section name header

Information ⬇

Editors

TuulaSalo
MariaSiponen

Oral Mucosal Ulcers

Essentials

  • Assess and eliminate possible irritating factors, e.g. sharp tooth edges or a rubbing prosthesis.
  • Any ulcer that has not healed in 2 weeks usually warrants biopsy which can be taken with a punch or knife. Always keep in mind the possibility of oral cancer.

Aetiology and treatment

Traumatic ulcers

  • Mechanical
    • Caused by e.g. biting, a chipped tooth or a rubbing prosthesis
    • Usually heals without sutures; however, ulcers that split the mucosa or the skin of the lip should be closed by suturing.
  • Thermal
    • Caused by hot food or drink
  • Chemical
    • Caused by e.g. ASA or a substance used in dentistry

Ulcers caused by an infection

  • Bacterial infections (syphilis, gonorrhoea, actinomycosis, tuberculosis)
  • Deep fungal infections in immunocompromised persons
  • Viral infections (e.g. HSV Viral Infections of the Oral Mucosa) may be ulcerated after the blister stage.

Aphthous ulcers (recurrent aphthous stomatitis) Systemic Interventions for Recurrent Aphthous Stomatitis, Chlorhexidine for Aphthous Stomatitis, Topical Corticosteroids for Aphthous Stomatitis

  • Round or oval, painful acute ulcers
  • Can be clinically categorized as small (≤ 1 cm), large (> 1 cm) and herpetiform (numerous very small ulcers). Small aphthae are common.
  • Small and large ulcers typically occur on the labial and buccal mucous membranes (often in the oral vestibule; picture ), more rarely on the tongue and gums. Herpetiform aphthae may occur anywhere in the oral cavity.
  • The aetiology is unknown. Genetic predisposition has been found in some patients.
  • The ulcers will heal within 1-6 weeks, depending on their size.
  • Possible triggering factors include e.g. stress, mucosal trauma, cessation of smoking, certain foods, haematological abnomalities (deficiency of iron Iron Deficiency Anaemia, folic acid, vitamin B12 Megaloblastic Anaemia or zinc), hormonal changes and toothpastes containing sodium lauryl sulfate (SLS) 1.
    • In some patients, the use of SLS free toothpaste may reduce the occurrence of aphthae.
  • If treatment is considered necessary, topical glucocorticoid products (paste or adhesive tablet) as well as chlorhexidine mouthwashes may be tried.
  • An extemporaneous gel made of 4 substances (betamethasone 0.1% cream 5 g, lidocaine hydrochloride 2% gel 5 g, chlorhexidine gluconate 1% gel 5 g and nystatin 100 000 IU/ml oral suspension 5 g) effectively alleviates aphthous pain.
    • In large, frequently recurring ulcers, mouth rinsing with tetracycline may be tried: a capsule containing 500 mg of tetracycline is dissolved in a glass of water, and the mouth is rinsed with the solution without swallowing it 4 times daily for 4-5 days.
  • A topical anaesthetic or a product that forms a protective film over the aphtha may be helpful for the pain.
  • Application of liquid containing hydroxymethoxybenzenesulphonic acid and sulphuric acid will necrotize the aphtha and after the painful application the area is pain-free.

Aphtha-like ulceration in other diseases

  • Conditions that may be associated with aphtha-like ulcers
    • Drug reactions (cytostatic drugs, antihypertensives, antidiabetic drugs, gold salts, anti-inflammatory agents, antimalarial drugs)
    • Herpes virus infection (first vesicle that rapidly becomes ulcerated)
    • Cyclic neutropenia Leucopenia
    • Gastrointestinal diseases (coeliac disease Coeliac Disease, Crohn's disease Crohn's Disease, ulcerative colitis Ulcerative Colitis)
    • Whenever genital ulcerations or symptoms in the eyes, skin or joints occur in association with aphthous ulcers, the possibility of Behçet's syndrome http://www.orpha.net/consor/cgi-bin/Disease_Search.php?lng=EN&data_id=703 should be considered.
    • Chronic granulomatous disease
    • Granulomatosis with polyangiitisVasculitides
    • Lichen ruber, pemphigus, pemphigoid, dermatitis herpetiformis, epidermolysis bullosa, SLE, reactive arthritis (formerly Reiter's syndrome), hyperimmunoglobulinemia D

Erythema multiforme

  • An acute, immune-mediated inflammatory disease of the skin an/or mucosal membranes
  • Skin changes typically occur in the extremities as erythematous concentric rings (cockades, or bull's eye lesions). They may be associated with bullae, and vesicular or erosive changes may be found on the lips and the oral mucosa (picture ) 2. Sometimes the oral lesions occur without clear skin changes.
  • The disease may affect several mucosal areas (e.g. genitals, pharynx, oesophagus, larynx, eyes).
  • Usually in young adults
  • The disease is self-limiting but may recur even several times.
  • The aetiology is unknown, but in about 50% of the cases it is possible to identify a triggering factor. Such factors include: infections (particularly HSV or mycoplasma), drugs, vaccination, chemicals, malignancies, immunological diseases and radiotherapy.
  • Similar but more severe and extensive conditions known as Stevens-Johnson syndrome and Lyell's syndrome (toxic epidermal necrolysis) are considered as independent diseases; see Erythema Multiforme.

Diagnosis

  • Diagnosis is usually based on the clinical picture and on the patient history that reveals a triggering factor.
  • If an HSV or mycoplasma infection is suspected the diagnosis should be appropriately confirmed.
  • Immunofluorescence of a fresh biopsy specimen (a non-specific finding) can be used to exclude other clinically similar diseases, if needed.

Treatment

  • Elimination of the cause, sufficient hydration, pain medication as required
  • Topical glucocorticoid preparations are usually effective in relieving symptoms caused by oral lesions.
  • Topical anaesthetic spray may be applied to make eating and drinking easier.
  • Chlorhexidine (2 mg/ml) mouthwashes 2-3 times daily to prevent the emergence of infectious complications and to maintain good oral hygiene
  • In a recurrent disease triggered by Herpes simplex virus, prophylactic medication with aciclovir may be beneficial.
  • Severe forms of the disease warrant hospitalization and systemic glucocorticoids.

Neoplasias

  • Oral squamous cell carcinoma may present as a chronic ulcer typically on the lateral aspects of the tongue, in the floor of the mouth or on the buccal or soft-palate mucous membranes. See also Cancers of the Head and Neck.

References

  • Chavan M, Jain H, Diwan N et al. Recurrent aphthous stomatitis: a review. J Oral Pathol Med 2012;41(8):577-83. [PubMed]
  • Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol 2012;51(8):889-902. [PubMed]
  • Challacombe SJ, Alsahaf S, Tappuni A. Recurrent Aphthous Stomatitis: Towards Evidence-Based Treatment? Current Oral Health Reports (2015);Vol. 2(3):158-167 http://qmro.qmul.ac.uk/xmlui/handle/123456789/12137.
  • Tarakji B, Gazal G, Al-Maweri SA et al. Guideline for the diagnosis and treatment of recurrent aphthous stomatitis for dental practitioners. J Int Oral Health 2015;7(5):74-80. [PubMed]
  • Bulur I, Onder M. Behçet disease: New aspects. Clin Dermatol 2017;35(5):421-434. [PubMed]

Evidence Summaries ⬆