Oral ulcers

San Francisco

- Patients presenting with oral ulcers is not an uncommon occurrence, but the precise etiology of these lesions may at times be a source of confusion to the clinician.

"Oral ulcers can occur as single or multiple lesions, and can present as acute, recurrent and chronic lesions. The etiologies can range from viral and bacterial infection to systemic and autoimmune diseases, and the timing and periodicity of their presentation can often direct the wary clinician to the correct diagnosis," says Lynne H. Morrison, M.D., F.A.A.D., of the Department of Dermatology at Oregon Health Sciences University, Portland, Ore.

According to Dr. Morrison, the most common cause of recurrent intraoral ulcers is recurrent aphthous stomatitis and not herpes simplex viral infection - a common misconception. Clinically, these two entities can be quickly differentiated, as recurrent oral aphthae typically occur on the non-keratinized non-attached mucosa, whereas recurrent intra-oral herpes occurs on the attached mucosa, such as the hard palate and gums.

"If a patient presents with recurrent aphthous stomatitis, it is worth evaluating them for potential underlying causes. These recurrent oral aphthae can sometimes be due to underlying nutritional deficiencies. Up to 20 percent of cases can have deficiencies in iron, B12 or folate levels, and it behooves the clinician to follow-up here," Dr. Morrison says.

Furthermore, underlying systemic diseases need to be ruled out, such as HIV, inflammatory bowel disease or celiac disease, as severe recurrent oral aphthae can be the initial presentation of these diseases.

Chronic oral ulcers are defined as persistent oral ulcers that last more than six weeks. Several autoimmune blistering diseases present with oral ulcerations, and, according to Dr. Morrison, these lesions are generally associated with more serious diseases, such as pemphigus, pemphigoid, systemic diseases and malignancies.

"These chronic ulcerative conditions are fairly uncommon and often not diagnosed until later in the course of the patient’s underlying disease. These oral ulcerations typically become more extensive and more easily recognized as the underlying disease and the morbidity of the patient progresses.

"Therefore, a patient with non-healing ulcers that have been present for over six weeks warrants a more in-depth evaluation," Dr. Morrison says.

Oral lichen planus is a little more common than pemphigus and pemphigoid in terms of presentation of sole mouth ulcerations. Oral lichen planus can present as white streaks and plaques in the mouth or as an atrophic red epithelium in addition to ulcerations (erosive lichen planus). Topical steroids are considered the first line of treatment here. Topical calcineurin inhibitors can also work well, and according to the literature, 88 percent of patients on average respond favorably to topical calcineurin inhibitor treatment.

According to Dr. Morrison, it is important to remember that topical calcineurin inhibitors are used off-label in oral lichen planus, and one concern with this approach is the potential development of lymphoma or non-melanoma skin cancer.

"Patients should be made aware of this potential risk and can be actively involved in the choice of therapy," Dr. Morrison says. DT