Introduction Ulceration of the oral mucosa is a common reason for patients to seek medical or dental advice. Patients may report recurrent episodes of oral ulceration, single episodes of ulceration, or persistent oral ulceration. Causes of oral ulceration (Table 5.1) include trauma, recurrent aphthous stomatitis (RAS), microbial infections (Chapter 4), mucocutaneous diseases (Chapter 11), drug therapy (Chapter 14), and squamous cell carcinoma (Chapter 10). Ulceration due to trauma, RAS, and Behçet's disease will be discussed in this chapter.

Principal causes of oral ulceration Trauma Recurrent aphthous stomatitis (RAS) Microbial infections Mucocutaneous diseases Systemic disorders Drug therapy Squamous cell carcinoma

Traumatic ulceration Aetiology Traumatic ulcers can be due to physical (mechanical, thermal, electrical) or chemical trauma. Common causes of mechanical trauma are sharp, broken down teeth, orthodontic and prosthetic appliances, and numb lips or tongue being bitten after a local anaesthetic injection. Chemical trauma can be caused by aspirin or ‘toothache’ remedies being placed directly on the oral mucosa

Clinical features Traumatic ulcers are sore, painful to touch, and tend to have an irregular border with erythematous margins and a yellow base. During the healing phase they frequently develop a ‘keratotic halo’.

Management Management involves the elimination of the suspected cause and use of an antiseptic mouthwash (for example, 0.2 per cent chlorhexidine) or a simple covering agent such as OrabaseÂ

If a putative traumatic ulcer persists for more than 10–14 days after elimination of the aetiological factor, then the patient should be referred for a specialist opinion and possible biopsy to exclude the possibility of an oral carcinoma.

Recurrent aphthous stomatitis Recurrent aphthous stomatitis (RAS) is the most common oral mucosal disease affecting humans and has been reported as affecting 20–25 per cent of the general population at any time. A higher prevalence has been reported in North American students, particularly at examination times, and in upper socio- economic groups. Interestingly, RAS is infrequently found in Bedouin Arabs

Clinical features The clinical features of RAS consist of recurrent bouts of one or several, shallow, ovoid, painful ulcers, occurring at intervals of a few days or up to 2–3 months. Three clinical presentations of RAS are recognized: minor recurrent aphthous stomatitis (MiRAS), major recurrent aphthous stomatitis (MjRAS); and herpetiform ulceration (HU). The clinical presentation of these types of RAS are shown in Table 5.2. Patients may sometimes present with a mixed pattern of RAS but this is relatively uncommon

Minor recurrent aphthous stomatitis (MiRAS) This is the most common form of RAS and approximately 80 per cent of patients have lesions of this type. It is reported that 56 per cent of the patients are females and that the peak age of onset of the ulcers is in the second decade (10–19 years). However, many patients experience their first ulcers at an age well outside these limits. Indeed, it is by no means uncommon to find this form of ulceration in much younger children

Aetiology of RAS The causative factors of RAS are unknown but are probably multifactorial, with precipitating systemic, local, microbial, and genetic factors all being implicated (Table 5.3). ‘Aphthous-like’ ulcers can be associated with a number of systemic conditions, but these may not exhibit the classical behaviour or pattern of RAS

Possible aetiological associations with RAS Trauma Smoking cessation Microbial agents Genetic factors Stress Menstruation Food hypersensitivity

Systemic conditions and ‘aphthous-like’ lesions Behçet's disease Nutritional deficiencies Gastrointestinal disorders Cyclical neutropenia HIV infection MAGIC syndrome FAPA syndrome Drug reactions

Nutritional deficiencies Haematinic (iron, folic acid, or vitamin B12) deficiencies have been reported to be twice as common in RAS patients as in controls and up to 20 per cent of RAS patients may have a haematinic deficiency. B-complex deficiency (B1, B2, and B6) has been reported in a Scottish cohort of RAS patients and zinc deficiency has been implicated in a few patients. Replacement therapy in RAS patients with nutritional deficiencies has not, however, met with uniform success

Gastrointestinal disorders The association of RAS with coeliac disease and Crohn's disease is fully discussed in Chapter 12. The prevalence of coeliac disease in patients who present with RAS is now thought to be less than 5 per cent. Patients with established Crohn's disease frequently report oral ulceration that is ‘aphthous-likeâ

Neutropenia A large percentage of patients with cyclical neutropenia present with ‘aphthous-like’ ulceration that occurs at intervals (often monthly), reflecting their neutropenic status. Other manifestations of neutropenia include fever, malaise, and susceptibility to bacterial and fungal infections. Patients who are functionally neutropenic (for example, those with chronic granulomatous disease or benign familial neutropenia) are also susceptible to ‘aphthous-type’ ulceration.

HIV-associated aphthous stomatitis These ulcers tend to occur in crops of five or fewer ulcers, on non-keratinized mucosa and may resemble minor or major aphthae. They are frequently very painful and last for several months. This type of ulceration can be extremely debilitating in these patients and can cause problems with eating. Care must be taken to exclude cytomegalovirus infection in HIV-infected patients. In addition, some of the drugs used to

Other systemic conditions and factors Other systemic conditions associated with ‘RAS-like’ ulceration include MAGIC (mouth and genital ulcers with inflamed cartilage) syndrome, FAPA (periodic fever, aphthous ulcers, pharyngitis, and cervical adenitis) syndrome, and relative IgA deficiency. Drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs), nicorandil, a potassium-channel activator, and methotrexate have been implicated in ‘RAS-like’ ulceration

important points in the history Age of onset Family history Frequency of ulceration Duration of ulceration Number of ulcers Site of ulcers (non-keratinized or keratinized) Size and shape of ulcers Associated medical condition(s) Genital ulceration Skin problems Gastrointestinal disturbances Drug history

Oral ulceration—important features to be noted Number of ulcers Size and shape of ulcer(s) Site of ulceration Edge of ulcer Base of ulcer Surrounding tissue Scarring Consistency

Investigations for patients with persistent RAS Haemoglobin and full blood count ESR/CRP Serum B12 Serum/red cell folate Anti-gliadin and anti-endomysial autoantibodies

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