What is the diagnosis and treatment for an older adult denture wearer experiencing swelling, pain, and an ulcer at the roof of their mouth?

Denture-Related Palatal Ulceration: Diagnosis and Management

The most likely diagnosis is traumatic ulceration from ill-fitting dentures, but immediate removal of the denture and biopsy within 2 weeks is mandatory if the ulcer does not heal, as oral squamous cell carcinoma frequently masquerades as denture trauma in elderly patients. 1, 2

Immediate Management

Remove the denture immediately and defer wearing it until the oral mucosa heals completely. 1 This is the single most critical first step, as continued denture wear perpetuates trauma and prevents healing. 3

• Inspect the denture for sharp edges, overextension, or unbalanced occlusion that may be causing mechanical injury to the palatal mucosa. 1, 3
• Clean the denture thoroughly by brushing with toothpaste, rinsing with water, and soaking for 10 minutes in chlorhexidine 0.2% antimicrobial solution before any reinsertion. 1
• Apply topical benzocaine up to 4 times daily for symptomatic pain relief while the ulcer heals. 4

Critical Red Flags Requiring Urgent Biopsy

Any ulcer that persists beyond 2 weeks without healing mandates biopsy to exclude malignancy, regardless of apparent denture trauma. 1, 5, 6 This is non-negotiable because:

• Oral squamous cell carcinoma commonly presents as a non-healing ulcer in denture wearers and is frequently misdiagnosed as traumatic ulceration, leading to dangerous delays in cancer treatment. 2
• A documented case showed a 6-month delay in diagnosing oral squamous cell carcinoma because it was initially attributed to denture trauma. 2
• Chronic denture irritation may predispose to malignant transformation in rare cases. 3, 7

Additional Concerning Features Requiring Immediate Biopsy:

• Ulcer with indurated or rolled borders 6
• Unilateral tongue immobility suggesting muscle/nerve invasion 1
• Painless ulcer (malignancy is often less painful than benign trauma) 1
• Patient age >40 years with tobacco or alcohol use 1
• Ulcer not improving after 7 days of denture removal 4

Diagnostic Workup Before or Concurrent with Biopsy

Obtain the following blood tests to exclude systemic causes and surgical contraindications: 1, 5

• Full blood count to rule out leukemia, anemia, or neutropenia (acute leukemia can present with palatal necrotic ulcers with yellowish-white pseudomembrane). 1, 5
• Coagulation studies to ensure safe biopsy. 5
• Fasting blood glucose to identify diabetes predisposing to candidal or invasive fungal infection. 1, 5
• HIV antibody and syphilis serology to exclude infectious causes. 1, 5

Differential Diagnosis Beyond Trauma

While traumatic ulceration is most common in denture wearers (affecting ~5% of users), consider these serious alternatives: 3

Infectious Causes:

• Denture stomatitis with candidiasis (affects 50% of denture wearers): presents as palatal erythema and inflammation, often painless. 3, 8
• Invasive fungal infection in diabetic/immunocompromised patients: requires testing for elevated 1-3-β-D-glucan and galactomannan. 1, 5
• Oral tuberculosis: produces stellate ulcers with undermined edges; requires acid-fast bacilli staining and chest imaging. 1, 9

Malignant Causes:

• Oral squamous cell carcinoma: the most critical diagnosis to exclude. 1, 2
• NK/T-cell lymphoma: can present with palatal necrosis and yellowish-white pseudomembrane. 1, 9
• Acute leukemia: widespread necrotic ulcers with decreased neutrophil count. 1, 9

Autoimmune/Systemic Causes:

• Pemphigus vulgaris or mucous membrane pemphigoid: requires direct immunofluorescence and serum antibodies (Dsg1, Dsg3, BP180, BP230). 9
• Crohn's disease: oral ulcers may coincide with abdominal pain; requires colonoscopy if GI symptoms present. 1, 9

Biopsy Technique When Indicated

• Take multiple biopsies if ulcers have different morphological characteristics. 1, 5
• Include perilesional tissue for direct immunofluorescence if bullous disease suspected. 5
• Perform maxillofacial CT before biopsy if bone destruction is suspected. 5

Treatment After Excluding Malignancy

If biopsy confirms benign traumatic ulceration:

• Have the dental team adjust or remake the denture to eliminate sources of trauma. 1
• Maintain meticulous oral hygiene: brush remaining teeth/gums with soft toothbrush twice daily, rinse with alcohol-free mouthwash 4 times daily. 1
• Avoid irritants: smoking, alcohol, citrus fruits, hot/spicy foods. 1
• Keep the mouth moist with ample fluid intake. 1

Common Pitfalls to Avoid

• Never assume a palatal ulcer is "just denture trauma" without confirming complete healing within 2 weeks. 2
• Never allow the patient to continue wearing the denture while "monitoring" the ulcer. 1
• Never skip biopsy in elderly patients (>65 years) with non-healing ulcers, even with obvious denture trauma. 2
• Do not forget to examine the entire oral cavity with dentures removed, including floor of mouth palpation and tongue mobility assessment. 1