From the Guidelines
Recurrent oral ulcers are often caused by a combination of local and systemic factors, including trauma, stress, nutritional deficiencies, hormonal changes, and underlying medical conditions such as inflammatory bowel disease, autoimmune disorders, and infections like tuberculosis and HIV. The evaluation of recurrent oral ulcers should begin with a thorough history and physical examination to identify potential causes. First, distinguish between aphthous stomatitis (canker sores) and other conditions by noting the appearance, location, and pattern of ulcers. Common etiologies include trauma, stress, nutritional deficiencies (particularly B12, folate, iron, and zinc), hormonal changes, food allergies, and certain medications. Systemic conditions that may present with oral ulcers include Behçet's disease, inflammatory bowel disease, celiac disease, HIV, and autoimmune disorders like lupus 1.
Some key points to consider in the diagnosis of recurrent oral ulcers include:
- Laboratory testing should include complete blood count, iron studies, vitamin B12, folate levels, and celiac screening
- For persistent or severe cases, consider referral to oral medicine or dermatology for biopsy to rule out malignancy or specific conditions like lichen planus
- Patients should be advised to avoid spicy foods, acidic beverages, and potential allergens while maintaining good oral hygiene
- Treatment typically begins with topical corticosteroids like triamcinolone dental paste 0.1% applied 2-4 times daily, or dexamethasone elixir as a rinse
- For pain management, topical lidocaine 2% can provide temporary relief
- Systemic therapy with prednisone (40-60mg daily with taper) may be necessary for severe cases
- Identifying and addressing the underlying cause is crucial for preventing recurrence and improving quality of life, as seen in cases of Crohn’s disease 1 and oral tuberculosis 1.
In cases where the diagnosis is unclear, a biopsy may be necessary to rule out underlying conditions, and further testing such as blood work and imaging studies may be needed to determine the underlying cause of the oral ulcers 1.
From the Research
Etiology of Recurrent Oral Ulcers
The etiology of recurrent oral ulcers is complex and multifactorial. Some of the common causes include:
- Infection 2, 3, 4
- Immune-related factors 2, 3, 4, 5
- Trauma 2, 3, 4, 6
- Neoplastic factors 2
- Medications 3, 5
- Autoimmune diseases 3, 4, 5
- Systemic diseases 3, 4, 5
- Genetic predisposition 5, 6
- Nutritional deficiencies 5
- Food allergies 5
- Stress 5, 6
- Smoking 6
- Viral and bacterial infections 6
Classification of Recurrent Oral Ulcers
Recurrent oral ulcers can be classified into different types, including:
- Traumatic ulceration 3
- Chemical ulceration 3
- Recurrent aphthous stomatitis 3, 5
- Medication-related ulceration 3
- Infectious ulceration 3, 4
- Mucocutaneous disease 3, 4
- Autoimmune/systemic disease 3, 4, 5
Diagnosis of Recurrent Oral Ulcers
Diagnosis of recurrent oral ulcers involves a detailed patient history, clinical examination, and laboratory tests. Some of the clinical criteria used to identify the cause of oral ulcers include: