ULCERATIVE CONDITIONS
Mouth ulcers are common and are usually due to trauma, such as from ill-fitting dentures, fractured teeth, or fillings (figure 1,figure 1) However, patients with an ulcer of over 3 weeks' duration should be referred for biopsy or other investigations to exclude malignancy (see Toolbox, wjm May 2001) or other serious conditions such as chronic infections.
Figure 1.
Comparison of minor (A) and major (B) aphthous ulcerations
Figure 1.
Comparison of minor (A) and major (B) aphthous ulcerations
Ulcers related to trauma usually resolve in about a week after removal of the cause and with the use of an anti-inflammatory and anesthetic throat spray to provide symptomatic relief and chlorhexidine 0.2% aqueous mouthwash to maintain good oral hygiene.
Summary Points
Patients with a mouth ulcer that persists more than 3 weeks should be referred for biopsy or other investigations to exclude malignancy or other serious conditions
Patients with aphthae are usually otherwise healthy
Topical corticosteroids aid resolution of ulcers. Systemic immunomodulation may be needed when ulcers are severe
Erythema migrans commonly affects the tongue, there are usually no serious connotations, and there is no effective treatment
Common forms of orofacial pain are burning mouth syndrome, atypical facial pain, and mandibular pain-dysfunction
Recurrent aphthous stomatitis (aphthae, canker sores)
Recurrent aphthous stomatitis typically starts in childhood or adolescence with recurrent small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or gray floors. It affects at least 20% of the population, and its natural course is one of eventual remission. There are 3 main clinical types:
Minor aphthous ulcers (80% of all aphthae) are less than 5 mm in diameter and heal in 7 to 14 days
Major aphthous ulcers are large ulcers that heal slowly over weeks or months with scarring
Herpetiform ulcers are multiple pinpoint ulcers that heal within about a month
Some cases have a familial and genetic basis; a minority involve etiologic factors that can be identified, including stress, trauma, stopping smoking, menstruation, and food allergy. Most patients seem to be otherwise well.
Aphthae are seen in patients with hematinic deficiency (iron, folate, or vitamin B12); celiac disease; Crohn's disease; HIV infection, neutropenia, and other immunodeficiencies; Neumann's bipolar aphthosis, where genital ulcers may also be present; and Behçet's syndrome, where there may be genital, cutaneous, ocular, and other lesions. The mouth ulcers in Behçet's syndrome are often major aphthae with frequent episodes and long duration to healing (figure 2).
Figure 2.
Major aphthous ulceration with severe scarring in a patient with Bechet's syndrome
In children, aphthae also occur in periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome. This syndrome resolves spontaneously, and long-term sequelae are rare. Corticosteroids are highly effective symptomatically; tonsillectomy and cimetidine treatment have been effective in some patients.
Diagnosis of aphthae is based on the patient's history and clinical features because specific tests are unavailable. A full blood chemistry (hemoglobin level, differential white cell count, and red cell indices), iron levels, and possibly red cell folate and serum vitamin B12 measurements, and other investigations may help exclude systemic disorders. Biopsy is rarely indicated.
Predisposing factors should be identified and corrected. Chlorhexidine mouthwashes may help. Symptoms can often be controlled with hydrocortisone hemisuccinate pellets or triamcinolone acetonide in carboxymethyl cellulose paste 4 times daily, but use of more potent topical corticosteroids or systemic corticosteroid therapy may be required. Thalidomide is also effective, but its use is rarely indicated.,
Table 1.
| Main systemic and iatrogenic causes of oral ulcers | |
|---|---|
| Microbial disease | Malignant neoplasms Blood disorders |
|
|
| Gastrointestinal disease | |
| |
| Cutaneous disease | Rheumatoid diseases |
|
|
| Drugs | |
| |
| Radiotherapy | |
Table 2.
| Causes of a complaint of burning mouth syndrome | |
|---|---|
| Local | Deficiency states |
|
|
| Psychogenic | Diabetes mellitus |
|
|
Malignant ulcers
Oral carcinoma may present as a solitary chronic ulceration (see Toolbox, wjm May 2001).
