Assessment of oral ulceration

acknowledgement or recollection of traumatic incident such as biting of the cheek or tongue; impingement from a sharp object (e.g., bone, pen, pencil); exposure to hot or cold (e.g., hot liquid, ice)

mucosal ulceration corresponding to site of insult

possible acute or chronic mouth pain (particularly on eating and drinking); concurrent skin lesions may be present

most commonly affected oral site is buccal mucosa, followed by tongue, lips, floor of mouth, palate, and gingiva; multiple bilateral and symmetrical lesions that may manifest as singular or variable mix of reticular (line, papule, plaques), atrophic, or ulcerative lesions; typical lacey white striations (Wickham's striae) usually present

recent exposure to triggering agent and temporal association with onset of oral pain or ulceration; resolves when inciting agent is withdrawn; resistant to usual treatments

solitary or multiple areas or non-specific erythema, vesicle formation, aphthous-like ulcer; cheek, lips, tongue frequently affected

recurrent (since childhood) solitary or multiple painful acute outbreaks that invariably heal within weeks to months; absence of other comorbidities; prodrome symptoms including altered sensation and swelling

minor recurrent aphthous stomatitis (RAS): 1-10 ulcers, <1 cm diameter, characteristic pseudomembranous covering, intense erythematous margin; major RAS: ulcers are deeper and may be irregular in shape, >1 cm diameter; herpetiform RAS: characterised by successive crops of small 1- to 3-mm round, shallow ulcers

often asymptomatic; history of dental trauma, infection, or untreated dental disease

singular ulcerated papule (‘gum boil’), often with evident drainage; obvious broken-down tooth or restoration; maxillary gingiva most commonly affected site; sinus tract (parulis)

mouth pain; possible prodromal fever, malaise, myalgia, loss of appetite, dysphagia, headache with primary infection; possible prodromal itching or burning with recurrent or secondary infection; possible antecedent trauma (e.g., injection, thermal burn)

primary infection: widespread vesicular eruption affecting all oral mucosal tissues; lymphadenopathy may be present; characteristic inflamed gingiva (erythematous and oedematous); recurrent (secondary infection): localised painful vesicular eruption limited to keratinised mucosa, absence of systemic signs and symptoms

any age may be affected, but most typically children <5 years old; prodromal symptoms of fever, malaise, headache, and neck or back pain may be present

characteristic pattern of 1- to 2-mm grey-white papulovesicular lesions affecting anterior tonsillar pillars, soft palate, uvula, and tonsils; typical uneventful resolution within 7 days

brief prodrome of low-grade fever, malaise, cough, anorexia, abdominal pain, and sore mouth; affects children <10 years old

non-specific 2- to 8-mm vesicles that erupt to form yellow-grey ulcers with erythematous halos, most frequently on the palate, tongue, and buccal mucosa; cutaneous 2- to 3-mm papules affecting hands and feet; typically resolves within 10 days

temporal association or suspicion of medical or dental procedure involving area of concern; many cases not apparent until after recovery from local or general anaesthesia; sources include instrumental (e.g., rotary, laser, electrosurgical, blade) and physical (e.g., newly placed appliances, stents, brackets ) insult

localised oedema, erythema, or ulceration corresponding to site of insult

high suspicion in patient with underlying predisposition (e.g., genetic disorders such as Lesch-Nyhan's, Cornelia de Lange's, Tourette's, familial dysautonomia, congenital insensitivity to pain, XXXXY syndrome, XXY syndrome, trisomy disorders), psychiatric illness (Munchausen), encephalitis, coma, bulbar palsy, autism, intellectual disability; patient awareness varies from none, as may occur with encephalitis, to compulsive, as may occur with mental illness; recurrent

non-specific oral ulcers; most likely affecting tongue, cheeks, lips

female predilection; prior anaemia, dieting, and/or alcoholism; possible history of absorptive disorders (e.g., Crohn's disease, coeliac disease, ulcerative colitis); constitutional signs and symptoms of pallor, fatigue, malaise, shortness of breath, headache, irritability

chronic ulcerations often affecting the tongue (glossitis), angular cheilitis, mucosal pallor, tachycardia

prior anaemia, dieting, and/or alcoholism; possible history of absorptive disorders (e.g., Crohn's disease, coeliac disease, ulcerative colitis); constitutional signs and symptoms of pallor, fatigue, malaise, burning mouth, neuropathy, paraesthesia, depression, psychosis

chronic, non-specific mucosal ulcerations; beefy red tongue; angular cheilitis

prior anaemia, dieting, and/or alcoholism; possible history of absorptive disorders (e.g., Crohn's disease, coeliac disease, ulcerative colitis); constitutional signs and symptoms of pallor, fatigue, malaise, burning mouth, neuropathy, paraesthesia, depression, psychosis

chronic, non-specific mucosal ulcerations; beefy red tongue; angular cheilitis

prior anaemia, dieting, and/or alcoholism; possible history of absorptive disorders (e.g., Crohn's disease, coeliac disease, ulcerative colitis); symptoms of fatigue, bruising, and bleeding gums

gingival oedema, bleeding, and ulcerations; secondary bacterial infections; loosening of teeth

