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Oral mucosal ulcerations are a common occurrence, often resolving spontaneously in transient cases, such as those resulting from minor traumas like cheek bites. However, certain situations may necessitate medical or dental intervention. For instance, oral carcinoma, a severe and potentially life-threatening condition, can initially present as a solitary oral mucosal ulceration. Diagnosing more common oral ulcerations in otherwise healthy patients is usually straightforward, relying on medical history and clinical examination. However, individuals with compromised immune systems (e.g. HIV, undergoing chemotherapy, or experiencing malnutrition) may exhibit severe, atypical ulcerations requiring comprehensive evaluation. Pathophysiology The oral cavity’s mucosa, particularly in areas like the floor of the mouth, cheeks, and ventral tongue, is thin and delicate, making it prone to injury. In contrast, the mucosa of the hard palate and gingiva is keratinized and more resistant to damage. The dynamic nature of oral mucosa makes it susceptible to systemic diseases. An oral ulcer, characterised by the complete loss of epithelium with variable loss of underlying connective tissue, creates a crater-like appearance. Edema and tissue proliferation may accompany the ulceration. Ulcers persisting beyond 2 weeks are considered chronic. A classification system categorises ulcers as simple, complex, or destroying: • Simple: A single ulcer without involving the surrounding mucosa. • Complex: Single or multiple ulcers with changes to surrounding mucosa, skin, and systemic manifestations. Lesions may appear white, red, or vesiculobullous. • Destroying: Diffuse lesions with tissue destruction and severe systemic involvement. Epidemiology Oral ulcerations are common, with most cases resolving without medical or dental intervention. Recurrent aphthous stomatitis, the most reported type, affects 5% to 25% of the general population. However, it is crucial to rule out oral malignancies, especially when ulcers persist for two weeks or more. In such cases, referral to an oral and maxillofacial surgeon or oral medicine specialist for biopsy is essential. Types of Oral Ulcers 1. Traumatic Ulcer: The most common oral ulcer results from trauma, often mechanical (e.g. biting) but also from thermal, radiation, or chemical causes. Symptoms of inflammation, pain, redness, and swelling are typical, with the central part of the ulcer sometimes covered by a yellow-white fibrinous exudate. Addressing the cause and ensuring mucosal healing within two weeks is recommended, with referral if the ulcer persists. 2. Aphthous Ulcer: Recurrent aphthous ulceration (aphthous stomatitis) affects 20-50% of the population and presents as painful ulcers, usually on non-keratinized oral mucosa. Various subtypes include minor, major, and herpetiform aphthous ulcers. Treatment often involves topical corticosteroids, particularly when started within 24 hours of onset. 3. Oral Squamous Cell Carcinoma (SCC): Oral cancer comprises more than half of head and neck cancer cases, with more than 90% being oral SCC. Risk factors include smoking, alcohol consumption, and betel quid use. Oral SCC typically presents as a non-healing ulcer that may be indurated, firm, with irregular margins and raised edges. Pain is not a reliable differentiator between malignant and benign ulcers. Patients with suspected malignant features require immediate referral to an oral and maxillofacial surgeon for tissue diagnosis and staging, often involving computed tomography (CT), magnetic resonance imaging (MRI), and other imaging modalities. Multidisciplinary care is crucial for managing oral SCC. Causes of mouth ulcers: • Recurrent Aphthous Stomatitis o Variants: minor, major, herpetiform o Associated conditions: haematinic deficiencies, gastrointestinal diseases (Crohn’s disease, ulcerative colitis, coeliac disease), congenital and acquired immunodeficiency, blood dyscrasias o Considerations: Behçet’s syndrome, MAGIC syndrome, Sweet’s syndrome, PFAPA syndrome • Trauma o Causes: Accidental, overextended dentures, sharp teeth o Rare causes: Burns, stomatitis artefacta, trauma to exophytic lesions • Dermatoses o Associated conditions: Erosive and atrophic lichen planus, discoid and systemic lupus erythematosus, erythema multiforme, linear IgA disease • Malignancy o Presentation: Squamous cell carcinoma often presents as a persistent primary ulcer o Trauma-related: Exophytic lesions may be traumatised and fungate • Infections o Causative agents: Tuberculosis, syphilis, Reiter’s syndrome, acute necrotising ulcerative gingivitis o HIV-related: Atypical lesions and ‘exotic’ infections in HIV disease, including deep mycoses • Orofacial Granulomatosis o Presentation: Linear or serpiginous ulcers, particularly in the buccal sulci o Associations: Gastrointestinal diseases and allergies • Neutropenic Ulcers o Causes: Congenital and acquired immunodeficiencies o Characteristics: Ulcers lack an inflammatory erythematous halo o Possible drug-related ulcers o Atypical viral, fungal, and bacterial lesions • Drugs o Drug-related causes: Aspirin and other caustic burns, cytotoxic drugs often cause mucositis and ulceration o Drug eruptions: Fixed and lichenoid drug eruptions, nicorandil, bisphosphonate ulceration • Viral Diseases o Common groups: Mostly herpes virus group and enterovirus group enanthemata • Dermatoses (Additional) o Associated conditions: Pemphigus (and variants), pemphigoid (and variants), congenital and acquired epidermolysis bullosa, dermatitis herpetiformis, bullous lichen planus • Angina Bullosa Haemorrhagica o Presentation: Idiopathic blood blisters, usually on the soft palate