Oral ulcerations are a very common sight within the oral cavity. Luckily, due to the high reparative nature of the oral mucosa, many oral ulceration cases can be resolved with minimal or no intervention at all. However, diagnosis the ulceration is the easy part. Determining the cause is much tougher.
Differential diagnosis
Ulcerations can be further subdivided based on specific presentations.
| Differential Diagnosis | Clinical Features |
| Drug induced oral ulcer | Ulceration with erythematous halo, usually on the tongue. Not responsive to typical treatments. |
| Pemphigus vulgaris | Bullae, painful, fundus with erythematous halo. |
| Mucous membrane pemphigoid | Easily rupturing bullae, most common on the palate and gingiva. |
| Erosive lichen planus | Erosions or ulcers, also resistant to typical treatments. |
| Lupus erythematous | Ulcerations without induration, white striae and easily bleeding. |
| Tuberculosis | Deep indurated oral ulcers, usually appearing on the tongue, with rolled borders and granulation tissue. |
| Mycosis | Chronic oral ulceration associated with an immunocompromised patient. |
| Squamous cell carcinoma | Exophytic, endophytic, or mixed oral ulcers. |
| Eosinophilic ulcer | Persistent for weeks or months, ulceration usually on tongue, with raised, indurated borders. |
Oral ulcerations – medications induced
This category of oral ulceration can be categorized into two:
| Mucositis/ ulceration | Normally caused by cytotoxic drugs used for anti-tumor chemotherapy. This is associated with sloughing and ulceration days after starting the chemotherapy. In addition, immunosuppressive medications can cause oral ulceration due to secondary infections involving Gram-negative bacteria and fungi. |
| Fixed drug eruption | Associated with repeated and treatment resistant ulcerations. This type can be clinically distinct, as it is usually larger than an aphthous ulcer, flat surface with white appearance, and no induration. In these forms, steroids are ineffective. |
Traditionally, NSAIDs have been commonly known to be the culprit for oral ulcerations. However, new drugs on the market treating arthritis, angina, and diabetes have been shown to do damage also.
| Antibiotics | Gastric ulcer medications |
| Anticholinergic | Hypoglycemic agents |
| Anti-hypertensives | Immunosuppressant |
| Antiretrovirals | Interferons |
| Anti-rheumatic drug | NSAIDs |
| Anti-septics | Platelet aggregation inhibitors |
| Bisphosphonates | Potassium channel blockers |
| Beta-blockers | Protease inhibitors |
| Corticosteroids | Vasodilators |
Treatment
As mentioned, topical steroid are ineffective against drug induced oral ulcerations. After prescribing oral steroids, if no improvements are seen within 1-2 weeks, drug induced oral ulceration is to be expected. This is the point where a thorough discussion with the medical doctor is necessary in order to either stop or reduce dose of the medication in question. Following this, a 1-2 week post op period should be followed to monitor any changes/ improvements.