Western University - Oral Ulcers

Definitions & Key takeaways

Oral ulcerations are lesions in the mouth caused by various factors, including trauma, infection, and cancer. Common types of ulcers include aphthous ulcers, traumatic ulcerations, and herpetic ulcerations. Diagnosis requires a thorough evaluation and may involve a tissue biopsy. Treatment depends on the cause of the ulcer and may include removing the source of trauma, antiviral medications, or biopsy. It is important to determine the etiology of an ulcer to rule out the possibility of oral cancer.

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Oral ulcerations are lesions in the mouth with loss of surface epithelium. There are several causes of oral ulcers, often indicated by their name.
For instance, a traumatic ulceration is an ulcer developed after an injury. Other common types of ulcers include the aphthous ulcer; non-specific ulcer; traumatic ulcer with stromal eosinophilia, or TUGSE; and herpetic ulceration.
Across all types, there is no difference in prevalence by gender. But, the general prevalence, location, and age vary by etiology.Typically, an oral ulceration appears as a well-defined, slightly depressed lesion with an erythematous or reddish to yellow center.
Sometimes, the yellowish center represents a thick fibrinopurulent membrane that is a mix of acute inflammation and fibrin.
This membrane can be removed by applying pressure. The ulcer may also have an irregular white halo with rolled borders.
Although these features are common, other clinical features vary by type.Aphthous ulcers or canker sores are the most common mucosal pathosis, found in 20% of adults with about 80% experiencing these ulcers before age 30.
Aphthous ulcers only occur on the unattached oral mucosa, unlike herpetic ulcers or cold sores which occur on the attached oral mucosa.
Most aphthous ulcers are related to stress, as often reported by patients. Yet, some individuals will suffer recurrences, termed recurrent aphthous stomatitis.
Researchers believe it may be caused by T cell dysfunction leading to mucosal breakdown or the presence of microorganisms.A traumatic ulceration is caused by an injury that cuts the epithelial surface below the basal cell layer.
Sources of trauma include ill-fitting dentures, hard foods like crusty bread and chips, biting injury, irritation from chemicals in toothpastes or rinses, and burns from hot foods or drinks.
It is often associated with an underlying inflammatory response. TUGSE is a subtype defined by the presence of many eosinophils.
Although its etiology is presumed to be traumatic, the etiology is most likely multifactorial and has not been entirely elucidated.
TUGSEs are typically long-standing ulcerations mimicking oral cancer. Clinically, TUGSEs may present as raised ulcerations with rolled margins that can either be asymptomatic or associated with pain.Ulcers may also be caused by infectious agents, particularly viruses like the herpes simplex virus and fungal infections.
Often oral herpes involves cold sores and ulcers in the face or mouth. More rarely, oral cancers, particularly oral squamous cell carcinoma, may lead to oral ulceration, highlighting the importance of determining the etiology of an ulcer.Diagnosis begins with screening and detection.
An oral evaluation includes a detailed medical and dental history, thorough clinical examination, and detailed documentation.
It is always important to determine the etiology of an ulcer since malignant tumors may present with a break in the surface epithelium.
History and location may help exclude some causes like the herpes simplex virus. Yet, a tissue biopsy is often needed to reach a definitive diagnosis.
Clinical correlation is often necessary and pertinent case information should be given to the pathologist when a biopsy sample is submitted.
To ensure the most accurate diagnosis, it is best to send specimens to an oral and maxillofacial pathologist. Oral and maxillofacial pathologists are dental specialists with extensive training in diagnosing lesions of the oral cavity.
The histopathology of an ulceration may be non-specific and the pathologist may not be able to determine the exact etiology.
However, a pathologist will be able to determine if the lesion represents a more significant pathologic process such as those associated with squamous cell carcinoma or deep fungal infection.The prognosis and treatment will vary by ulcer type and stage of identification.
If trauma caused the ulceration, it must be identified and removed. After the local irritating factor is removed, the lesion should resolve within two weeks.
The standard of care is to biopsy an unresolved ulcer after two weeks. Other causes of ulcers should be treated accordingly, such as antiviral medications for herpes simplex.
Now, as a quick recap, an oral ulceration is a lesion devoid of overlying epithelium. Generally, ulcers appear as well-defined slightly depressed lesions with an erythematous to yellow center and may vary by etiology.
Diagnosis begins with a clinical assessment and can be definitively made after a biopsy of the ulcer and surrounding tissue.
Treatment is based on the underlying cause, such as removing the source of trauma. If the ulcer does not resolve itself within two weeks, a biopsy must be performed, as a more serious condition such as oral cancer may be present.