Clinical Guide > Oral Health > Oral Ulceration

# Oral Ulceration

January 2011

### Chapter Contents

      - Background 
      - S: SubjectiveO: ObjectiveA: AssessmentP: PlanPatient EducationReferencesBackground 
Oral ulcerations appear as necrotic or eroded areas on the oral mucosa, including the tongue. Most such lesions are idiopathic (aphthous) or of viral etiology (e.g., herpes simplex virus [HSV]; rarely herpes zoster [VZV]). Oral ulcerations may be caused by fungal, parasitic, or bacteriologic pathogens; malignancy; or other systemic processes. This chapter will focus on herpetic and aphthous ulcers.

Herpetic ulcerations tend to appear on keratinized tissues such as the hard palate or gingiva. Recurrent aphthous ulcers tend to manifest on nonkeratinized tissues such as buccal mucosa, soft palate, and lingual (bottom) surface of the tongue, and, by definition, recur.
S: Subjective
The patient complains of painful ulcerated areas in mouth. He or she may have difficulty eating, drinking, swallowing, or opening the mouth, and may complain of sore throat.

Inquire about previous occurrences of oral ulcerative disease as well as ulcerative gastrointestinal diseases, including HSV, cytomegalovirus (CMV), or histoplasmosis. Ask about recent sexual exposures. Inquire about recent trauma or burns. Note current medications and any recent changes in medications; obtain history of tobacco (smoked and chewed) and alcohol use.
O: Objective
Look for red or white-bordered erosions or ulcerations varying in size from 1 mm to 2 cm on the buccal mucosa, oropharynx, tongue, lips, gingiva, and hard or soft palate. Lesions caused by HSV tend to be shallow and occur on keratinized tissues. HSV lesions may appear as clusters of vesicles that may coalesce into ulcerations with scalloped borders. Aphthous ulcers present with a white or gray pseudomembrane surrounded by a halo of inflammation.
A: Assessment
Rule out syphilis and other suspected pathogens as well as trauma, seizure, and other physical injury.
P: PlanDiagnostic Evaluation
The diagnosis of HSV and aphthous ulcers usually is made on the basis of characteristic lesions. Location, duration, and recurrence are key elements in determining the nature of the oral ulcer. As mentioned previously, HSV-related ulcers most often present on keratinized fixed tissues; aphthous ulcers appear on nonfixed tissues such as buccal mucosa, and have a tendency to recur. Check the absolute neutrophil count (ANC), as a low count (<500 cells/µL) may be associated with nonresponsive ulcerative disease. If diagnosis is uncertain, it is possible to perform HSV culture or HSV antigen detection using direct florescent antibody (DFA) testing on oral ulcerations that appear on keratinized tissues or the dorsal and lateral surfaces of the tongue, scraping near the margin of the lesion or unroofing a fresh vesicle, if available, and scraping the base. The sensitivity of HSV testing decreases when collections are taken from older, resolving herpetic							areas; herpetic lesions >72 hours old usually will not yield a positive culture.

If other diagnoses are suspected, perform culture or biopsy as indicated. Also perform biopsy for ulcers that do not respond to therapy (in nonneutropenic patients).

Note that syphilis is very common among some HIV-infected populations. For patients in whom primary syphilis (manifested by an oral chancre) is suspected, perform (or refer for) darkfield examination; check Venereal Disease Research Laboratory (VDRL) or rapid plasma reagin (RPR) results (note that VDRL or RPR results may be negative in primary syphilis); see chapter *Syphilis* for further information. It is worth noting that, whereas chancres are described as painless, open sores in the mouth usually are associated with some degree of pain.
Treatment
If HSV culture is positive, or if HSV is strongly suspected owing to the appearance of the lesions or the patient's history, treat with HSV antiviral medication (e.g., valacyclovir, famciclovir, or acyclovir) while waiting for results of culture. Do not use topical steroids without a concomitant oral HSV antiviral if the lesion is of possible herpetic etiology. Refer to chapter *Herpes Simplex, Mucocutaneous* for more information regarding management and treatment of HSV lesions.

Recalcitrant minor aphthous ulcerations should be treated with topical corticosteroids (e.g., fluocinonide 0.05% or clobetasol 0.05% ointments mixed 1:1 with Orabase). For multiple small lesions or lesions in areas where topical ointments are difficult to apply, consider dexamethasone elixir (0.5 mg/5 mL); the patient is to rinse TID with 5 mL for 1 minute, then expectorate. As with all oral topical steroids, patients should not drink or eat for 30 minutes after rinsing. Continue treatment for 1 week or until lesions resolve.

In some cases, recurrent aphthous ulcers may respond to one of the various "magic mouthwashes" that contain combinations of antibiotic, antifungal, corticosteroid, antihistamine, and anesthetic medication. The inclusion of an antihistamine (e.g., diphenhydramine) or an anesthetic (e.g., lidocaine) may be helpful in treating pain associated with these ulcers.

For large or extensive aphthous ulcers, systemic corticosteroids may be needed: prednisone 40-60 mg PO daily for 1 week followed by a taper should prove beneficial. If this is ineffective, refer for biopsy to rule out CMV, other infection, or neoplastic disease.

For patients with major oral aphthous ulcers that are recalcitrant to other therapies, thalidomide 200 mg daily for 2 weeks may be considered. Thalidomide is teratogenic and should not be used for women of childbearing potential without thorough patient education and two concomitant methods of birth control. Consult with an expert.

Pain control may be needed in order for the patient to maintain food intake and prevent weight loss. Most of the topical treatments noted above will ease pain as well as treat the ulcer. Additional considerations for pain control include the following:
- Oral anesthetics : Various products are available, including gels (eg, Gelclair, an adherent oral rinse that acts as an oral bandage), viscous liquids, and sprays (e.g., benzocaine, lidocaine). These may be applied topically or swished and expectorated. They will provide temporary relief, but may lead to a temporary loss of taste sensation.
- Systemic : If topical treatments are inadequate, consider systemic analgesics (e.g., nonsteroidal antiinflammatory drugs or opiates). Refer to chapter  Pain Syndrome and Peripheral Neuropathy .

Assess nutritional status and consider adding liquid food supplements, if indicated. Suggest soft, nonspicy, or salty foods if the ulcer is interfering with food intake. Refer to a registered dietitian if client is experiencing pain, problems eating, or weight loss.

Refer to an oral health specialist or an HIV-experienced dentist as needed.
Patient Education- Advise patients to report any oral pain or difficulty swallowing to their health care provider.
- Instruct patients in the application of topical ointments, and indicate that they may require assistance if the lesion is difficult for them to see on their own.
- It is important for patients to maintain good nutrition and food intake while their oral ulcers heal. Advise them to eat soft, bland foods, and refer to a nutritionist if they have difficulty. 
References- Greenspan D.  Oral Manifestations of HIV . In: Coffey S, Volberding PA, eds.  HIV InSite Knowledge Base  [textbook online]; San Francisco: UCSF Center for HIV Information; June 1998. Accessed June 10, 2010.