Evaluation of oral ulceration in primary care

Introduction

Oral ulcers are common, with an estimated point prevalence of 4% in the United States.1 Aphthous ulcers may affect as many as 25% of the population worldwide. Patients with an oral ulcer may present initially to a general practitioner or a dental practitioner. Most ulcers are benign and resolve spontaneously but a small proportion of them are malignant. The incidence and prevalence of oral cancers varies across the world. The five year prevalence of oral cavity cancer in developed countries is 275 373 cases and in less developed countries 464 756 cases.2 Some of the highest incidences are seen in the Indian subcontinent, southern France, and South America. Importantly, the incidence of oral cancer is rising in most populations, particularly in young women. In the United Kingdom, around 2500 cases of oral cavity cancers are seen every year.

A community based, cluster randomised intervention trial has shown that early detection of an oral squamous cell malignancy reduces mortality. According to the UK Department of Health’s national referral guidelines for suspected cancer, a generalist may refer an oral ulcer that persists for more than three weeks to a specialist to be seen within two weeks of referral.3 An audit of 1079 such referrals, which showed that only 18% of patients referred had a malignancy, highlighted the difficulties encountered by health care practitioners in differentiating potentially malignant ulcers from benign ones.4 A recent study used a validated theoretical framework to evaluate general medical practitioners’ attitudes towards oral examination and found that lack of confidence, knowledge, and training contributed to difficulties in differentiation.5 The aim of this review is to provide a clinically oriented overview of the common causes of acute oral ulcers and to present …