Physical Examination, Causes, and Management of Patients With Oral Ulcer

In this episode, Amit Correa, MD, speaks about the clinical evaluation and management of patients with an oral ulcer, including the causes, management of a patient with an aphthous ulcer, malignant and premalignant lesions of the oral cavity, and blood conditions that can lead to an oral ulcer or lesion in the mouth. 

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Amit Correa, MD, is a hematology and oncology fellow at The University of Tennessee.



Jessica Bard: Hello everyone and welcome to another installment of Podcast360, go-to resource for medical news and clinical updates. I'm your moderator, Jessica Bard with Consultant360 Specialty Network. Oral ulcers are one of the most common lesions affecting the mouth. Approximately 20% of people will develop an oral ulcer at some point, according to the Cleveland Clinic. Dr. Amit Correa is here to speak with us today about oral ulcers. Dr Correa is a hematology and oncology fellow at the University of Tennessee. Thank you for joining us today, Dr Correa. What is an oral ulcer?

Dr Amit Correa: So I'm going to talk a little bit about oral ulcers. In my field, leukemia lymphoma, we have a lot of patients on immunosuppressive agents. Sometimes cancer can manifest with some kind of oral lesions as well. So I do see a lot of oral ulcers that I'm going to just go over some of my experiences with oral ulcers. So I'm going to start with defining an oral ulcer, which is essentially a break in the continuity of the mucosa of the oral cavity. This could be over the lips, the gums, the floor of the mouth dorsal or the ventral aspect of the tongue, the mucosal surface of the cheeks, and less commonly the hard palate. It could also involve the anterior or the posterior tonsil pillars.

Jessica Bard: How should a clinician evaluate a patient with an oral ulcer?

Dr Amit Correa: So I'm going to basically have this question answered in a way where a patient comes into a primary care clinic and a patient comes in with an oral ulcer and what should a primary care physician consider? So to start off with, it's important to get a good history. And it doesn't need to be a very extensive history, but there are certain points that one should definitely hit on. One is the duration of an ulcer. The reason one should bring up this particular question is a shorter duration, if the ulcer starts and heals within three weeks, that's a good sign it’s likely an aphthous ulcer. If the ulcer persists more than four weeks, that's when you should start thinking of other systemic manifestations, including a malignancy. The other important thing is to also have an idea of what the inciting event is. Could it be a patient, was using dentures and have some sharp dentures or was a particular food triggered the ulcer or the patient had some trauma by eating or bit himself. That could lead to an oral ulcer.

So, when you do take a focused history, duration is very important, and to get an idea of what the inciting event was very important. The other important thing is to try and figure out what the location of the ulcer is and why I bring this particular point up is squamous cell carcinoma of the oral cavity usually occurs over the tongue. And it's usually over the size of the tongue and over the vent aspect of the tongue. So if you see an ulcer in those particular locations that persists over four weeks, then that's something that you should be a little more concerned about. The other important thing is, we've already gone over duration. The other thing is to just keep an eye on, if the ulcer changes its appearance, has it become bigger? Has it become more red? Or there just some certain changes that the patient has noticed in the ulcer that could lead you one way or the other.

The other very important thing is to ask if the patient has any systemic manifestations, for example, does the patient have a fever? Does the patient have a rash involving the back or the torso or something like that? Does the patient have joint pains in the smaller joints of the hands or the larger joints? Because that could indicate a systemic condition, like say SLE or something like that, which could manifest with oral ulcers. The other important thing is to get a good medication history. A lot of the drugs that we use for immunosuppressive purposes and a lot of the athletes in rheumatology also use some of these drugs, like methotrexate, can cause older ulcers. So that's something that one should ask about when they take a good history. In addition to that, one should definitely ask about smoking because smoking can be predisposed to not just oral ulcers, but they definitely have an increased risk for developing squamous cell carcinoma of the mouth.