acute or chronic mouth pain; concurrent skin lesions may be present

predominant oral involvement of tongue, buccal mucosa, and gingiva

acute or chronic mouth sores; concurrent skin or eye lesions may be present; cancer may be present

solitary or multiple variably sized and irregularly shaped ulcerations; most common on buccal mucosa, tongue, and palate; lesions on nasopharynx or oesophagus may be present; positive Nikolsky's sign; intact bullae may be present

acute or chronic mouth sores; ocular symptoms (conjunctivitis, symblepharon), and concurrent skin lesions may be present

flaccid bullae; irregular erosions and ulcerations; common on gingiva, buccal mucosa, tongue, and palate; gingiva are often friable, fiery red, and atrophic (desquamative gingivitis); positive Nikolsky's sign

acute or chronic mouth sores; conjunctivitis and concurrent skin lesions may be present; typically distributed over the trunk and extremities

lesions characteristically resemble a string of pearls (urticarial plaque surrounded by vesicles); flaccid bullae; irregular erosions and ulcerations; common on gingiva, buccal mucosa, tongue, and palate; gingiva are often friable, fiery red, and atrophic (desquamative gingivitis); positive Nikolsky's sign

acute or chronic mouth sores; ocular symptoms (conjunctivitis, symblepharon) and concurrent skin lesions may be present

flaccid bullae; irregular erosions and ulcerations; common on gingiva, buccal mucosa, tongue, and palate; gingiva are often friable, fiery red, and atrophic (desquamative gingivitis); positive Nikolsky's sign; scarring, restricted oral opening, and ankyloglossia may be present in severe cases

acute or chronic mouth sores; identifiable trigger; possible temporal association to recent change in medication, oral hygiene product, or restorative material; removal of trigger leads to resolution, may take months to heal

multiple bilateral and symmetrical lesions that may manifest as singular or variable mix of reticular (lines, papules, plaques), atrophic, or ulcerative lesions; lacey white striations (Wickham's striae) are invariably present; asymmetrical localised involvement highly suggestive of contactant response

prior or ongoing exposure to anti-resorptive drugs; antecedent intra-oral trauma (e.g., dentoalveolar surgery) noted in most patients; pain is frequently noted; high risk in oncology patients exposed to prolonged dosing of the most powerful nitrogen-containing bisphosphonates; patients exposed to low-dose anti-resorptive drug (e.g., osteoporosis prevention) are at much lower risk

solitary or multiple areas of mucosal ulceration with exposed necrotic bone; mandible more frequently involved than maxilla

temporal association with use of oral rinses, topical medications, or disinfectants; inappropriate medication use (e.g., excess mouthwash exposure, placing aspirin tablet in cheek); ongoing or recent exposure to cancer chemotherapeutic agents that adversely affect normal proliferation and repair of mucosal tissues (e.g., alkylating agents, antimetabolites that affect DNA synthesis, anthracyclines, platinum-based agents, vinca alkaloids, and taxanes)

localised oedema, erythema, or ulceration corresponding to site of insult; may be severe with cancer chemotherapeutic agent exposure

typical abrupt onset of mouth and lip ulcers ± cutaneous lesions; may be recurrent; exhaustive enquiry into antecedent exposure to drugs, toxins, infection, immunisation indicated

erythema multiforme minor: mainly cutaneous presentation with typical target lesions; symmetrical distribution; predilection for extensor surfaces; <10% body surface affected; mild oral erosions and ulcerations; erythema multiforme major: similar cutaneous lesions but more widespread and severe; oral mucosa usually affected; <10% body surface affected

typical abrupt onset of mouth and lip ulcers ± cutaneous lesions; possible ocular and/or genital lesions; may be recurrent; exhaustive enquiry into antecedent exposure to drugs, toxins, infection, immunisation indicated; constitutional signs and symptoms of pallor, fatigue, malaise, shortness of breath, headache, irritability

Stevens-Johnson syndrome: cutaneous involvement more severe and widespread than in erythema multiforme major; atypical flat target lesions; multiple mucosal sites involved; tachycardia; toxic epidermal necrolysis: extensive cutaneous involvement (10% to ≥30% body surface affected); poorly defined lesions with extensive epidermal detachment; mucosal lesion similar to Stevens-Johnson syndrome; tachycardia

rare; history of trauma or exposure to a chemical or biological agent

extensive deep ulcers with indurated borders located in hard or soft palate

onset usually in third to fourth decade of life; possible family history of the condition

oral ulcers, uveitis, genital ulcers; aphthae appear in oral cavity on oral mucosa, gingiva, lips, soft palate, and pharynx

rare; includes mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome, periodic fever with aphthous stomatitis, pharyngitis and adenitis (PFAPA) syndrome, tumour necrosis factor receptor-associated periodic syndrome (TRAPS)

aphthous-like ulcerations in association with fever, pharyngitis, and lymphadenopathy

rare; peripheral arthritis; axial arthritis

aphthous-like ulcerations in association with inflammation of a large joint (e.g., knee), inflammation of eyes (conjunctivitis and uveitis), and urethritis

