Oral Ulceration – Presentation, Causes and Treatment of Ulcers

Ulcers are extremely common and many patients present with them in practice. It is important to identify the causes of ulcers and know how to manage them.

What are ulcers?

Ulcers occur due to a break in epithelium, which then exposes underlying connective tissue. Usually, the full thickness of the epithelium is lost and replaced by a fibrin slough. There is also usually inflammatory cells present.

Ulcers can be primary ulcers (occurring on their own) or secondary (occurring as vesicles first then rupturing to form ulcers).

Causes and Management

There are a variety of causes and various patterns that can be identified. Ulcers may be single or multiple episodes, and may be single or multiple. Some of the causes include:

• Trauma
• Malignancies
• Recurrent Aphthous Stomatitis (RAS)
• GI Disorders
• Drug-Induced
• Irradiation

Each of these are discussed below in more detail with the associated management options.

The basic things to ask in a history include: size, shape, location, number of ulcers, duration, how often, pain, alleviating/precipitation factors, other symptoms (systemic or otherwise)

The basic things to look for on examination include: size, shape, site, number, margins, depth, base, other features

Trauma

• History – usually single episode, single ulcer. Patient notes a history of trauma (chemical, thermal, self-inflicted).
• Cause – these can occur due to one-off events such as burning your mouth on hot food (thermal), trauma due to medication such as aspirin (chemical) and trauma due to habits. This is the most common cause of ulcers.
• Management – Remove the associated cause and review the patient in 2 weeks time to ensure healing. Advice warm salty mouthrinses (WSMR), Difflam or Corsodyl to help with healing.

Malignancies

• These should always be considered when a patient presents with an ulcer
• History:
  • Non-healing ulcer that has persisted for over 2 weeks (hence the need to review traumatic ulcers)
  • Painless ulceration
  • Irregular/atypical ulcer
  • May be indurated
  • Patient has a red flag history e.g. heavy smoking or alcohol consumption
  • Common locations include lateral borders of the tongue, soft palate and retromolar pad.
• Causes – causes of malignancies are well known and primarily including smoking and alcohol consumption. However, others include HPV, syphillis and precancerous lesions.
• Management – it is always important to review suspect cases. Where there is an ulcer that has failed to heal within 2 weeks of removing a cause, or an ulcer has persisted for 2 weeks without a cause then these should immediately be referred to be biopsied.

Recurrent Aphthous Stomatitis (RAS)

• History – shallow, painful, round/oval ulcers. May be single/multiple and recurrent. Commonly surrounded by an erythematous halo.
• Cause – There are 3 main types of RAS
  • Minor
    • Most common form of RAS
    • Generally affects younger patients (10-30yrs)
    • Usually up to 5 ulcers at a time, up to 10mm in diameter
    • Short duration (7-14 days)
    • Occur towards the front of the mouth – non-keratinised mucosa
    • Heal without scarring
  • Major
    • Larger ulcers (up to 3cm)
    • Long duration (several weeks up to 3 months)
    • Occur towards the back of the mouth – keratinised mucosa
    • May heal with scarring
  • Herpetiform
    • Multiple clustered small ulcers (1-2mm)
    • These may join together to form larger ulcers
    • Generally on the floor of mouth, margins and ventral surface of the tongue
    • Last up to 10 days
  • There may be underlying factors which contribute to the ulcer development including stress, hormonal changes, trauma, haematological deficiencies, GI disorders and immune deficiencies.
• Management
  • Exclude any other cause of the ulcers. If the patient is deficient then correct this, manage any underlying problems.
  • Symptomatic management can be provided – Difflam, Corsodyl, WSMR.
  • Local treatments include beclometasone sprays, betamethsone mouthwashs and hydrocortisone pellets.
  • In patients where this fails to help, systemic methods can be used – prednisalone short-termm) and thalidomide. For herpetiform ulcers, steroids are not used and doxycycline mouthwashes are used instead.

GI Disorders

• History – the patient will usually have other GI symptoms (bowel problems, abdominal pain). Other oral lesions may be present – mucosal tags etc.
• Cause – conditions including Crohn’s disease, ulcerative colitis and coeliac disease
• Management – symptomatic management of the ulcers is required then more intense management of the patients systemic condition e.g. dietary elimination, steroids to suppress inflammatory response and correction of deficiencies.

Drug-Induced

• History – generally associated with the onset of a new medication. Generall,y chronic ulcers that may present as multiple ulcers over a period of time.
• Causes – medication such as nicorandil, methotrexate, allopurinol and cytotoxic drugs. Some drugs may cause a drop in a patient’s white cell count (neutropenia) which may then lead to ulcers.
• Management  – contacting the doctor to see if the drug may be replaced is usually recommended. In many situations, this cannot be done and local management should be carried out – Difflam/WSMR/Corsodyl mouthwashes. Sometimes doxycylcine mouthwashes can be used to help.

Irradiation

• History – history of radiotherapy to head/neck region
• Cause – the irradiation leads to early and late ulcers
• Management – these generally settle over time following completion of radiotherapy. Symptomatic management is recommended.

Other causes

Numerous other conditions may lead to ulcers and these briefly include:

• Herpes simplex infection
• Herpes zoster infection
• Erythema multiforme
• Behcets Disease
• Lichen planus
• Vesicular bullous disorders

Further Investigations

When the cause of an ulcer is not certain, further investigations may be requested including:

• Blood tests – assess for Ferritin, B12 and folate deficiencies; assess for inflammatory markers
• Coeliac screen
• Allergy tests
• Biopsies

General Management

Although management is generally discussed above, a basic framework can be followed in any situation:

• Prevention/Correction 
  • Correct any deficiencies
  • Manage any underlying systemic diseases
  • Dietary control
  • Remove/prevent trauma
• Symptomatic Management
  • WSMR
  • Good oral hygiene
  • Difflam
  • Corsodyl
  • Orobase toothpaste
• Suppressive management
  • Topical – beclametasone spray, betamethasone mouthwash, hydrocortisone pellets
  • Systemic – prednisalone, thalidomide, azathioprine

An oral medicine referral is always very useful for further investigation.

Summary

• Ulcers commonly present in practice as painful lesions.
• They have multiple causes including trauma, malignancies and RAS.
• Further investigations may be needed, including blood tests and biopsies.
• Management varies based on the cause but can generally be divided into prevention, symptomatic and suppressive management.

References and Recommended Reading

• Cawson’s Essentials of Oral Pathology and Oral Medicine
• Oral Pathology (Oxford Medical Publications)