Oral Medicine and Oral Pathology/Oral ulceration

The main Wikipedia articles for this topic are:


 * Oral ulceration
 * Aphthous stomatitis (recurrent aphthous stomatitis)

The above pages aim to provide encyclopedic coverage of the topic, however this Wikiversity page is more aimed at people who wish to learn more about how oral ulceration is managed clinically, in a how-to format. Consequently this page will mainly cover the following areas:


 * How to take a medical history of a patient complaining of oral ulceration.
 * How to examine a patient with oral ulceration.
 * The differential diagnosis of the causes of oral ulceration, including what special investigations may be required.
 * How to approach the treatment of a patient with oral ulceration, including a suggested treatment algorithm.

Oral ulceration is a common complaint, and consequently it will be encountered very often on the oral medicine clinic. Aphthous stomatitis alone is thought to affect around 20% of the general population, making it the most common disease of the oral mucosa.

Oral ulceration is of relevance to both general dentistry and the dental specialties, and there should be a sound understanding of how to manage the clinical topic. General (family) physicians will also encounter patients with oral ulceration and should have some knowledge, even if it is just an awareness of the red flag signs and symptoms of a malignant ulcer. Some medical specialists such as dermatology, gastroenterology and ophthalmology also should have knowledge of how the topic of oral ulceration overlaps with their own specialty.

Definitions
An oral ulcer is a lesion wherein there is a full thickness breach of the epithelial continuity of the oromucosa. Ulcers may extend to varying degrees into the tissues underlying the epithelium: the submucosa, or even muscle or periosteum.

2 other types of lesions: excoriations and erosions, are similar to ulcers are also considered in this topic. Erosions, sometimes mistakenly used as a synonym of ulceration, are lesions which involve only the epithelial layer, with little or no damage to the underlying connective tissue. Erosions are shallow craterous lesions, and the term implies only superficial damage. In contrast to ulcers, there is not usually a yellow fibrinous slough that covers the base of the lesion. Instead, erosions may appear as red lesions. Excoriation is a term that is not often used, and refers to a lesion that is deeper than an erosion but shallower than an ulcer. The base of an excoriation may uncover the tips of the connective tissue papillae with their capillary loops, and consequently punctiform bleeding may be observed (pinhead dots of bleeding). Remember that the epithelial layer has no blood vessels

Ulcers are sometimes primary lesions, or they can be secondary lesions, where they are the result of a primary lesion, such as blisters (bullae) or epithelial atrophy (thinning). In the mouth, constant exposure to trauma during eating and from the teeth, and the moist environment from saliva often lead to rapid breakdown of blisters into ulcers or erosions. As such, the vesiculobullous diseases which may occur in the mouth are often considered within the topic of oral ulceration. Often, a erythematous maccule will precede some types of oral ulcers (e.g. aphthous ulcers), and the maccule could be considered a primary lesion. Exophytic lesions may grow impinge on the neutral zone, and be ulcerated by the teeth during chewing, or simply attract more mechanical trauma because of their prominence relative to surrounding tissues.

History
A careful history is important in diagnosing an oral ulcer, indeed many of the diagnoses are directly formed from the history.

The complaint
Persons with oral ulceration may actually use the words "mouth ulcer" since it is in common use, or they may complain of a sore, raw or burning area in the mouth. It should be remembered that a patient who uses the word ulcer may not have any visible ulcer, or may have a different type of lesion rather than an ulcer.

Before the ulcer forms, some people with apthous stomatitis may notice prodomal symptoms such as burning, itching or stinging, which may precede the appearance of any lesion by some hours. This is similar to the forewarning some patients experience before the formation of a lesion in herpes labialis.

History of complaint
There are several questions that should be asked to any patient who complains of oral ulceration. The most important is how long the current ulcer has been present, and whether there is a history of similar ulcers in the past.

Ulcers can be considered as short term when they last for less than 3 weeks, and persistent when they last for more than 3 weeks. As a general rule of thumb, any ulcer which does not show signs of healing within 2-3 weeks of onset should be suspected as potentially malignant, and referral to a clinician who specializes in diagnosing and treating oral cancer should be arranged. Usually, it is more appropriate for the biopsy to be carried out by the specialist who is more experienced at selecting the best biopsy site etc.
 * How long has the ulcer been present?

Recurrent ulceration narrows the differential diagnosis significantly. In this context, the term "recurrent" usually refers to ulcers which appear periodically and heal completely between attacks. Recurrent ulcers may manifest as a single ulcer during each period of ulceration, or as multiple ulcers (sometimes termed a crop of ulcers).
 * Previous periods of ulceration?

The main causes of recurrent oral ulceration are RAS, erythema multiforme, traumatic ulcers, ulcers secondary to gastrointestinal disease.

If the patient has a history of developing similar ulcers at different sites in the mouth, which heal completely each time, this suggests recurrent aphthous stomatitis or aphthous-like ulceration and makes malignancy most unlikely. How frequently crops of ulcers appear is also a part of the clinical picture which helps to distinguish between minor recurrent aphthous stomatitis and major recurrent aphthous stomatitis, the ulcer free interval being shorter in the latter type of RAS. If ulceration is nearly continuous, this indicates severe disease, whilst at the other end of the spectrum, if ulcers form only once per year, this is mild. Similarly the age at which the individual first developed the ulceration helps to build the clinical picture.

If the patient gives a history of repeated formation of ulcers at the same site, this may suggest a local cause of trauma such as an adjacent sharp edge on a broken tooth, restoration or prosthesis. Traumatic ulcers only recur at the same site if the cause has not been removed.

Aphthous-like ulceration may occur in cyclic neutropenia. These mouth ulcers are worst during periods of reduced circulating neutrophils, which occurs about every 21 days.

