How should I evaluate and manage oral ulcers in an otherwise healthy adult?

Evaluation and Management of Oral Ulcers in Healthy Adults

For oral ulcers in an otherwise healthy adult, begin with a focused clinical assessment to determine duration and morphology, manage ulcers lasting <2 weeks with topical therapy, but immediately pursue biopsy and laboratory workup for any ulcer persisting >2 weeks or failing to respond after 1-2 weeks of treatment to exclude malignancy and systemic disease. 1, 2

Initial Clinical Assessment

Document these specific ulcer characteristics at presentation:

• Size, number, location, and depth of each lesion 1, 3
• Presence of white or yellow pseudomembrane with surrounding erythematous halo (suggests recurrent aphthous stomatitis) 1, 2
• Shape and location matching a traumatic source (sharp tooth, dental appliance, hot food)—this pattern confirms traumatic etiology 1, 3
• Stellate morphology with undermined edges—this specific appearance suggests tuberculosis 1, 2
• Duration: classify as acute (<2 weeks), recurrent (≥4 episodes/year), or chronic (>2 weeks) 1, 4

Management Algorithm Based on Duration

Ulcers <2 Weeks Duration

• Eliminate identifiable trauma (adjust dental appliances, smooth sharp teeth, avoid acidic/salty/hard foods) 1, 5
• Avoid sodium lauryl sulfate-containing toothpastes, alcohol, and carbonated drinks 5
• First-line topical therapy: antiseptic agents (triclosan) or local anesthetics (lidocaine) 5
• Second-line if ineffective: topical corticosteroids (betamethasone sodium phosphate, fluticasone propionate, or clobetasol 0.05% ointment) 1, 5
• Barrier preparations (Gengigel, Gelclair) for additional pain control 1

Ulcers ≥2 Weeks or Not Responding After 1-2 Weeks of Treatment

Mandatory laboratory workup before biopsy: 1, 2, 3

Test	Rationale
Complete blood count	Detect anemia (iron/folate/B12 deficiency), leukemia, neutropenia [1,3]
Coagulation profile	Identify bleeding risk before biopsy [1,3]
Fasting blood glucose	Screen for diabetes predisposing to invasive fungal infection [1,3]
HIV antibody	Rule out HIV-related ulceration [1,2,3]
Syphilis serology	Exclude syphilitic ulceration [1,2,3]
Serum antibodies (Dsg1, Dsg3, BP180, BP230)	Evaluate for pemphigus vulgaris or mucous membrane pemphigoid if bullous disease suspected [1,3]

Biopsy is mandatory for: 1, 2

• Any solitary chronic ulcer to exclude squamous cell carcinoma 1, 2, 4, 6
• Any ulcer persisting >2 weeks regardless of appearance 1, 2
• Ulcers with atypical morphology or unclear etiology 1, 2

Biopsy technique: 1

• Obtain adequate depth and size—superficial or small biopsies miss diagnostic features 1
• Perform multiple biopsies if lesions vary in appearance across different sites 1
• Request direct immunofluorescence for suspected autoimmune conditions 1, 3
• Consider immunohistochemistry and T-cell receptor profiling based on initial histology 1

Specialist Referral Criteria

Refer to oral medicine specialist for: 1, 2, 3

• Ulcers lasting >2 weeks 1, 2
• Ulcers not responding to 1-2 weeks of appropriate treatment 1, 2
• Recurrent aphthous stomatitis (≥4 episodes/year) requiring systemic therapy 4, 7
• Atypical presentations requiring biopsy or advanced diagnostic testing 2, 3
• Cases with systemic symptoms suggesting underlying disease (inflammatory bowel disease, Behçet's disease, autoimmune bullous disorders) 1, 3, 4

Oral medicine specialists perform specialized diagnostic procedures including biopsy, coordinate multidisciplinary care when systemic disease is identified, and manage complex cases requiring systemic immunosuppression 1

Critical Pitfalls to Avoid

• Never rely solely on topical treatments for persistent ulcers without establishing definitive diagnosis—this delays identification of malignancy or systemic disease that directly impacts mortality 1, 2, 3
• Do not accept pathology reports stating "inflammatory ulcer with lymphocytic infiltration" as final diagnosis—this is nonspecific and may require consultation with experienced pathologists or repeat biopsy 1
• Do not overlook systemic causes (anemia, inflammatory bowel disease, HIV, autoimmune disorders)—this leads to delayed diagnosis and inappropriate management 1, 3
• Recognize that acute monocytic leukemia presents with widespread necrotic ulcers when neutrophil counts are severely decreased 1

Recurrent Aphthous Stomatitis (≥4 Episodes/Year)

For confirmed recurrent aphthous stomatitis after excluding systemic causes: 4, 5, 7

• Topical corticosteroids remain first-line for each episode 5, 7
• Colchicine combined with topical treatments is suitable for most cases of recurrent aphthous stomatitis 4
• Systemic options for severe refractory cases: pentoxifylline or prednisolone 5
• Thalidomide is most effective but use is limited by frequent adverse effects and should be reserved for refractory cases, particularly in Behçet's disease 4