Oral ulceration

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Summary

Ulcers in the mouth can be caused by many local and systemic factors.

Any ulcer, white or red patch in the mouth that has been present for 2-3 weeks needs to be assessed by a dentist or doctor immediately to make sure that it is not an early sign of mouth cancer.  Mouth cancer when diagnosed early can be treated far more effectively (80-90% successful) than later presentation. For more information visit www.mouthcancer.org.

However there are many other less serious causes of persistent ulcers in the mouth, many of which are far more common than mouth cancer. See further down for a full list.

Features That Require Urgent Assessment

  • Ulcers that do not heal within 3 weeks
  • Red and white patches on cheeks, gums, lips, tonsils, floor of mouth or palate
  • Lumps or swelling in the mouth or in the head and neck area

A very common cause of ulceration in the mouth is a condition called Recurrent Aphthous Stomatitis (RAS). It is thought to be caused by the body's immune system, probably mediated by genetic predisposition. However the exact mechanism remains unclear. See below for more detail on causes.

Types of Recurrent Aphthous Stomatitis

  1. Minor - the most common. They are normally 2mm-10mm in diameter. They usually occur on the lips, cheeks and tongue and heal without scarring within 7-10 days.
  2. Major - these ulcers are large and can last from two to six weeks. They can happen anywhere in the mouth including the gums, soft palate (roof of the mouth) and throat.
  3. Herpetiform - these are tiny painful ulcers. Twenty to thirty appear at a time and may join together to form large areas of ulceration.

Home care advice

The pain from ulcers can be relieved by: 

  • Salty water rinses – one teaspoon of salt in a tumbler of warm water. Keep each mouthful in for 30 seconds until tumbler is empty. Repeat 3x daily.
  • Excellent oral hygiene even if it feels sore
  • Benzydamine spray or mouthwash as needed 
  • Painkillers according to pack instructions
  • Soft diet to reduce trauma to area
  • Rubbing Dentures – use fixative to help reduce movement – if still painful, remove dentures when possible to reduce trauma
  • Corsodyl mouthwash for 1 week 

MOST ULCERS HEAL WITHIN 10 DAYS. NON-HEALING ULCERS AND WHITE OR RED PATCHES THAT HAVE BEEN PRESENT FOR MORE THAN 2 WEEKS NEED TO BE ASSESSED BY A DENTIST OR DOCTOR URGENTLY

Causes

Ulcers secondary to trauma

Mechanical

  • Sharp tooth/filling
  • Ill fitting denture
  • Non-accidental

Burns

  • Chemical
  • Thermal
  • Radiation
  • Electrical

Recurrent

  • Recurrent apthous stomatitis (see above)

Single persistent ulceration

  • Squamous cell carcinoma (SCC)

Ulcers secondary to systemic disease

Dermatological disease

  • Lichen planus
  • Pemphigus vulgaris
  • Mucous membrane pemphigoid (MMP)
  • Erythema multiforme

Gastrointestinal disease

  • Orofacial granulomatosis 
  • Crohn’s disease
  • Ulcerative colitis

Haematological

  • Anaemia due to deficiency (Iron, Vitamin B12, Folate)
  • Neutropenia
  • Leukaemia

Rheumatological

  • Lupus erythematosus
  • Mixed connective tissue disease
  • Reactive arthritis (Reiter’s syndrome)

Miscellaneous

  • Behçet’s syndrome
  • Drug-induced 
  • MAGIC syndrome
  • PFAPA syndrome
  • Sweet’s syndrome
  • TUGSE

Ulcers secondary to infections

Bacterial

  • Acute ulcerative gingivitis
  • Tuberculosis
  • Syphilis

Viral

  • Herpetic gingivostomatitis
  • Chickenpox
  • Infectious mononucleosis
  • Herpangina
  • Hand, foot and mouth disease
  • HIV infection

Fungal

  •  Deep mycoses