Mouth conditions, ulcers

Probability diagnosis

Recurrent aphthous ulceration

Trauma (e.g. rough tooth, biting)

Acute herpes gingivostomatitis

Candidiasis

Serious disorders not to be missed

Cancer:

• SCC

• leukaemia

Agranulocytosis

HIV

Syphilitic: chancre or gumma

Tuberculosis

Pitfalls (often missed)

Aspirin burn

Inflammatory bowel disease (e.g. Crohn)

Herpes zoster virus

Glandular fever (EBV)

Lichen planus

Coxsackie virus:

• herpangina

• hand, foot and mouth disease

Epstein–Barr mononucleosis

Immunosuppression therapy

Lupus erythematosus

Rarities:

• Behçet syndrome

• pemphigoid and pemphigus vulgaris

• erythema multiforme

• radiation mucositis

Masquerades checklist

Diabetes (Candida)

Drugs (see list)

Anaemia (iron-deficiency)

Is the patient trying to tell me something?

Unlikely.

Key history

Take a history of trauma, skin problems, stress, dental problems, drugs, allergy and possible infections, including herpes simplex, Candida albicans, sexually transmitted diseases and Coxsackie virus infection. Consider an immunosuppressive disorder.

Key examination

The examination should focus on the patient’s general health, dental status, characteristics of the ulcer, cervical lymphadenopathy and the skin in general

Key investigations

Depending on the clinical picture investigations may include:

• FBE

• ESR

• swabs for M&C

• autoantibody screen

• syphilis serology

• blood sugar

• vitamin B12 and folate levels

• biopsy.

Diagnostic tips

• Non-healing ulcers warrant biopsy to exclude squamous cell carcinoma.

• Remember to enquire about medication such as phenytoin, cytotoxics, immunosuppressants, carbimazole.

• A blood dyscrasia may be possible.

• Consider inflammatory bowel disease and coeliac disease in your considerations.

• Aphthous ulcers are usually 3–5 mm in diameter; minor ones have an erythematous margin.