Oral Ulcers

Oral Ulcers: Basics - Defining the Lesion

• Oral ulcer: A localized defect or excavation of the oral mucosa where the covering epithelium is lost, exposing underlying connective tissue (lamina propria). Often painful.
• Classification based on:
  • Duration: Acute (< 2 weeks) vs. Chronic (> 2 weeks)
  • Number: Single vs. Multiple
• Key examination features: Note size, shape (round, oval, irregular), base (e.g., slough, granulation tissue), border (e.g., raised, flat, rolled), and surrounding mucosa (e.g., erythema, induration).

⭐ Recurrent aphthous stomatitis (RAS) is the most common cause of recurrent oral ulceration.

Etiology Unmasked - Ulcer Culprits

• Traumatic: Mechanical (denture, sharp tooth), thermal, chemical (aspirin).
• Infectious:
  • Viral: HSV-1, VZV, Coxsackie A (HFMD).
  • Bacterial: TB, Syphilis, ANUG.
  • Fungal: Candidiasis (immunocompromised).
• Immunological:
  • RAS (Minor: <1cm, heal 7-10d; Major: >1cm, scar; Herpetiform).
  • Behçet's disease, Lichen Planus (erosive), Pemphigus.
• Neoplastic: SCC (persistent, indurated ulcer).
• Systemic:
  • Deficiencies: Iron, Vit B12, Folate.
  • GI disorders: Crohn's, Celiac disease.
  • Drugs: NSAIDs, Methotrexate, Nicorandil.

⭐ Behçet's disease triad: recurrent oral ulcers, genital ulcers, and uveitis.

Spotlight on Ulcers - Key Conditions

• Aphthous Ulcers (Canker Sores)
  • Recurrent, painful; typically on non-keratinized mucosa.
  • Types: Minor (most common, <1cm, heal 7-10 days), Major (Sutton's disease, >1cm, scar), Herpetiform (multiple, pin-point).
  • Tx: Topical steroids, analgesics.
• Herpetic Stomatitis (HSV-1)
  • Vesicles rupture to form ulcers; affects keratinized & non-keratinized mucosa.
  • Primary: Gingivostomatitis (children). Secondary: Herpes labialis (cold sore).
  • Prodrome: Tingling/burning.
  • Tx: Acyclovir.
• Behçet's Disease
  • Triad: Recurrent oral & genital ulcers, uveitis.
  • Pathergy test positive. Systemic vasculitis.
• Squamous Cell Carcinoma (SCC)
  • Persistent, non-healing ulcer > 3 weeks; often painless initially.
  • Indurated base, rolled (everted) edges.
  • Risk factors: Tobacco, alcohol.
  • 
• Tuberculous Ulcer
  • Painful, undermined edges, yellowish (caseous) floor. Often tongue.
  • Associated with pulmonary TB.

⭐ Aphthous Major (Sutton's Disease) ulcers are larger (>1 cm), deeper, last longer (weeks to months), and frequently heal with scarring, distinguishing them from Aphthous Minor ulcers.

Diagnostic Path - Clues & Biopsy

• Clues:
  • History: Duration (acute <3 wks vs chronic >3 wks), recurrence, habits.
  • Exam: Site, morphology (induration, rolled edges?), nodes.
• Biopsy:
  • Indications: Chronic ulcer >2-3 wks, suspicious features (induration, fixation).
  • Technique: Incisional, from ulcer edge, including normal-appearing tissue.
  • ⭐ > Any persistent oral ulcer (>3 weeks) mandates biopsy to exclude malignancy.
• Adjuncts: Tzanck smear (HSV), culture, serology as needed.

Management Roadmap - Soothe & Solve

• Soothe (Symptomatic Relief):
  • Topical anesthetics (e.g., lidocaine gel).
  • Antiseptic mouthwash (chlorhexidine 0.2% bid).
  • Analgesics (paracetamol/NSAIDs).
  • Dietary modification: avoid irritants.
• Solve (Target Etiology):
  • Recurrent Aphthous Stomatitis (RAS):
    • Mild: Topical corticosteroids (triamcinolone).
    • Severe: Systemic steroids, colchicine, or thalidomide.
  • Herpetic ulcers: Antivirals (acyclovir).
  • Nutritional deficiency: Correct (e.g., B12, iron, folate).

⭐ Behçet's disease is a key systemic cause: recurrent oral & genital ulcers, plus uveitis.

High‑Yield Points - ⚡ Biggest Takeaways

• Aphthous ulcers: Most common, painful, recurrent; non-keratinized mucosa.
• Behçet's disease: Recurrent oral & genital ulcers, uveitis; pathergy test positive.
• Herpetic stomatitis (HSV-1): Vesicles then ulcers on keratinized mucosa; Tzanck smear shows multinucleated giant cells.
• Squamous Cell Carcinoma (SCC): Persistent indurated ulcer, often with rolled borders; biopsy is crucial.
• Lichen Planus: Erosive form causes painful ulcers; Wickham's striae often present.
• Traumatic ulcers: Follow identifiable injury; heal once cause is removed.