What is the approach to managing oral ulcers?

Management of Oral Ulcers

The management of oral ulcers requires a systematic diagnostic approach followed by targeted treatment, with topical corticosteroids being the most effective first-line therapy for most types of oral ulcers. 1

Diagnostic Approach

Initial Assessment

• Determine duration of ulcers:
  • Acute: less than 2 weeks
  • Chronic: persisting beyond 2 weeks or non-responsive to 1-2 weeks of treatment 2

Classification of Oral Ulcers

1. Recurrent Aphthous Stomatitis (RAS):

   • Minor aphthous ulcers (80-85%): <1cm, heal within 7-14 days
   • Major aphthous ulcers: larger, deeper, may leave scars
   • Herpetiform ulcers: multiple small clustered ulcers 1, 3

2. Traumatic Ulcers:

   • Shape corresponds to traumatic stimulus
   • Location related to trauma site 2

3. Infectious Ulcers:

   • Viral (herpes simplex, herpes zoster)
   • Bacterial (tuberculosis)
   • Fungal infections 1

4. Systemic Disease-Related Ulcers:

   • Behçet's disease
   • Inflammatory bowel disease
   • Celiac disease
   • Nutritional deficiencies 3

5. Autoimmune/Immune-Related Ulcers:

   • Pemphigus vulgaris
   • Bullous pemphigoid
   • Erosive lichen planus 1, 4

6. Malignant Ulcers:

   • Squamous cell carcinoma (typically solitary, non-healing) 4, 5

7. Drug-Induced Ulcers 6

Diagnostic Algorithm

For ulcers that cannot be diagnosed after clinical examination:

1. For ulcers persisting >2 weeks or non-responsive to treatment:

   • Proceed to blood tests 2

2. Blood tests to consider:

   • Full blood count (to identify blood disorders)
   • Coagulation studies
   • Fasting blood glucose
   • HIV antibody
   • Syphilis serology
   • Consider: iron, folate, vitamin B12, ferritin levels 2, 1

3. If blood tests inconclusive:

   • Biopsy is indicated, especially for:
     • Solitary chronic ulcers (rule out malignancy)
     • Suspected autoimmune conditions 2, 5

4. For suspected bullous diseases:

   • Evaluate serum specific antibodies (Dsg1, Dsg3, BP180, BP230)
   • Consider direct immunofluorescence (DIF) 2

Treatment Approach

First-Line Treatments

• Topical corticosteroids: Most effective first-line treatment 1
  • Options include:
    • Clobetasol 0.05% ointment
    • Betamethasone sodium phosphate
    • Fluticasone propionate
    • Triamcinolone acetonide 0.1%

Pain Management

• Topical anesthetics: Lidocaine viscous 2% solution (15 mL swished and expectorated every 3 hours, max 8 doses/24 hours) 1
• Barrier preparations: Gengigel or Gelclair for pain control 1

For Severe or Refractory Cases

• Intralesional corticosteroids: Triamcinolone acetonide injections 1
• Topical immunosuppressants:
  • Tacrolimus 0.1% ointment twice daily
  • Ciclosporin mouthwash (expensive, unpleasant taste) 1
• For recurrent aphthous stomatitis:
  • Colchicine with topical treatments
  • Thalidomide (most effective but limited by adverse effects) 3

Supportive Care and Prevention

Oral Hygiene

• Use soft toothbrush and mild non-foaming toothpaste
• Rinse with saline solution 4-6 times daily
• Use alcohol-free mouthwash 1

Dietary Modifications

• Avoid spicy, acidic, rough foods
• Stay hydrated 1

Denture Care

• Remove dentures before applying medications
• Clean gums thoroughly
• Consider adhesives to improve fit
• Remove dentures at night 1

Common Pitfalls and Caveats

1. Misdiagnosis: Failing to distinguish between aphthous ulcers and herpes labialis (requires antiviral therapy) 1

2. Overlooking malignancy: Every solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 3, 5

3. Missing systemic disease: Recurrent aphthous stomatitis may be associated with underlying conditions requiring specific treatment 3

4. Drug-induced ulcers: Always consider medications as potential causes of oral ulcers 6

5. Inadequate follow-up: Monitor for systemic disease and assess pain regularly, with follow-up every 3-6 months for persistent cases 1

By following this systematic approach to diagnosis and treatment, most oral ulcers can be effectively managed to reduce morbidity and improve quality of life for affected patients.