Diff.diagnosis of oral ulcerations

• Ulcers

  Damage to both epithelium and lamina propria, with a crater, sometimes made more obvious clinically by swelling caused by oedema or proliferation in the surrounding tissue
• Erosions


  Breaches of the epithelium in which there is little damage to the underlying lamina propria
• Causes of oral ulcerations

  • Local causes: trauma, burns, drugs
  • Recurrent aphthous stomatitis
  • Malignant ulcers
  • Systemic disease: blood disorders, gastrointestinal disorders, mucocutaneous disease, connective tissue disease, vasculitides, infective diseases, neoplastic disorder
• Traumatic ulcers

  • Usually a single ulcer is seen, with an obvious cause (e.g. a denture flange)
  • The patient is otherwise well, although there may be a small degree of ipsilateral cervical lymph node enlargement
  • Chronic irritation may cause hyperplasia or hyperkeratosis of the adjacent mucosa, but induration should raise the suspicion of malignancy
  • The edges of the ulcer are usually irregular and the shape depends on the nature of the irritant
• Management of traumatic ulcers

  1. Remove aetiological factors and prescribe a chlorhexidine 0.2% mouthwash

  2. Maintenance of good oral hygiene and the use of benzydamine or hot saline mouthbaths may help

  3. Most ulcers of local cause heal spontaneously in about 1 week if the cause is removed and such supportive care given

  4. Biopsy is needed if there is any suspicion of malignancy or if the ulcer does not heal within 3 weeks of removal of the apparent cause
• Drug-induced ulceration

  • Cytotoxic agents, particularly methotrexate, producing ulcers
  • Agents producing lichen-planus-like (lichenoid) lesions, such as non-steroidal anti-inflammatory agents, some antihypertensives, antidiabetics
  • Agents causing local chemical burns (especially aspirin held in the mouth)
  • Agents causing erythema multiforme (especially sulphonamides and barbiturates)
• Management of drug-induced ulceration

  1. Diagnosis of a drug reaction is made from the drug history and sometimes by testing the effect of withdrawal

  2. Treatment is to stop the causative drug and treat the ulceration symptomatically with topical benzydamine and, possibly, aqueous chlorhexidine
• Recurrent Aphthous Stomatitis (RAS)

  Recurrent mouth ulcers which affect up to 20% of the population, are the most common lesions seen in practice, and typically start in childhood
• RAS

  • The aetiology of RAS is unknown and most patients with RAS are otherwise apparently well
  • There appears to be a genetically determined immunological reactivity to unidentified antigens, possibly microbial
  • About 10–20% of patients prove to have associations with a deficiency of a haematinic such as iron, folate or vitamin B12
  • A very small number of patients may have RAS related to: coeliac disease, menstruation, stress, food allergy, Behçet's syndrome, immunodeficiencies, including HIV disease and cyclic neutropenia
• Types of RAS

  • Minor aphthae (Mikulicz's aphthae (MiRAS))
  • Major aphthae (Sutton's ulcers (MaRAS))
  • Herpetiform ulcers (HU)
• Management of RAS

  1. Aphthae are diagnosed from the history and clinical features

  2. Blood tests may be useful for excluding possible deficiencies or other conditions

  3. Features that might suggest a systemic background, and indicate referral

  4. Treat any underlying predisposing factors where possible, and control the aphthae with chlorhexidine 0.2% aqueous mouthwash, topical corticosteroids, or tetracycline rinses
• Malignant ulcers

  • Most malignant oral ulcers, probably more than 90%, are squamous cell carcinomas
  • Other primary malignant neoplasms can be Kaposi's sarcoma, lymphoma, antral carcinomas or salivary gland tumours
  • Metastases, especially from breast, lung and prostate malignancy may also arise
  • Aetiological factors include tobacco habits, alcoholic beverages, diet poor in fresh fruit and vegetables, and exposure to sunlight
• Potentially malignant or premalignant oral lesions

  • Erythroplasias
  • Some dysplastic leukoplakias
  • Some lichen planus
  • Some oral submucous fibrosis
  • Some chronic immunosuppression (lip cancer mainly)
  • Rare conditions such as discoid lupus erythematosus, Paterson–Kelly syndrome, tertiary syphilis
• Potentially malignant oral lesions

  • Frequently show epithelial atrophy and hence appear clinically particularly as red lesions, or erythroplasia
  • May be associated with white lesions as erythroleukoplakia (speckled leukoplakia)
  • The majority of erythroplasias have histopathological features of severe oral epithelial dysplasia
• Presentation of oral carcinoma

  • Ulcer
  • Red lesion
  • White lesion
  • Mixed red and white lesion
  • Lump
  • Fissure
• Oral carcinoma

  • Usually forms a solitary chronic indurated ulcer, with a raised rolled edge and granular floor
  • Cervical lymph node enlargement may be detectable
  • Intraorally carcinoma typically affects the posterolateral tongue as a lump or ulcer, with submandibular node involvement
  • On the lip, carcinoma presents with thickening, induration, crusting or ulceration, usually at the vermillion border of the lower lip just to one side
• Management of oral carcinoma

  1. Biopsy and specialist referral are almost invariably indicated

  2. It is essential to differentiate an intraoral carcinoma from other causes of persistent mouth ulceration

  3. Predisposing factors such as tobacco and alcohol use should be stopped

  4. Oral carcinoma is now treated by surgery and/or irradiation, with chemotherapy occasionally used
• Radiation-induced lesions

  • Mucositis: diffuse erythema and ulceration
  • Xerostomia: leading to dysphagia, disturbed taste, radiation caries, candidosis, bacterial sialadenitis
  • Liability to osteoradionecrosis
  • Trismus
  • Telangiectasia
  • In children, jaw hypoplasia and hypoplasia and retarded eruption of developing teeth