I have a sore on my left maxillary gingiva; what are the likely causes and how should I manage it?

Evaluation and Management of Left Upper Gum Sore

A sore on the left maxillary gingiva requires systematic evaluation to exclude serious conditions including malignancy, systemic disease, and infection, with any lesion persisting beyond 2 weeks mandating biopsy. 1

Immediate Assessment

Examine the lesion under good lighting for specific characteristics that guide diagnosis:

• Location and appearance: Document whether the sore is localized to attached gingiva, involves tooth-bearing areas, or extends to other oral mucosa 2
• Presence of yellowish-white covering: This suggests possible invasive fungal infection (especially if diabetic or immunosuppressed), acute leukemia, NK/T-cell lymphoma, or tuberculosis 3
• Vesicles or bullae: These indicate possible herpes simplex, pemphigus, or pemphigoid, though they rupture rapidly in the oral environment 4
• Associated dental pathology: Check for dental caries, periodontal pockets, or recent dental procedures that could cause trauma or infection 2

Common Etiologies by Presentation

Solitary Lesions

• Traumatic injury: Chemical (aspirin burn, peroxide), physical (flossing injury, sharp tooth edge, ill-fitting denture), or thermal (hot food) causes are common and typically self-limiting 5
• Periodontal abscess: Presents with localized swelling, suppuration from gingival sulcus, increased pocket depth, and tooth mobility; requires drainage and debridement 6
• Squamous cell carcinoma: Must be excluded in any persistent solitary ulcer, as it can present as small white ulcerative lesions 1

Multiple or Widespread Lesions

• Acute necrotizing ulcerative gingivitis: Rapid onset with papilla necrosis, bleeding, and pain 7
• Recurrent aphthous ulcers: Most common cause of recurrent oral ulcers, typically on non-keratinized mucosa 4
• Herpes simplex: "Cold sores" typically on keratinized gingiva and hard palate 4

Mandatory Initial Laboratory Workup

Before proceeding to biopsy, obtain:

• Full blood count with differential: To exclude leukemia, anemia, and neutropenia 1, 8
• Coagulation studies: Required before any biopsy to prevent bleeding complications 3, 8
• Fasting blood glucose: Hyperglycemia predisposes to invasive fungal infections 3
• HIV antibody and syphilis serology: Essential screening for infectious causes 3, 1

If the patient is diabetic or immunosuppressed with yellowish plaques, add:

• Fungal markers: 1,3-β-D-glucan and galactomannan to detect invasive fungal infection 3, 8

Biopsy Indications

Any oral lesion persisting beyond 2 weeks requires biopsy, especially if unresponsive to 1-2 weeks of symptomatic treatment. 1

• Excisional biopsy: Preferred for small lesions ≤3mm 1
• Incisional biopsy: From ulcer edge including adjacent normal tissue for larger lesions 1
• Multiple biopsies: Required when lesions have different morphological characteristics 3, 1
• Delay biopsy only if: Coagulation parameters are abnormal or platelet counts are inadequate 8

Immediate Management While Awaiting Diagnosis

Provide symptomatic relief:

• Pain control: Viscous lidocaine 2% and benzydamine hydrochloride rinses 3
• Supportive care: Alcohol-free mouthwash, soft toothbrush, avoid irritants, apply white soft paraffin to lips 3
• For suspected fungal infection: Nystatin oral suspension or miconazole oral gel as first-line therapy 3

Specific Treatment Based on Diagnosis

Traumatic Lesions

• Eliminate the insult: Remove irritant, adjust denture, smooth sharp tooth edges 5
• Symptomatic therapy: Most resolve spontaneously once trauma is removed 5

Periodontal Abscess

• Establish drainage via pocket lumen 6
• Subgingival scaling and root planing with curettage of inflamed tissue 6
• Systemic antibiotics: Consider metronidazole for severe cases or systemic symptoms 7, 6
• Definitive periodontal treatment after acute phase resolves 6

Acute Necrotizing Ulcerative Gingivitis

• Superficial debridement with careful mechanical oral hygiene 7
• Chlorhexidine rinses with daily re-evaluation 7
• Metronidazole: First-line systemic antimicrobial for severe or non-responding cases 7

Critical Pitfalls to Avoid

• Never delay biopsy beyond 2 weeks for persistent ulcers—this represents excessive delay in diagnosing potentially life-threatening conditions including malignancy 1
• Do not assume benign appearance excludes malignancy—squamous cell carcinoma can present as small, innocent-appearing ulcers 1
• Avoid missing systemic disease associations—inquire about gastrointestinal symptoms, constitutional symptoms, immunosuppression, and medication history 1, 8
• Do not perform biopsy before confirming normal coagulation and adequate platelet count 8
• In neutropenic patients with oral ulcers, immediately consult hematology to evaluate for acute leukemia—this is life-saving 8