Management of Persistent Oral Ulcers
A persistent oral ulcer that has not healed for a month requires immediate medical evaluation to rule out serious underlying conditions including malignancy, systemic disease, or infection.
Diagnostic Approach
Initial Evaluation
- Document the characteristics of the ulcer including duration, size, shape, location, and associated symptoms 1
- Assess for local factors that may cause traumatic ulceration such as sharp teeth edges or dental appliances 1
- Evaluate for systemic symptoms that might indicate underlying disease 1
First-line Testing
- Full blood count to screen for anemia, leukemia, and other blood disorders 2, 1
- Fasting blood glucose to identify hyperglycemia, which can predispose to fungal infections 2, 1
- HIV antibody testing to rule out HIV-associated ulceration 1
- Syphilis serology testing to exclude syphilitic ulcers 2, 1
Biopsy Considerations
- Biopsy is strongly indicated for any oral ulcer persisting beyond 2-4 weeks despite treatment 1, 3
- Multiple biopsies may be needed if ulcers have different morphological characteristics 1
- For suspected bullous diseases, direct immunofluorescence should be performed 1
Treatment Approach
Immediate Symptomatic Management
- Apply white soft paraffin ointment to the lips every 2-4 hours 2
- Use a mucoprotectant mouthwash three times daily (e.g., Gelclair®) to protect ulcerated surfaces 2
- Clean the mouth daily with warm saline mouthwashes 2
Pain Management
- Use an anti-inflammatory oral rinse containing benzydamine hydrochloride every 3 hours, particularly before eating 2
- For moderate pain, consider topical NSAIDs (e.g., amlexanox 5% oral paste) 2
- For severe pain, topical anesthetic preparations such as viscous lidocaine 2% (15 mL per application) can be used 2
Antimicrobial Management
- Use antiseptic oral rinse twice daily to reduce bacterial colonization (options include 1.5% hydrogen peroxide mouthwash or 0.2% chlorhexidine digluconate mouthwash) 2
- If candidal infection is suspected, treat with nystatin oral suspension 100,000 units four times daily for 1 week, or miconazole oral gel after meals four times daily for 1 week 2
Anti-inflammatory Treatment
- Consider topical corticosteroids four times daily (e.g., betamethasone sodium phosphate 0.5 mg in 10 mL water as a rinse-and-spit preparation) 2
- For more potent treatment, clobetasol propionate 0.05% mixed with Orabase can be applied directly to the affected areas daily 2
- For recalcitrant cases, intralesional triamcinolone acetonide injections may be beneficial 2
Special Considerations
When to Suspect Serious Underlying Conditions
- Ulcers associated with systemic symptoms such as fever, weight loss, or joint pain warrant broader evaluation 2, 1
- Multiple oral ulcers may indicate systemic diseases like Crohn's disease, which should be investigated with appropriate tests including colonoscopy if abdominal symptoms are present 2
- Neutropenia or other blood count abnormalities may indicate hematologic malignancies requiring bone marrow biopsy 2
Common Pitfalls to Avoid
- Relying solely on clinical appearance without appropriate testing for persistent ulcers can lead to delayed diagnosis of malignancy 1, 3
- Inadequate biopsy technique can miss important diagnostic features 1
- Treating symptoms without establishing a definitive diagnosis for persistent ulcers is not recommended 1, 4
Referral Indications
- Refer to an oral medicine specialist or dermatologist if ulcers persist for more than 2 weeks or do not respond to initial treatment 1
- Consider multidisciplinary referral when systemic disease is suspected (e.g., gastroenterology for IBD-related ulcers, hematology for blood disorders) 1