Mouth ulcers in systemic disease
Ulcers may be manifestations of disorders of the skin, connective tissue, blood, or gastrointestinal tract. The skin disorders most often associated with mouth ulcers are lichen planus, pemphigus, pemphigoid, erythema multiforme, epidermolysis bullosa, and angina bullosa hemorrhagica (blood-filled blisters that leave ulcerated areas after rupture) (figure 3). In view of the clinical consequences of pemphigus, accurate diagnosis of oral bullae is important, and referral for direct and indirect immunofluorescence of biopsy tissue is often indicated.
Figure 3.
Bulla in a patient with oral pemphigoid
Drug-induced mouth ulcers
Among the drugs that may be responsible for mouth ulcers are cytotoxic agents, antithyroid drugs, and nicorandil.
NONULCERATIVE CAUSES OF ORAL SORENESS
Erythema migrans (benign migratory glossitis, geographic tongue)
This common condition of unknown etiology, which affects about 10% of children and adults, is characterized by map-like red areas of atrophy of filiform tongue papillae in patterns that change even within hours (figure 4). The tongue is often fissured. Lesions can cause soreness or may be asymptomatic.
Figure 4.
Red areas of atrophy of filiform tongue papillae characterize erythema migrans
No treatment is reliably effective, althogh zinc supplements may lead to some improvement. Similar lesions may be seen in Reiter's syndrome and psoriasis.
Burning mouth syndrome (oral dysesthesia, glossopyrosis, glossodynia)
This condition is common in middle-aged and older adults is characterized by a persistent burning sensation in the tongue, usually bilaterally. The cause is unclear, but response to topical anesthesia suggests it is a form of neuropathy. Discomfort is sometimes relieved by eating and drinking, in contrast to the pain from ulcerative lesions, which is typically aggravated by eating.
Organic causes of discomfort—such as erythema migrans, lichen planus, a deficiency glossitis (related to deficiency of iron, folate, or vitamin B12), xerostomia, diabetes, and candidiasis—must be excluded. More often, the condition is attributable to underlying depression, monosymptomatic hypochondriasis, or anxiety about cancer or a sexually transmitted disease. Burning mouth syndrome is more common in patients with Parkinson's disease.
Reassurance and, occasionally, psychiatric consultation, vitamin supplements, or antidepressant therapy may be indicated, but these measures are not reliably effective.
Table 3.
| Causes of orofacial pain | |
|---|---|
| Local diseases | Neurologic disorders |
|
|
| Psychogenic pain | Vascular disorders |
|
|
| Referred pain | |
|
|
Desquamative gingivitis
Widespread erythema, particularly if associated with soreness, is usually caused by desquamative gingivitis. This condition is fairly common and is seen almost exclusively in middle-aged and older women (see Toolbox, wjm April 2001).
OROFACIAL PAIN
Most orofacial pain is caused by:
Local disease, especially dental, mainly a consequence of caries (see Toolbox, wjm April 2001)
Psychogenic states
Neurologic disorders (such as trigeminal neuralgia). Similar features are seen in the rare SUNCT syndrome (short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing)
Vascular disorders (such as migraine). Evidence suggests that chronic pain may be related to thrombosis or hypofibrinolysis causing small areas of jaw ischemia and necrosis; this condition has been termed neuralgia-inducing cavitational necrosis
Referred pain (such as angina)
Psychogenic orofacial pain
This ill-defined entity includes burning mouth syndrome, atypical facial pain, atypical odontalgia, and the syndrome of oral complaints.
The pain is often described as dull, boring, or burning and the location is ill-defined. Most patients are middle-aged to older women. They typically have constant chronic discomfort or pain, rarely use analgesic preparations, sleep undisturbed by pain, have consulted several clinicians, have no objective physical signs or positive results of laboratory investigations, and have recent adverse life events, such as bereavement or family illness, as well as multiple psychogenic-related complaints.
