Clinical Review

ABC of oral health

Mouth ulcers and other causes of orofacial soreness and pain

BMJ 2000; 321 doi: 10.1136/bmj.321.7254.162 (Published 15 July 2000)
Cite this as: BMJ 2000;321:162

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  1. Crispian Scully,
  2. Rosemary Shotts

    Ulcerative conditions

    Mouth ulcers are common and are usually due to trauma such as from ill fitting dentures, fractured teeth, or fillings. However, patients with an ulcer of over three weeks' duration should be referred for biopsy or other investigations to exclude malignancy (see previous article) or other serious conditions such as chronic infections.

    Main systemic and iatrogenic causes of oral ulcers

    Microbial disease

    • Herpetic stomatitis

    • Chickenpox

    • Herpes zoster

    • Hand, foot, and mouth disease

    • Herpangina

    • Infectious mononucleosis

    • HIV infection

    • Acute necrotising gingivitis

    • Tuberculosis

    • Syphilis

    • Fungal infections

    Cutaneous disease

    • Lichen planus

    • Pemphigus

    • Pemphigoid

    • Erythema multiforme

    • Dermatitis herpetiformis

    • Linear IgA disease

    • Epidermolysis bullosa

    • Chronic ulcerative stomatitis

    • Other dermatoses

    Malignant neoplasms

    Blood disorders

    • Anaemia

    • Leukaemia

    • Neutropenia

    • Other white cell dyscrasias

    Gastrointestinal disease

    • Coeliac disease

    • Crohn's disease

    • Ulcerative colitis

    Rheumatoid diseases

    • Lupus erythematosus

    • Behcet's syndrome

    • Sweet's syndrome

    • Reiter's disease

    Drugs

    • Cytotoxic agents

    • Nicorandil

    • Others

    Radiotherapy

    Ulcers related to trauma usually resolve in about a week after removal of the cause and use of benzydamine hydrochloride 0.15% mouthwash or spray (Difflam) to provide symptomatic relief and chlorhexidine 0.2% aqueous mouthwash to maintain good oral hygiene.

    • Patients with a mouth ulcer lasting over three weeks should be referred for biopsy or other investigations to exclude malignancy or other serious conditions

    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 grey floors. It affects at least 20% of the population, and its natural course is one of eventual remission. There are three main clinical types:

    Minor aphthous ulceration (top) and major aphthous ulceration (bottom)

    • Minor aphthous ulcers (80% of all aphthae) are less than 5 mm in diameter and heal in 7–14 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 …

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