Classically, ulceration in erythema multiforme recurs every 6-8 weeks in severe cases, but in milder cases there may only be 1-2 attacks per year.


 * Pain

For ulcers generally, most often mechanical contact from foods or drinks (especially acidic food and drink), the teeth, dentures, or the tongue or a finger is painful. Ulceration of the tongue can make speaking and chewing painful, and ulceration of the soft palate and oropharynx can cause odynophagia (painful swallowing).

Medical history

 * Radiotherapy


 * Chemotherapy


 * Osteoporosis


 * Angina


 * NSAIDs


 * Gastrointestinal diseases may affect the oral mucosa directly or secondarily cause ulceration (or exacerbate pre-existing RAS) due to malabsorption (mainly via decreased absorption of iron, folate and B12). Remember that the oral cavity is anatomically part of the GI tract. Hence, all patients with oral ulceration should be asked if they have a diagnosed GI disorder, and if not they should be asked about GI symptoms such as diarrhea, constipation, abdominal cramps and blood in stool in case there is an undiagnosed GI disorder. Oral ulcers are seen particularly in Crohn's disease, where they are described as linear with hyperplastic margins. In ulcerative colitis, occasionally there may be large leathery ulcers, multiple pustules and irregular hemorrhagic ulcers in the mouth. In Celiac disease there may be herpetiforme-type oral ulcers.

Examination
There are several features that need to be looked for when examining a patient with oral ulceration. These features are assessed first during inspection (looking), and then palpation (feeling).

Inspection
Traumatic ulcers are most common on the lateral borders of the tongue and the buccal mucosa in the occlusal plane. An adjacent sharp edge to the ulcer suggests mechanical trauma. Ulceration of the lower lip is common when the patient bites into the tissues whilst a inferior alveolar nerve block is wearing off following dental treatment.
 * Site

Ulceration and sloughing necrosis of the tips of the interdental papillae, especially in the lower anterior region, is almost pathognomonic of ANUG.

OSCC most frequently occurs in a "high risk oval" that is defined by the lower lip, floor of mouth, ventral and lateral borders of the tongue, retromolar areas, tonsillar pillars, and lateral soft palate.

Ulceration that is unilateral may be ulceration following breakdown of vesicles in herpes zoster reactivation (intra-oral shingles)


 * Number

The size of ulcers is one of the distinguishing features in aphthous stomatitis, enabling the designation of the sub-type minor (<10 mm), major (>10 mm) or herpetiforme (<1 mm).
 * Size

Linear, fissure-like ulcers may be seen in Crohn's disease. A semicircular ulcer in the shape of a fingernail may suggest self inflicted ulceration.
 * Shape


 * Base

A raised, rolled margin is suspicious.
 * Edge

Palpation
As always, an oral lesion may be invective, so gloves need to be worn.

Malignant ulcers tend to be hard on palpation (induration). The Ulcers caused by trauma are often soft on palpation when they are healing.
 * Hardness

One finger secures the lesion and an attempt to move the surrounding tissues is made with another finger. Ulcers which are fixed to underlying structures are more likely to be malignant, but it is not pathognomonic.
 * Mobility

This is a possible feature of a malignant ulcer.
 * Contact bleeding

Most ulcers are painful, especially when they have just formed. In contrast, early malignant ulcers are often painless. Later on, a neglected malignant ulcer may involve adjacent nerves and cause pain.
 * Pain

Differential diagnosis
One way of recalling the causes of mouth ulcers is to use the mnemonic device "So Many Laws And Directives, BIGS" (source: ) which stands for:


 * Systemic disease:
 * Blood disorders
 * anaemia
 * gammopathies
 * haematinic deficiencies
 * hypereosinophilic syndrome
 * leukaemias
 * myelodysplastic syndromes
 * neutropenia
 * other white cell dyscrasias
 * Infections
 * viruses:
 * chickenpox
 * hand, foot and mouth disease
 * herpangina
 * herpetic stomatitis
 * HIV
 * infectious mononucleosis
 * bacteria:
 * acute necrotizing gingivitis
 * syphilis
 * tuberculosis
 * fungi:
 * blastomycosis
 * cryptococcosis
 * histoplasmosis
 * paracoccidioidomycosis
 * parasites:
 * leishmaniasis
 * Gastrointestinal disease
 * coeliac disease
 * Crohn’s disease (and orofacial granulomatosis)
 * ulcerative colitis
 * Skin diseases
 * chronic ulcerative stomatitis
 * dermatitis herpetiformis
 * epidermolysis bullosa
 * erythema multiforme
 * lichen planus
 * linear IgA disease
 * pemphigoid and variants
 * pemphigus vulgaris
 * other dermatoses


 * Others:
 * rheumatic diseases:
 * lupus erythematosus
 * Sweet syndrome
 * Reiter syndrome
 * Vasculitides:
 * Behçet syndrome
 * Wegener’s granulomatosis
 * periarteritis nodosa
 * giant cell arteritis
 * Endocrine disorders:
 * diabetes
 * glucagonoma
 * Disorders of uncertain pathogenesis:
 * eosinophilic ulcer
 * necrotizing sialometaplasia
 * Malignant neoplasms
 * (Oral or encroaching from antrum, salivary glands, nose or skin)


 * Carcinomas
 * Lymphomas
 * Sarcomas
 * Others
 * Local causes
 * Local Trauma:
 * sharp teeth or restorations
 * appliances
 * non-accidental injury
 * self-inflicted
 * iatrogenic
 * Burns:
 * heat
 * cold
 * chemical
 * radiation
 * electric
 * Aphthae
 * Recurrent aphthous stomatitis
 * PFAPA
 * Drugs
 * Alendronate
 * Cytotoxics
 * NSAIDs
 * Nicorandil
 * Propylthiouracil
 * Many others