Case• 19. Troublesome mouth ulcers
A 38-year-old woman with mouth ulcers has noticed a recent exacerbation in their severity. You need to make a diagnosis and decide on suitable investigations and treatment.
The patient complains of mouth ulcers which have been troubling her recently.
History of complaint
She has suffered from occasional mouth ulcers, usually small, one at a time, over a period of more than 20 years. However, recently they seem to have become worse and she now has several. Normally she ignores them but, because she was attending your surgery for a filling, she thought she would ask whether anything could be done.
The patient is otherwise fit and well.
▪ The patient has already provided several pieces of information of value for differential diagnosis. How do you assess her ulcers on the basis of the information available?
The patient has noted an outset of ulceration early in life with recurrent attacks of single ulcers or small crops of ulcers. There are very many causes of oral ulceration but these ulcers appear to be recurrent, that is they appear periodically and heal completely between attacks. Recurrent ulceration has relatively few common causes.
▪ What are the common causes of recurrent oral ulceration?
• Recurrent aphthous stomatitis (RAS)
— Minor type
— Herpetiform type
— Major type
• Erythema multiforme
• Occasional cases of traumatic ulceration
• Ulcers associated with gastrointestinal disease.
▪ How will you differentiate between these conditions?
Almost entirely on the basis of the findings in the history. Some features of the examination, blood tests or a biopsy may be helpful in certain cases, but the history is most important.
▪ What features of the ulceration would you ask about to determine the diagnosis? Explain why for each.
See Table 19.1 This patient’s answers are shown in the right-hand column.
|Feature||Reason||This patient’s ulcers …|
|Site||Recurrent aphthous stomatitis (RAS) almost exclusively affects nonkeratinized mucosa. Erythema multiforme affects predominantly the vermilion border of lip, buccal mucosa and anterior mouth. Recurrent traumatic ulceration usually recurs at the same site, often close to a sharp tooth.||… affect the labial mucosa and anterior buccal mucosa, especially in the sulci behind the lips. They never occur on the dorsal tongue or palate.|
|Size||Recurrent aphthous ulcer size depends on type. Minor ulcers are usually up to 8 mm in diameter, herpetiform 0.2–3 mm, and major ulcers are larger than 1 cm, sometimes up to 3 or 4 cm in diameter.||… are usually 3–5 mm in diameter.|
|Duration of each ulcer||Minor RAS ulcers heal in approximately 10 days. Herpetiform ulcers may heal in about the same time or sometimes a shorter period (they are often smaller). Major RAS lesions may fail to heal for weeks or even months. Erythema multiforme is variable depending on severity and heals in 10–21 days.||… last a week or so before each ulcer heals.|
|Number of ulcers||Minor RAS lesions usually appear singly or in crops of 4–5 ulcers; major RAS lesions are fewer in number, often only one or two; herpetiform ulcers are numerous, from 30 to 100 at a time.||… are normally single, occasionally 2–3 develop at once. Recently there have been up to 5 at once.|
|Frequency of attacks||Frequency of attacks of RAS varies with severity. Ulcers may appear almost continuously or just once a year. Sometimes they coincide with menstruation. Erythema multiforme classically recurs at 6–8 week intervals in severe cases but the frequency may be only one or two attacks in a year.||… are usually confined to one or two attacks a year but she has had three crops in the last 4 months.|
|Shape||RAS ulcers are usually round or oval and sharply defined, especially in the early stages. They may become more irregular as healing takes place. Herpetiform ulcers coalesce to form irregular shapes. Ulcers in erythema multiforme are irregular and ragged and often poorly defined, merging with inflamed surrounding mucosa. Those on the lips are often covered by bloody fibrin sloughs.||… are round or oval.|
|Whether multiple ulcers develop synchronously or asynchronously||In RAS, ulcers may develop in crops within a few days of one another, or asynchronously. One crop may appear before another has healed. Herpetiform RAS lesions usually appear in crops together. In erythema multiforme all the ulcers develop synchronously.||… usually appear within a few days of one another.|
|Are ulcers preceded by vesicles?||The presence of vesicles indicates possible viral infection or vesiculobullous disease. This fact may be helpful in the differential diagnosis of herpetiform ulcers, which resemble viral ulcers but are not preceded by vesicles.||… have not been preceded by any vesicles, at least as far as the patient has been aware.|
|Age of onset||RAS usually has onset before or around adolescence. Erythema multiforme typi/>|