In addition to that, things like betel nut and things like that, which is not really very common in our part of the world, but in other parts of the world, it may be. In addition to that, you want to ask the patient both their medical history. When you're doing that, you really want to ask them if they've had any autoimmune conditions in the past and do they have any ongoing autoimmune conditions. As I said, SLE or rheumatoid arthritis or something like that. You want to ask them if they've had a previous malignancy. And by that, I really mean that they may be on some medication for leukemia lymphoma, any other cancer, or something like that. Or they may have had a bone marrow transplant and need some immunosuppression or some condition called graft-versus-host, which can manifest with an oral ulcer. So really those are the important questions one should ask. For the important aspects, one should consider while taking a focused history for a patient with oral ulcers.

Jessica Bard: What should the physical examination entail?

Dr Amit Correa: Once you get a focused history, the next step would be to do a good physical exam. The important part of the physical exam is to do a detailed inspection of the mouth. So you want to look at all surfaces of the oral mucosa. You want to look under the upper lip, under the lower lip, go have a look at the sides, with where the cheeks are, so you may want to use a flashlight or something like that to get a good view. You want to have a good look at the tongue as well, and you may actually ask the patient to lift his or her tongue up so that the tongue touches the hard palate, that way you can look under the tongue and you can have a look at the frenulum. You can have a look at the floor of the mouth because those can be areas where you can have oral ulcers as well.

In addition, you want to look at the hard palate. You want to look at the anterior and the posterior tonsil pillars as well, just to get a very good idea that you've examined the mouth well, and you haven't missed any other lesion that the patient is not aware of. In addition to that, it is important to sometimes even palpate the ulcer. So just put on a pair of gloves and put your hand inside the patient's mouth with the torchlight, and just feel over the ulcer. If the ulcer just feels very soft and that way it's fine, but if it's very indurated and hard, that is an indication that this patient could be having an underlying malignancy and that could be a warning or tail sign that something more needs to be done. In addition to that, it is important to examine the neck as well.

So I would suggest to just examine the cervical lymph nodes, just to make sure the patient doesn't have any enlarged lymph nodes. And lymph nodes may be enlarged with any infection, like HSV, EBV or CNB that can lead to ulcer formation, or even with an aphthous ulcer that gets secondarily infected. You can have enlarged lymph nodes, but I believe what you would expect is that those lymph nodes go away after about two to three weeks. If those lymph nodes do persist beyond that duration of time, then again, that is concerning.

Jessica Bard: What are the various causes of an oral ulcer?

Dr Amit Correa: So, an oral ulcer is a common problem that patients can have, and they commonly come to their primary care provider or their dentists with this condition. Having said that the most common cause of an ulcer is an aphthous ulcer. And believe it or not, with all the research we've done over the years, we really don't know what predisposes one to developing an aphthous ulcer. There are various theories as to why that happens. The most common being, it could be a T-cell dysfunction, with theory being that there could be some antigens on the surface of the oral mucosa that activates T-cells, and then these T-cells, in turn, lead to cause an inflammatory reaction, which leads to the formation of an oral ulcer. Oral ulcers could also be part of some syndromes. For example, Behcet syndrome is essentially an inflammatory and multisystem disorder affecting organs, like the GI tract, and the articular surfaces of cartilages, and they can have pulmonary involvement as well.

You can have syndromes like the MAGIC syndrome, in which patients can have mouth and genital ulcers and inflamed cartilage. This is normally seen more in children. And then you can have conditions like Cyclic neutropenia, where the patients can have cycles of... The ulcers in this particular condition, tend to be vascular in nature, and they tend to cluster together. So that's how HSV ulcers tend to manifest. Herpes zoster or varicella-zoster can cause oral ulcers as well. And they tend to cause oral ulcers in the immunocompromised. So if you have HIV or you have some kind of cancer, you're getting chemotherapy for that, you're on steroids for a long duration of time, or you just get older. Sometimes, when you are 65, 70 and you haven't taken the shingles vaccine, you can have some manifestations of Herpes zoster leading to some oral ulcers. Another condition that can lead to oral ulcers is CMV.

