
  9. Review article: oral ulceration – etiopathogenesis , clinical diagnosis and management on the gastrointestinal clinic E A Field et al Ailment Pharmacol Ther 2003 ; 18 : 949-962
  10. Oral Medicine Full Referral Guide Yorkshire & the Humber Feb 2017

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