Attempts to relieve pain by restorative treatment, endodontia, or exodontia are usually unsuccessful. Many patients lack insight and will persist in blaming organic diseases for their pain. Some patients are depressed or hypochondriacal and may respond to antidepressant therapy. Many patients, however, refuse drug or psychiatric therapy. Those who will respond invariably do so early in the course of treatment.
Atypical odontalgia manifests as pain and hypersensitive teeth, typically indistinguishable from pulpitis or periodontitis, but without detectable pathologic change. It is probably a variant of atypical facial pain and should be treated similarly.
Temporomandibular joint pain-dysfunction syndrome (myofascial pain-dysfunction syndrome, facial arthromyalgia)
This common disorder typically afflicts young women. Symptoms are highly variable but are characterized by:
Recurrent clicking in the temporomandibular joint at any point of jaw movement and occasional crepitus, especially with lateral movements
Periods of limitation of jaw movement, with variable jaw deviation or locking, but rarely severe trismus
Pain in the joint and surrounding muscles, which may be tender to palpation
Patients with a nighttime habit of clenching or grinding the teeth (bruxism) may awake with joint pain that abates during the day. In people who clench or grind their teeth during working hours, the symptoms tend to worsen toward evening and sometimes have a psychogenic basis.
Etiologic factors include muscle overactivity (such as bruxism and clenching), disruption of the temporomandibular joint, and psychological stress (such as anxiety and stressful life events). Precipitating factors include wide mouth opening, local trauma, nail biting, and emotional upset. Rarely is there ony one etiologic factor; a combination of factors is contributory. Occlusal factors do not in general seem to be important.
The diagnosis of this syndrome is clinical. Radiographic changes are uncommon, and arthrography or magnetic resonance imaging is seldom indicated.
Most patients recover spontaneously; therefore, management involves reassurance and conservative measures, including rest, jaw exercises (opening and closing), a soft diet, and analgesic medication. If these steps are insufficient, it can be helpful to use heat, ultrasound treatment, anxiolytic or antidepressant agents, or plastic splints on the occlusal surfaces (occlusal splints) to reduce joint loading. A few patients fail to respond to these measures and require local corticosteroid or sclerosant therapy, local nerve destruction, or joint surgery as a last resort.
Further reading
Krause I, Rosen Y, Kaplan I, et al. Recurrent aphthous stomatitis in Behçet's disease: clinical features and correlation with systemic disease expression and severity. J Oral Pathol Med 1999;28:193-196.
Marbach JJ. Medically unexplained chronic orofacial pain. Temporomandibular pain and dysfunction syndrome, orofacial phantom pain, burning mouth syndrome, and trigeminal neuralgia. Med Clin North Am 1999;83:691-710.
Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol Med 1998;9:306-321.
Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease. N Engl J Med 1999;341:1284-1291.
Scully C. A review of common mucocutaneous disorders affecting the mouth and lips. Ann Acad Med Singapore 1999;28:704-707.
Scully C, Flint S, Porter SR. Oral Diseases. London: Martin Dunitz; 1996.
Tammiala-Salonen T, Forssell H. Trazodone in burning mouth pain: a placebo-controlled, double-blind study. J Orofac Pain 1999;13:83-88.
Van der Waal I. The Burning Mouth Syndrome. Copenhagen: Munksgaard; 1990.
Acknowledgments
Crispian Scully is grateful for the advice of Rosemary Toy, general practitioner, Rickmansworth, Hertfordshire.
Competing interests: None declared
This article was published in BMJ 2000;321:162-165.
This article is the 4th in a series of articles on oral health. See this article on our web site for links to other articles in the series
Authors: Crispian Scully is dean and Rosemary Shotts is honorary lecturer at the Eastman Dental Institute for Oral Health Care Sciences, University College London, University of London (www.eastman.ucl.ac.uk).
The ABC of Oral Health is edited by Crispian Scully and was published by the BMJ Publishing Group, London, in November 2000.