Evaluation of oral ulceration

Oral ulcerations of the mucosal surfaces are common. Most are self-resolving and transient (e.g., after a simple cheek bite). They are usually painful, prompting patients to seek medical or dental consultation. An important exception is oral squamous cell carcinoma, which often initially manifests as a painless solitary oral mucosal ulceration.[1]Lewis MAO, Lamey PJ. Oral ulceration (part 1). Br Dent J. 2023 Dec;235(11):869-74. http://www.ncbi.nlm.nih.gov/pubmed/38066141?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Oral squamous cell carcinomaFrom the collection of Dr Huber [Citation ends].​ The diagnosis of the more common oral ulcerations, in an otherwise healthy patient, is straightforward and determined from the medical history and clinical exam. However, patients with impaired immunologic function (e.g., HIV, chemotherapy, malnutrition) may present with more severe, widespread, atypical presentations that require a comprehensive assessment.

Pathophysiology

Most of the mucosa lining the oral cavity (e.g., floor of the mouth, cheeks, ventral tongue) is thin and delicate, rendering it susceptible to trauma. By contrast, the mucosa of the hard palate and gingiva is keratinized and more resistant to injury. The biologically dynamic nature of the oral mucosa makes it vulnerable to the effects of systemic disease.[2]Hodgson TA, Rachanis CC. Oral fungal and bacterial infections in HIV-infected individuals: an overview in Africa. Oral Dis. 2002;8(suppl 2):80-7. http://www.ncbi.nlm.nih.gov/pubmed/12164666?tool=bestpractice.com

An oral ulcer or ulceration is characterized by the destruction of the overlying oral epithelium accompanied by variable loss of the underlying connective tissue, which results in a crateriform appearance. It may be augmented by edema and/or proliferation of the surrounding tissue.[3]Compilato D, Cirillo N, Termine N, et al. Long-standing oral ulcers: proposal for a new 'S-C-D classification system'. J Oral Pathol Med. 2009 Mar;38(3):241-53. http://www.ncbi.nlm.nih.gov/pubmed/19141062?tool=bestpractice.com Ulcers are the final common manifestation of a spectrum of conditions ranging from autoimmune diseases to neoplasia, traumatic injury, infectious lesions, nutritional deficiencies and drug reactions, and they represent a diagnostic challenge for dental and medical practitioners.[3]Compilato D, Cirillo N, Termine N, et al. Long-standing oral ulcers: proposal for a new 'S-C-D classification system'. J Oral Pathol Med. 2009 Mar;38(3):241-53. http://www.ncbi.nlm.nih.gov/pubmed/19141062?tool=bestpractice.com [4]Milia E, Sotgiu MA, Spano G, et al. Recurrent aphthous stomatitis (RAS): guideline for differential diagnosis and management. Eur J Paediatr Dent. 2022 Mar;23(1):73-8. https://www.ejpd.eu/wp-content/pdf/EJPD_2022_23_01_14.pdf http://www.ncbi.nlm.nih.gov/pubmed/35274547?tool=bestpractice.com

Oral ulcers are most commonly classified into:[5]Munoz-Corcuera M, Esparza-Gomez G, Gonzalez-Moles MA, et al. Oral ulcers: clinical aspects: a tool for dermatologists: part II: chronic ulcers. Clin Exp Dermatol. 2009 Jun;34(4):456-61. http://www.ncbi.nlm.nih.gov/pubmed/19522982?tool=bestpractice.com [6]Handa H, Khere P, Shrivastava K. A brief review on classification of oral ulcerative lesions. Oral Surg Oral Med Oral Pathol Oral Radiol. 2021;7(1):3-9​. https://joooo.org/archive/volume/7/issue/1/article/16378

• Acute ulcers: sudden onset, short duration.

• Chronic ulcers: gradual onset, long-lasting (ulcers that have not healed within 2 weeks).