Now CMV causes oral ulcers, they tend to be larger than the ulcers seen in HSV. They tend to be a single lesion as opposed to multiple lesions. And you may also see some lesions over the palms and soles. But usually, with CMV, it's a wider infection that tends to affect patients that are immunocompromised. So in a healthy person, you really don't see it. You may see it in children when they are two or three years of age or even younger, or you may see it in people who are immunocompromised, as I said earlier, have HIV, or are on chemotherapy, leukemia patients. Patients who have undergone transplants are on immunosuppressive medications and things like that. The other condition that can lead to oral ulcers, is HIV, especially when the CD4 count tends to fall. It can cause oral ulcers and believe it or not, it can also predispose to other conditions leading to oral ulcers, like sometimes Candida, sometimes HSV sometimes Herpes zoster, et cetera.

Syphilis is another cause of oral ulcers. It used to be more common in the past, but now with the advent of penicillin and things like that, you don't see it as much. So those are the infectious causes for oral ulcers. In addition to that, you can have systemic inflammatory processes that can lead to oral ulcer. So conditions like Crohn's disease, and ulcerative colitis, which tend to affect the GI tract can lead to oral ulcers as well. Celiac disease can lead to oral ulcers and then SLE is a disease thing that can affect practically any system in the body. And that can definitely lead to oral ulcers as well. The other important condition that can lead to oral ulcer is malignancies. And we already spoke about Squamous Cell carcinoma that can manifest as an oral ulcer. And what is important is that, unlike an aphthous ulcer, these ulcers tend to persist beyond four weeks.

A patient can have enlarged lymph nodes in the neck and the patient can have a very indurated ulcer. If you palpate those ulcers, they have a lot of induration and that's a clue to know that this could be a malignant process. What else even malignancies, I've already spoken about that. Patients that are immunocompromised, on chemotherapy, have low T cell immunity, and things like that, they can definitely have oral ulcer as well. So in addition to that one point that I do want to mention is you want to make sure that you get a good drug history, because as I've mentioned previously, drugs like methotrexate, sometimes even colchicine can lead to oral ulcers. So those essentially are the important causes of oral ulcers.

Jessica Bard: What are some other common conditions in the oral cavity that a clinician should be aware of?

Dr Amit Correa: There are certain conditions though, in the oral cavity that can be rather common. And a lot of us could have those conditions and really not be aware that we have those conditions, but they are benign and they really do not need much of a workup. So I'll start off with a condition called Leukoedema. It's a benign mucosal condition. It presents in a very asymptomatic fashion. It may be bilateral and you may see a grayish-white appearance over the mucosa. And if you actually stretch out the mucosa, when you're examining the patient, it actually goes away. It tends to be more prevalent in the African American community. And the incidence could be as high as from one to 90%. So it's very, very common, and watch out for this particular condition, but really nothing needs to be done about it. The patient just needs to be reassured and that's good enough.

Another important condition that again, one would see often is Fordyce granules. Now Fordyce granules are really granules or lesions that are about one to two millimeters. They're discrete papules. And really they represent ectopic sebaceous glands. The sebaceous gland should be on the skin, but if they're ectopically located in the oral mucosa, you can see the small granules over the surface of the buccal mucosa. Again, nothing needs to be done about it. The patient just needs to be reassured and that's all that is required. Another important condition that you would see is called physiological oral pigmentation. This is commonly seen in patients who have darker skin. What can tend to happen is they can have some melanocytes that accumulate in the oral cavity. And in these patients or these particular people, you can see a dark discoloration over the gums and things like that. It's something that's totally benign it's because of increased melanin production. And one should not confuse this with melanoma. It's a completely benign process.

