Oral Ulcers

Our mouth sends out signals in the form of certain deviations from the normal. It is upto us to recognise these hints and act judiciously.

Oral ulcers are one of the commonest lesions in the entire oral cavity and there can be of multiple causes. The treatment for the same should be based on the elimination of the causative factors to bring about an immediate relief.

In my previous article, I discussed the various home remedies which can be used on a first hand basis to alleviate pain and discomfort. However, the takeaway was NOT to neglect professional help. Continuing this thought forward, here, I will attempt to discuss some of the most common oral ulcers and their probable aetiologies. Through this article, I attempt to reduce the anxiety among the highly anxious subjects and motivate the nonchalant ones to visit their dentist for a professional help.

Oral ulcers present a varied appearance in terms of form and location. They may appear as a solitary ulcer of a short duration or they may appear as multiple ulcers of long standing origin or they may even have a recurrent course.

Traumatic Ulcers (TU)Herpetic Ulcers (HU)Sustained Traumatic Ulcers (STU)Mucocutaneous Disorders (MD)Recurrent Apthae (RA)
Acute Necrotising Ulcerative Gingivitis (ANUG)Hypersensitivity Reactions (HR)Erythema Multiforme (EM)Fungal Infections (FI)Cyclic Neutropenia (CN)

Acute Solitary Ulcers:

Common sites for a traumatic ulcer – lips and tongue

Traumatic Ulcers: Traumatic ulcers are usually found on the lips and tongue. They appear as raised, reddish borders, necrotic pseudomembrane. It usually heals within 10 days, with proper treatment.

Punched out ulcerations of marginal gingiva and papillary gingiva

Acute Necrotising Ulcerative Gingivitis: Poor oral hygiene, pre existing gingivitis (inflammation of the gingival tissues), debilitating disorders (diabetes, HIV) may predispose to ulceration of the gingiva. this condition is characterised by “punched out ulcerations” of the marginal and papillary gingiva. It usually affects young adults (18-25 years) and the classic diagnosis is based on the three cardinal symptoms – sore gums, bleeding gums and punched out ulcerations. The treatment is based on the mechanical removal of calculus and effective debridement with 0.12% chlorhexidine, twice daily. Adjuncts to this treatment may include systemic delivery of antibiotics such as amoxicillin, 250 mg and metronidazole, 250 mg three times a day for a week. Although these ulcers may appear as multiple lesions, however they may be classically recognised as a solitary lesion.

Well demarcated raised borders of the ulcer
on the posterior palate

A similar appearing ulceration may be evident on the palate of middle aged men. It is classically due to ischemia of salivary glands which might occur due to mechanical irritation (as a result of ill fitting dentures) or constant chemical irritation as a result of smoking or radiotherapy. It also appears as a crater like ulceration with well delineated borders, found on the posterior part of the palate. It can be calliberated between 1-5 cm and with proper treatment, it may resolve within 5 to 7 weeks.

Acute Multiple Ulcers:

Pin head ulcers coalescing into a single ulcers

Herpetic Ulcers: Herpes infection is a less common viral infection due to the reactivation of varicella zoster virus, which may occur spontaneously or due to the suppression of immune system. Any factor that may lead to reduction of the immunity (psychological stress, malignancy, malignancy or radiotherapy) may be a direct cause for the ulceration. The virus has its natural course that affects the maxillary branch of the Trigeminal nerve (most commonly ophthalmic nerve). Oral manifestations may vary among different herpes species. It may be characterised by pin head sized vesicles that might rupture and give rise to ulcerations that my later coalesce to form a large ulcer often with a burning tenderness on the palate, or buccal gingivae. These ulcers are mostly covered in yellowish pseudomembrane and have a unilateral course. Treatment is mostly systemic administration of anti viral therapy. They most often heal within 5-7 days without scarring with proper treatment.

Hypersensitivity Reactions: These ulcerations are much like those that occur on the skin due to a drug hypersensitivity. They most commonly occur on the vermilion border of the lips. They appear as red or white multiple lesions which relapse on the removal of the drug. It might also characterise as swelling and itching with or without swelling.

Chronic Solitary Ulcers:

Erythema Multiforme: This is also a type of hypersensitivity reaction, with different aetiologies. It is characterised as irregular red macules or papule that tend to grow larger known as “target lesions”. It has a proclivity for lips and buccal mucosa and is evident as ‘bloody encrustations on the lips’, with special female predilection. Healing usually occurs within 10-20 days and the treatment generally comprises of liquid diet, topical analgesics and topical anaesthetics.

Target Iris Lesions
Lesion with hyperkeratotic borders

Sustained Traumatic Ulcers: Due to repetitive trauma from mechanical causes and are common sites on the lips and tongue. It appears as raised lesion with hyperkeratosis borders and a yellow, removable, fibrinopurulent membrane. The treatment is aimed at removal of the irritant factor and application of topical steroids.

Chronic Multiple Ulcers:

Mucocutaneous Disorders: There are certain conditions such as Pemphigus, Pemphigoid or Lichen Planus that are autoimmune disorders that affects the skin as well as the mucosa. These conditions mostly affect females with a common cause of suppressed immunity. Therefore, they have a predilection of middle aged females. These lesions appear as raised bulls lesions over a non inflamed base. These are irregular ulcers that frequently rupture into bleeding bullae and are noticed on the hard palate, buccal mucosa and lips. The lesions tend to engage a larger area of the oral cavity in the form of classic “desquamation”. However, Lichen Planus has a varied appearance of lace like mucosal configurations with superimposed erythema and atrophying bullae. The mainstay of treatment is topical or systemic steroids (1-2 mg/kg), according to the severity of the condition.

Fungal Infection: These are lesions that are mostly found on the palate, lips and gingiva. It begins as a painless, erythematous and granulomatous ulcers with indurated borders, resulting from necrosis due to underlying fungal (most common oral fungal infection being Candidiasis) etiology. The treatment is aimed at general debridement and elimination of the candidate infection by way of systemic medications and topical anaesthetic agents.

Recurrent Ulcers:

Recurrent Apthae: They maybe solitary or multiple lesions that present with a prodromal burning sensation lasting for 2-48 hours before an ulcer appears. The site of predilection is the same as regular apthae (inner lips, cheeks, floor of mouth and ventral surface of the tongue). They are usually associated with episodes of psychological stress which may cause a hormonal imbalance and lead to ulceration in the non keratinised regions of the mouth. These ulcers are painful and round and are erythematous defects, covered with fibrin. They maybe minor (<1 cm) or major (1-3 cm) and last for about 10 days to 6 weeks. They mostly heal with scarring and the treatment is topical or systemic steroids.

Cyclic Neutropenia: It is a condition that is characterised by a cyclic episodes of circulating neutropenia. It is also mostly manifested by ulceration in the oral cavity lasting for 3-5 days. It is also associated with fever of unknown origin, gingivitis, stomatitis and periodontal destruction.

In this article, I have presented only few of the commonest conditions that might cause ulceration in the oral cavity and their probable treatment modalities. The oral cavity presents a wide array of lesions which might often share similar appearances and therefore a professional guidance is sought before deciding on the treatment approach for a particular condition.

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