Oral ulceration: a diagnostic problem.

Most mouth ulcers are caused by trauma or are aphthous. Nevertheless, they may be a manifestation of a wide range of mucocutaneous or systemic disorders, including infections, drug reactions, and disorders of the blood and gastro-intestinal systems, or they may be caused by malignant disease. The term mouth ulcers should not, therefore, be used as a final diagnosis. An ulcer may develop from miucosal irritation from prostheses or appliances, or from trauma such as a blow, bite, or dental treatment; in such cases the diagnosis is usually clear from the history and from the ulcer healing rapidly in the absence of further trauma. Failure to heal within three weeks raises the possibility of another diagnosis such as malignancy. A single persistent ulcer may result from a range of causes, but malignant disease must always be excluded. About 90% of malignant neoplasms of the oral mucosa are squamous cell carcinomas.' These may present not only as a persistent ulcer or fissure (which may or may not have typical features such as induration and a rolled edge) but also as, or associated with, white lesions (leucoplakias) or red lesions (erythroplasias). Any mouth ulcer that fails to resolve within three weeks after the removal of an obvious local cause should be regarded with suspicion and a biopsy specimen taken or the patient referred for advice. Most recurring mouth ulcers are due to aphthous stoma-titis. In one American series over half the healthy students questioned gave a history of this,2 and the condition often appears first in childhood or teenage life. Characteristically aphthae are painful round or ovoid ulcers; they occur most frequently on the buccal mucosa, vestibule, undersurface of the tongue, and floor of the mouth; they may be single or multiple, and they heal without scarring. These minor aphthae usually measure less than 5 mm in diameter and heal within one week to 10 days. A few patients have much larger and more persistent ulcers, which sometimes affect the dorsum of the tongue or palate as well as other sites and may heal with scarring (major aphthae). Other patients may develop crops of numerous painful ulcers which enlarge and coalesce to produce large ragged ulcers (herpetiform ulcers). The diagnosis of recurrent aphthous stomatitis is usually straightforward since the history and clinical appearances are characteristic. The cause of recurrent aphthous stomatitis is still not clear, but a few patients have an identifiable and …