Oral Ulcers

Ulcers of the Oral Cavity.

The oral cavity is susceptible to a variety of disorders, many of which manifest as ulcers. These ulcers can arise from infections, immune disorders, trauma, neoplasms, skin disorders, blood disorders, drug allergies, vitamin deficiencies, and other miscellaneous causes. Ulcers in the oral cavity can result from a multitude of factors, each with distinct aetiologies and manifestations.

Table: Causes of ulcers of the oral cavity

1. Infections (a) Viral. Herpangina, herpes simplex (primary and secondary), hand, foot and mouth disease (b) Bacterial. Vincent infection, TB, syphilis (c) Fungal. Candidiasis 2. Immune disorders. Aphthous ulcer, Behçet syndrome 3. Trauma (a) Physical. Cheek bite, jagged tooth, ill-fitting denture (b) Chemical. Silver nitrate, phenol, aspirin burns (c) Thermal. Hot food or fluid, reverse smoking 4. Neoplasms 5. Skin disorders. Erythema multiforme, lichen planus, benign mucous membrane pemphigoid, bullous pemphigoid, lupus erythematosus 6. Blood disorders. Leukaemia, agranulocytosis, pancytopenia, cyclic neutropenia, sickle cell anaemia 7. Drug allergy. Mouth washes, toothpaste, etc. Reactions to systemic drugs 8. Vitamin deficiencies 9. Miscellaneous. Radiation mucositis, cancer chemotherapy, diabetes mellitus, uraemia

1. Infections. It can be viral, bacterial or fungal.

Viral Infections

• • Herpangina: A Coxsackie virus infection, primarily affecting children. Initial symptoms include multiple small vesicles on the faucial pillars, tonsils, soft palate, and uvula, which rupture to form ulcers. These ulcers are typically 2–4 mm in size, with a yellow base and red areola, resolving within a week.
  • Herpetic Gingivostomatitis (Orolabial Herpes): Caused by the herpes simplex virus, this condition presents in two forms:
  • Primary infection: Common in children, characterized by clusters of vesicles that rupture to form ulcers, accompanied by systemic symptoms like fever, malaise, and lymphadenopathy.
  • Secondary or recurrent infection: Typically affects adults, presenting milder symptoms due to partial immunity. Lesions commonly appear on the vermilion border of the lip (herpes labialis) or, less frequently, intraorally on the hard palate and gingiva.
  • Hand, Foot, and Mouth Disease: A viral infection in children, presenting with oral lesions on the palate, tongue, and buccal mucosa, along with vesicles on the hands, feet, and occasionally buttocks.

Bacterial Infections

• • Vincent Infection (Acute Necrotizing Ulcerative Gingivitis): Caused by a fusiform bacillus and a spirochaete (Borrelia vincentii), this infection commonly affects young adults and middle-aged individuals, starting at the interdental papillae and spreading to the gingivae, which become covered with necrotic slough.
  • Specific Bacterial Infections: Tuberculosis, syphilis, and actinomycosis may present as chronic oral ulcers.

Fungal Infections

• • Candidiasis (Moniliasis): Caused by Candida albicans, candidiasis presents in two forms:
  • Thrush: Appears as white-gray patches on the oral mucosa and tongue, common in infants, children, and immunocompromised adults.
  • Chronic Hypertrophic Candidiasis: Also known as candidal leukoplakia, this condition presents as a white patch that cannot be wiped off, commonly affecting the anterior buccal mucosa.

2. Immune Disorders

• Aphthous Ulcers: Recurrent and superficial ulcers typically found on the movable mucosa, such as the inner lips, buccal mucosa, tongue, floor of the mouth, and soft palate. They present as small, multiple ulcers with a central necrotic area and red halo, healing within two weeks without scarring.
• Behçet Syndrome: Characterized by a triad of aphthous-like ulcers in the oral cavity, genital ulcerations, and uveitis, with a distinct punched-out edge to the ulcers.

3. Trauma

Traumatic Ulcers: Result from physical injuries such as jagged teeth, ill-fitting dentures, cheek bites, or injuries from foreign objects. Chemical burns from substances like silver nitrate, phenol, or aspirin, as well as thermal burns from hot food or fluids, can also cause ulcers.  

4. Neoplasms

Malignancies: Chronic ulcers in the oral cavity or oropharynx may be indicative of malignancies, most commonly squamous cell carcinoma, though other types such as carcinoma of the minor salivary glands or non-Hodgkin lymphoma can also present similarly.  

5. Skin Disorders

• Erythema Multiforme: A condition of unknown etiology that involves both skin and mucous membranes. Oral lesions typically consist of vesicles or bullae that rupture to form ulcers, often accompanied by hemorrhagic crusts on the lips.
• Pemphigus Vulgaris: An autoimmune disorder presenting with multiple aphthous ulcers in the oral cavity, often preceding skin lesions.
• Benign Mucous Membrane Pemphigoid (BMMP): Another autoimmune disorder characterized by bullae that rupture to form superficial ulcers, primarily affecting the cheeks, gingivae, and palate.
• Lichen Planus: Presents in two forms—reticular (asymptomatic white striae on the buccal mucosa) and erosive (painful ulcers with a keratotic periphery).
• Chronic Discoid Lupus Erythematosus: Oral lesions similar to the erosive form of lichen planus, often associated with skin lesions.

6. Blood Disorders

Blood dyscrasias, such as leukemia, agranulocytosis, pancytopenia, and cyclic neutropenia, can lead to oral ulcers due to impaired immune defense, resulting in increased susceptibility to infections.  

7. Drug Allergy

Systemic drugs such as penicillin, tetracycline, sulfa drugs, and barbiturates, or contact allergens from mouthwashes, lozenges, or dental materials, can cause erosive, vesicular, or bullous lesions in the oral cavity.  

8. Vitamin Deficiencies

Deficiencies in vitamins such as B12 and folic acid may result in the formation of oral ulcers.  

9. Miscellaneous Causes

• Radiation Mucositis: Following radiation therapy to the oral cavity or oropharynx, mucositis initially presents as redness, progressing to large ulcerated areas.
• Mucositis from Cancer Chemotherapy: Drugs like methotrexate, 5-FU, and bleomycin can induce mucositis, presenting as erythema, edema, and ulceration.

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Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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