Ulceras bucales

Common Non-systemic Causes of Oral Ulcers

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Introduction Patients may complain of a sore mouth or pain and yet have no obvious organic cause, but in most an organic lesion can be observed. In some patients this is an obvious ulcer or erosion, in others mucositis or an atrophic mucosa may be seen. Ulcers and erosions can be the final common manifestation of a spectrum of conditions (Table2.1) ranging from the simplest traumatic breach of the epithelium, to epithelial damage resulting from an immunological attack as in pemphigus, pemphigoid, lichen planus and aphthae; to damage because of an immune defect as in human immunodeficiency virus (HIV) disease and leukaemia; to infections as in herpesviruses, tuberculosis and syphilis; to nutritional defects such as in vitamin deficienciesand some intestinal disease; or to neoplasia. The term ‘ulcer’ is used usually where there is damage to both epithelium and lamina propria, and a crater, sometimes made more obvious clinically by swelling caused by oedema or proliferation in the surrounding tissue. The term ‘erosion’ (desquamation if involving the gingivae) is often used for breaches of the epithelium in which there is littledamage to the underlying lamina propria. Such lesions, if penetrating the epithelium only partially, usually have a red or red and yellow appearance. If they penetrate the full thickness of the epithelium, however, they are typically covered by a fibrinous exudate and may then have a yellowish appearance. This chapter discusses the causes and management of common non-systemic ulcerative disorders ofthe oral mucosal ulcers. Most ulcers or erosions are due to local causes such as trauma or burns, some are caused by aphthae or malignant neoplasms.

Table 2.1 Causes of mouth ulcers.
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Local causes: – trauma – burns Drugs Recurrent aphthous stomatitis Malignant ulcers Systemic disease: – blood disorders – gastrointestinal disorders – mucocutaneous disease – connective tissuedisease – vasculitides – infective diseases Others

ULCERS OF LOCAL AETIOLOGY
Trauma from bites or from dentures and orthodontic appliances is common. Self-induced lesions due to lip-biting after a local anaesthetic injection, cheek-biting (a neurotic habit) and in some syndromes (Figs 2.1 and 2.2) may cause ulceration. Rarer causes include ulceration of the lingual fraenum caused by repeatedcoughing or cunnilingus, and palatal bruising, petechiae and ulceration from fellatio. Other local causes include burns from heat or cold, chemicals, electrical injury or irradiation (Fig. 2.3).

Clinical Features
Usually a single ulcer is seen, with an obvious cause (e.g. a denture flange). The patient is otherwise well, although there may be a small degree of ipsilateral cervical lymph nodeenlargement. Chronic irritation may cause hyperplasia or hyperkeratosis of the adjacent mucosa, but induration should raise the suspicion of malignancy.

OROFACIAL DISEASES - Update for the Dental Clinical Team

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Management
Remove aetiological factors and prescribe a chlorhexidine 0.2% mouthwash. Maintenance of good oral hygiene and the use of benzydamine or hot saline mouthbaths may help(Table 2.2). Most ulcers of local cause heal spontaneously in about 1 week if the cause is removed and such supportive care given. Biopsy is needed if there is any suspicion of malignancy (see below) or if the ulcer does not heal within 3 weeks of removal of the apparent cause – it may be a neoplasm or another serious disorder.

Figure 2.1 Traumatic ulceration of the lower lip.

DRUG-INDUCEDLESIONS
A wide spectrum of drugs can occasionally cause mouth lesions, by various mechanisms. Ulcers are common in those treated with cytotoxic drugs. The more common examples of drug reactions include:
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Cytotoxic agents, particularly methotrexate, producing ulcers. Agents producing lichen-planus-like (lichenoid) lesions, such as non-steroidal anti-inflammatory agents, some...