Another common lesion is called frictional keratosis, and these are white lesions that typically one could see over the cheek or the tongue, and they tend to occur because those are the areas that frequently come in contact with the teeth. And so there's always some amount of friction or micro trauma or recurring trauma that occurs in those areas because of which it can lead to, some keratosis or whitening of those parts of the cheeks next to the molars. But again, nothing needs to be done about it. And just need to tell the patient to be kind of more cognizant about when they eat and have a more sense of awareness when you eat so that you make sure that you bite your food in a very good fashion and you don't eat too fast or something like that, where you tend to bite the sides of your cheeks and you traumatize your cheeks. So basically those are some important conditions that one should be aware of in the oral mucosa that really you come across very often in your practice, but already nothing needs to be done about.

Jessica Bard: How should a clinician treat a patient with an aphthous ulcer?

Dr Amit Correa: So when a patient does come in with an aphthous ulcer, it's important to give the patient some kind of recommendations as to what will help the ulcer heal faster, for one. And the other thing is you want to try and decrease the patient's pain much as possible. So oral hygiene is important and normally mouthwashes are good because you want to make sure ulcer doesn't get secondarily infected. And so non-alcohol-containing mouthwashes is a good way to rinse ones mouth. The other thing is to try and avoid exacerbating factors. Very often, patients can actually tell you what exacerbates their ulcer. So it is a particular food type, sometimes spicy food, sometimes smoking sometimes just sharp dentures. So if the patient is able to identify what predisposes them to develop an ulcer or what makes the ulcer worse, it is very important to tell them to avoid that.

And that's where you can actually talk to the patient and try to make the patient feel more aware of what predisposes them to develop an ulcer. And then you can try to tell them to stay away from those, kind of, factors. The other important thing is pain control because when one is chewing food or when one is talking, the pain can be significant enough that it can hamper your quality of life. And so it's essentially just using some lidocaine and just applying it over the ulcer, especially when one talks, someone's going through a meeting, someone has a presentation to do, maybe it's a good thing to put some lidocaine before you go in for a presentation or before your meals. It's usually about, 5 to 10 minutes before you start eating. It's a good time to put some lidocaine over your ulcer to help with pain control.

The other important thing is sometimes vitamin deficiencies can manifest as oral ulcers. And the vitamin B12, there are some studies that indicate just regular supplements, vitamin B12 can help with oral ulcer healing. So, just give the patient some B complex for maybe a 14 to 21-day duration, maybe good. Some other things that one could check are folate deficiency, iron deficiency and if those are actually low, then repeating that will definitely help with the better ulcer healing. Another important thing for oral ulcers is dexamethasone washes. So one can use like elixir, which is essentially a dexamethasone wash. You just need to put it in your mouth, switch it, keep it in your mouth for about 30 seconds and then just spit it out. So you can do this about three to four times a day, and that should help with the healing of oral ulcers.

There are some particular patients that can have pretty bad oral ulcers in the sense that they can have really bad pain. They can have multiple oral ulcers, even after 4, 5, or 10 days, the ulcers still persist. It's still painful in patients like that, using oral prednisone could be a good option, just 10 to 20 milligrams, usually order of 4 or 7-day period is a good duration for that. What one should be cognizant of is, some people tend to have a phenomenal pulpitis. It really means that some form of micro trauma can trigger an oral ulcer. So if a patient has that kind of a phenomena, say they bite themselves, or they traumatize themselves, then their oral cavity, they should take prednisone soon after. So soon as they have some kind of microtrauma take prednisone, take 10 to 20 milligrams for about 4 to 5 days, doing this sometimes even prevents the ulcer from forming.

And definitely, if the ulcer does form, the intensity of the ulcer is not that bad. So that's a good mitigation strategy that one could advise their patients. So keep a little bit of prednisone with you. Keep about 30 tablets of 10 milligrams, and each time you bite yourself or have some micro trauma, take some prednisone just for a 4 or 5-day period, and just 10 to 20 milligrams is good enough. Some other medications that have shown be beneficial are colchicine. And I normally use prednisone as my first line. 10 milligrams is a really tiny dose is mighty effective. I really found all my patients respond very well to it.

