2. Oral ulceration is one of the most common
complaints of patients who attend their GPs with an
oral problem and the differential diagnosis is
extensive.
Although the cause of ulceration is often local, the
oral mucosa is an important site of manifestation of
many systemic conditions and oral ulceration may be
the initial presentation in such cases.
Ulcers may arise de novo (primary ulcers) or
secondary to breakdown of vesicles or bullae
(secondary ulcers) and may be recurrent or
persistent.
3. A) Primary ulcers
1- Recurrent aphthous stomatitis
minor, major and herpetiform variants
associated with haematinic deficiencies, GIT disease
(Crohn’s disease, ulcerative colitis and coeliac
disease), congenital and acquired immunodeficiency
and blood dyscrasias
consider Behçet’s, MAGIC, and Sweet’s and PFAPA
syndromes
4. 2- Trauma
usually accidental, or trauma from overextended
dentures or sharp teeth; rarely, burns, stomatitis
artefacta or trauma to exophytic lesion
3- Dermatoses
erosive and atrophic lichen planus, discoid and
systemic lupus erythematosus, erythema
multiforme, linear IgA disease
5. 4- Malignancy
squamous cell carcinoma usually presents as a
persistent primary ulcer
5- Infections
TB, syphilis, Reiter’s syndrome and acute
necrotising ulcerative gingivitis; atypical
lesions and ‘exotic’ infections in HIV disease,
including deep mycoses
6. 6- Orofacial granulomatosis
linear or serpiginous ulcers, particularly in the
buccal sulci; associations with gastrointestinal
diseases and allergies
7- Neutropenic ulcers
congenital and acquired immunodeficiencies;
ulcers lack an inflammatory erythematous halo;
may be drug related; atypical viral fungal and
bacterial lesions
7. 8- Drugs
aspirin and other caustic burns; cytotoxic drugs
often cause mucositis and ulceration; fixed and
lichenoid drug eruptions, nicorandil and
bisphosphonate ulceration
8. B) Secondary ulcers
1- Viral diseases
mostly herpes virus group and enterovirus group
enanthemata
2- Dermatoses
pemphigus (and variants), pemphigoid (and variants),
congenital and acquired epidermolysis
bullosa, dermatitis herpetiformis and bullous lichen
planus
3- Angina bullosa haemorrhagica
idiopathic blood blisters, usually on the soft palate
9. Because of the rich innervation of the oral mucosa,
most ulcers are painful.
An important exception to this rule is early squamous
cell carcinoma until it involves the periosteum, bone
or deep mucosal tissues
It typically presents as an ulcer with a rolled everted
edge and sloughing or granular base. The exophytic
form, verrucous carcinoma, is uncommon but has a
better prognosis.
10. Persistent, painless ulcers that are found on
routine examination, particularly in the
elderly, should thus not be ignored,
especially in those who smoke or drink
alcohol regularly, or where there is evidence
of erythroplakia or leucoplakia. The
incidence of oral cancer is increasing.
11. Recurrent aphthous stomatitis
common and may affect 10 % of the population at some
time
One in 15 patients have an underlying cause
three variants – minor, major and herpetiform
The pathogenesis is immunologically mediated
respond to simple treatments such as topical steroids, eg
0.1 per cent triamcinolone acetonide and antimicrobial
mouthwashes, eg chlorhexidine, povidone-iodine or
benzydamine.
In adults, herpetiform aphthous stomatitis usually responds
to tetracycline mouthrinse and swallow
12. Nicorandil ulceration. The ulceration is persistent,
painful, deep, punched out, with little
inflammatory halo and no induration.
13. squamous cell carcinoma; the ulcer is persistent,
often relatively painless, with raised,rolled edges,
necrotic base and indurated on palpation
14. Recurrent aphthous ulceration (minor type).
painful, with a yellow-white sloughing base and
inflammatory erythematous halo; not indurated and
heal spontaneously within two weeks
15. Lichenoid eruption (to a beta-blocker). There is
central ulceration, but peripherally reticular
(strial) white lesions are present; the ulceration is
persistent and painful, but will resolve completely
with cessation of the offending drug
16. Erythema multiforme acute onset, painful, superficial
and irregular; often the entire oral mucosa is involved
and there is bloody crusting of the lips
