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Oral Ulceration
Oral Ulceration
geekymedics.com/oral-ulceration/
Introduction
An ulcer is defined as a break in the skin or mucous membrane which fails to
heal leading to a loss of surface tissue, disintegration and epithelial necrosis. 1
This article provides a brief overview of the common causes of oral ulceration.
History
Along with a comprehensive medical, social, dental and family history, key points to
cover in the history include:
Clinical examination
Important points to address in the clinical examination include:
Aetiology of RAS
The aetiology of RAS remains unknown however a number of factors, including stress,
trauma, smoking cessation, hormonal imbalance, food hypersensitivity and genetics can
predispose an individual to RAS.4
Clinical presentation
RAS has three typical clinical presentations which are discussed below.
Minor RAS
Minor RAS is the most common clinical presentation. Ulcers appear in clusters of 1-
6 on non-keratinised mucosa. Minor RAS is self-limiting and usually heals within 7-
10 days with no scarring.
Major RAS
Major RAS can present on keratinised and non-keratinised oral mucosa. These
ulcers are usually greater than 10mm in diameter, occurring in groups of 1-6 (figure
2). Major RAS is self-limiting but can last for several months. These ulcers usually
heal with scarring. It is important for clinicians to be aware that these ulcers can
mimic a malignant ulcer.4
Herpetiform RAS
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Figure 1. Minor recurrent aphthous stomatitis.5
Nutritional deficiencies
Several nutritional deficiencies are linked with the oral manifestation of RAS. The
common nutritional deficiencies seen in patients with RAS are iron, vitamin B12 and
folate.
Behcet’s disease
This is a multisystem inflammatory disorder, which commonly presents in the oral
cavity as aphthous ulceration. Other defining features of Bechet’s disease include
genital ulceration, uveitis, erythema nodosum, arthritis, gastrointestinal lesions,
vascular lesions and central nervous system involvement.8
Aetiology
Clinical presentation
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Bechet’s disease presents in the oral cavity as minor, major or herpetiform recurrent
aphthous ulceration, recurring at least three times over a 1- year period. Oral
ulceration is the hallmark of this disease.8
Crohn’s disease
Crohn’s disease is an autoimmune disorder affecting the gastrointestinal tract.
Aetiology
Clinical presentation
Approximately 80% of the individuals with Crohn’s disease exhibit oral lesions. These
include persistent lip swelling, cobblestone appearance of the oral mucosa,
mucogingivitis, deep linear ulceration, aphthous ulcers along with angular
cheilitis and perioral dermatitis.9
Traumatic ulceration
Aetiology
These ulcers usually heal within 7-10 days after the cause has been eliminated.
Clinical presentation
The most common sites are buccal mucosa, tongue and lower lip.
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Figure 4. The appearance of a traumatic ulcer on
buccal mucosa.12
Aetiology
Clinical presentation
Pyrexia
Malaise
Lymphadenopathy
Halitosis
Difficulty swallowing
Intraoral pinhead vesicles which coalesce into large painful ulcers
Aetiology
This is a highly infectious viral disease caused by the Coxsackie virus affecting infants
and children under 5 years of age.13
Site of ulceration
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Hands
Feet
Oral cavity: tongue, palate, buccal mucosa, gums, lips
Clinical presentation
Erythema multiforme
Erythema multiforme (EM) is an immunological vesiculobullous disorder
affecting the skin and mucous membranes.
Aetiology
Clinical presentation
EM lesions are acute with mild or no prodromal symptoms. Oral lesions occur on the
lips and anterior oral mucosa. The lesions present as asymmetrical, erythematous,
lesions. These lesions usually heal without scarring.14
Risk factors
Smoking, tobacco chewing and excessive alcohol intake increase the risk of
developing oral cancer.
Clinical presentation
These ulcers can present anywhere on the oral mucosa but the following areas are the
high-risk sites, where SCC is more likely to develop:
An ulcerative SCC can present as a crater-like lesion with rolled out margins, an
indurated border and a velvety base (figure 5). 11
Pemphigus vulgaris
Pemphigus vulgaris is an autoimmune, life-threatening disease presenting as blisters
and erosions of the skin and mucous membrane. 13
Clinical presentation
In the oral cavity, the most affected sites are the buccal mucosa, palate and gingivae.
The clinical presentation of the oral lesions starts as a bulla, which breaks to form
shallow ulcers. When rubbed, the thin layer of epithelium sheds leaving a denuded
base (known as Nikolsky’s sign).13
Clinical presentation
Investigations
Further investigations are required when the aetiology of oral ulceration is unclear.
Laboratory investigations
Other investigations
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Reviewer
Dr Rajinder Dodd
Editor
Dr Chris Jefferies
References
1. Edsberg, L.E., Black, J.M., Goldberg, M., McNichol, L., Moore, L. and Sieggreen,
M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging
System. Published in 2016. Available from: [LINK]
2. Minhas, S., Sajjad, A., Kashif, M., Taj, F., Waddani, H.A. and Khurshid, Z. (2019).
Oral Ulcers Presentation in Systemic Diseases: An Update. Published in 2019.
Available from: [LINK]
3. Scully, C. and Shotts, R. Mouth ulcers and other causes of orofacial soreness and
pain. Published in 2001. Available from: [LINK]
4. Tarakji, B., Gazal, G., Al-Maweri, S.A., Azzeghaiby, S.N. and Alaizari, N. (2015).
Guideline for the Diagnosis and Treatment of Recurrent Aphthous Stomatitis for
Dental Practitioners. Published in 2015. Available from: [LINK]
5. Tarakji, B., Gazal, G., Al-Maweri, S.A., Azzeghaiby, S.N. and Alaizari, N. Minor
aphthous ulceration. License: [CC-BY]. Available from: [LINK]
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aphthous ulceration. License: [CC-BY]. Available from: [LINK]
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Herpetiform aphthous ulceration. License: [CC-BY]. Available from: [LINK]
8. Nair, J.R. and Moots, R.J. (2017). Behcet’s disease. Published in 2017. Available
from: [LINK]
9. Lankarani, K.B., Sivandzadeh, G.R. and Hassanpour, S. (2013). Oral
manifestation in inflammatory bowel disease: A review. Published in 2013
Available from: [LINK]
10. Collins, P. and Rhodes, J. (2006). Ulcerative colitis: diagnosis and management.
Published in 2006. Available from: [LINK]
11. Mortazavi, H., Safi, Y., Baharvand, M. and Rahmani, S. (2016). Diagnostic
Features of Common Oral Ulcerative Lesions: An Updated Decision Tree.
Published in 2016 Available from: [LINK]
12. Mortazavi, H., Safi, Y., Baharvand, M. and Rahmani, S. Traumatic ulcer coated
with pseudomembrane and surrounded by inflammatory halo. License: [CC-BY].
Available from: [LINK]
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13. Sundharam, Sivapatha & Sundararaman, Preethi & Kannan, S Karthiga. (2018).
Oral Ulcers – A Review. Published in 2018. Available from: [LINK]
14. Hasan, S., Jangra, J., Choudhary, P. and Mishra, S. (2018). Erythema
Multiforme: A Recent Update. Biomedical and Pharmacology Journal, 11(1),
pp.167–170.
15. Mortazavi, H., Safi, Y., Baharvand, M. and Rahmani, S. Ulcerative SCC of tongue.
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