I've not really used colchicine for this purpose, but the literature does indicate that colchicine can be used. And you can start at 0.6 milligrams once a day and increase the dose to about 1.2 milligrams. So that 0.6 milligrams twice a day. Dapsone is another medication that people have tried. You can take 25 to 50 milligrams once a day. Again, the duration of treatment should not be more than 14 days with these medications. If one is using dapsone, one should definitely make sure that they check the patient's CBC because if the patient does have G6PD deficiency or something like that, they can have hemolysis. So those are the important treatment aspects for, with regard to oral ulcer.

Jessica Bard: Talk to us about some important malignant and premalignant lesions of the oral cavity?

Dr Amit Correa: Some important premalignant lesions of the oral cavity is, one condition is called oral leukoplakia. Now, these are white lesions that can present over the oral cavity and the white membrane over these lesions cannot be wiped out. Now, if you do have candida or something like that, and you do have white lesions associated with Candida, the white lesion can be the whiteness or the white membrane over the lesion can be sled off, but with oral leukoplakia, this is not possible. So if a lesion does appear like oral leukoplakia, that means you see a white lesion that cannot be wiped off. And if this lesion tends to persist over greater than six weeks, then one should definitely consider oral leukoplakia, which can be predisposed to form cell carcinoma on the tongue and refer the patient to an expert for further treatment.

Another condition is called erythroplakia. Now erythroplakia is not that common. It's an uncommon oral lesion that appears rather red for erythematosus. And again, it can predispose to Squamous Cell Carcinoma and a malignant condition of the oral cavity. So again, one should be very careful when they see these kind of lesions. And again, monitor these lesions closely. These lesions tend to persist more than six weeks. At that point, it is important to refer the patient to an expert,

Jessica Bard: What blood conditions can lead to oral ulcers or lead to lesions in the mouth?

Dr Amit Correa: So, with regard to blood conditions that can lead to lesions in the mouth, which is we start with vitamin deficiencies. Because a lot of vitamins like B12 deficiency, in particular, even sometimes iron deficiency can cause oral ulcers and some kind of conditions or lesions in the mouth, and they can also be associated with anemia. So we, as a hematologist should be aware that when we see oral ulcers along with anemia, one should consider B12 or iron deficiency. The other conditions that can lead to oral ulcers is neutropenia. For patients that have low neutrophil counts. They can have oral ulcer as well. There's a condition called cyclic neutropenia in this particular condition. When patients have a low neutrophil count, they can actually have some oral lesions. Then patients that have immunocompromised, patients that are getting chemotherapy patients that have some lymphocyte abnormalities patients that had a bone marrow transplant or something like that, or had any other form of transplant and our own immunosuppression, those patients who have oral ulcers as well.

Another condition that's not commonly seen is graft versus host disease. This can be seen after any form of transplant, like, bone marrow transplant, kidney transplant, liver transplant, and things like that. And those conditions can also manifest as oral ulcers. In addition to that, those patients can also have dryness of the mouth and the dryness of the eyes, which are indications of graft versus host disease. So those are some of the blood conditions or the hematologic conditions that can lead to oral ulcers.

Jessica Bard: Is there anything else that you'd like to add today?

Dr Amit Correa: So I think we went over the basics of oral ulcers. It is a condition that one would see commonly in a doctor's office. And it's important to know what should your evaluation be. When once these oral ulcers one should be aware of what is the most common cause of an oral ulcer. One should be aware of how to treat this particular condition. And one should definitely be aware to recognize any red flags that could indicate a malignancy like a erythroplakia, leukoplakia, or Squamous cell carcinoma of the oral cavity. So as long as at the primary care level, one takes care of these important issues, I think you'll do a good job at managing oral cells.

Jessica Bard: Well, perfect. Thank you so much for your time today. I appreciate you joining us on the podcast.

Dr Amit Correa: Thank you