constitutional symptoms of fatigue, fever, and weight loss are common

oral lesions occur with skin lesions and are ulcerated or atrophic, erythematous with a central zone, surrounded by white, fine, radiating striae; ulcers may have fine stippling of white dots; tendency of ulcers to bleed; skin lesions may be in butterfly pattern

headache; jaw claudication; scalp tenderness; acute visual loss; involvement of lingual artery may lead to tongue ischaemia and ulceration

ulcerative necrosis of affected area; tongue most common intra-oral site

non-specific symptoms of fatigue, lethargy, loss of appetite, fever, night sweats; upper respiratory complaints (e.g., severe rhinorrhoea, allergic rhinitis, epistaxis, oral or nasal ulceration, cough, otalgia, otitis, fever)

hyperplastic petechiae-laden (strawberry) gingivitis; destructive ulceration with possible extension to palate

prior haematopoietic stem cell transplantation

oral features mimic those of lichen planus (lichenoid changes), Sjogren's disease (dry mouth), and scleroderma (fibrosis and reduced oral range of motion)

recent onset of gingival pain; 'dead feeling' in teeth; common predisposing stressful event (e.g., overwork, excess libation, poor diet); smoker; quick response to therapy

characteristic punched-out crater-like gingival ulcers; spontaneous gingival haemorrhage; possible fetor oris, pseudomembrane formation; fever; malaise; sub-mandibular lymphadenopathy

acknowledgement or suspicion of high-risk behavioural habits that may have led to exposure to infection; possible influenza-like symptoms; minimal discomfort

primary syphilis: oral chancre presents as solitary painless indurated ulceration persisting 3-7 weeks and healing without scarring; most likely sites of involvement are lips, tongue, commissures, gingiva, palate, and tonsils; lymphadenopathy common; secondary syphilis: mucous patches presenting as shallow, irregularly shaped plaques or ulcerations with erythematous borders; grey-white necrotic membrane covering may be present; snail track appearance; concurrent cutaneous rash; genital lesions; tertiary syphilis: locally destructive granulomas (gummas) or glossitis may be present with mucosal atrophy

acknowledgement or suspicion of high-risk behavioural habits that may have led to exposure to infection; recent history of fever, chills, malaise; genital involvement (pain on urination, discharge)

multiple non-specific fiery red ulcerations; possible white pseudomembrane; lymphadenopathy may be present

oral pain; underlying immunodeficiency condition acknowledged or suspected; high-risk demographic (e.g., homeless, institutionalised, intravenous drug abuse); fever, malaise, fatigue, night sweats, anorexia, chronic and/or productive cough

painful granulomatous ulceration; lymphadenopathy may be present; lesions may be locally destructive and mimic squamous cell carcinoma; common sites of occurrence are tongue, palate, buccal mucosa, or lip

localised mouth pain; concurrent cropping skin lesions if there is a primary VZV infection; recurrent or secondary VZV infections typically associated with immunosuppressive disorder or reduced innate immune function

uncommonly observed painful vesicular oral eruption with primary infection; recurrent or secondary VZV infection manifests painful vesicular eruption that often coalescences to form irregular shallow erosions

immunosuppressive condition usually present; fever, malaise, sore throat

oral lesions usually trivial; oral ulcers on posterior oropharynx; lymphadenopathy may be present

immunosuppressive condition such as HIV, uncontrolled diabetes mellitus, or advanced malignancy usually present

deep-seated ulcer, most commonly affecting tongue, palate, maxillary alveolar process; gingival involvement uncommon; palatal perforation from paranasal or sinus source is common; oral ulcerations, sinusitis, or facial cellulitis

immunosuppressive condition such as HIV, uncontrolled diabetes mellitus, advanced malignancy usually present

deep-seated ulcer, most commonly affecting tongue, palate, maxillary alveolar process; gingival involvement uncommon; palatal perforation from paranasal or sinus source is common; yellow or black lesions, with necrotic ulcerated base, typically located on palate or posterior tongue

immunosuppressive condition such as HIV, uncontrolled diabetes mellitus, advanced malignancy usually present

deep-seated ulcer, most commonly affecting tongue, palate, maxillary alveolar process; gingival involvement uncommon; palatal perforation from paranasal or sinus source is common; chronic nodular indurated or granular masses and ulceration; tissue destruction with bone erosion; major oral sites are mucosa, tongue, palate, and gingiva

immunosuppressive condition such as HIV, uncontrolled diabetes mellitus, advanced malignancy usually present

deep-seated ulcer, most commonly affecting tongue, palate, maxillary alveolar process; gingival involvement uncommon; palatal perforation from paranasal or sinus source is common; single or multiple mucosal ulcerations; sessile projections; granulomatous or verrucous lesions

predominantly occurs in Central and South America; typical pulmonary, mucocutaneous, or disseminated systemic disease; oral lesions are common, most of which are secondary and arise from inoculation of infected sputum

oral lesions are commonly observed and typically manifest as oral ulcerative granulomas affecting any part of oral cavity

profound fatigue, fever, malaise, sore throat

oral lesions usually trivial; oral ulcers on posterior oropharynx; lymphadenopathy may be present

exposure to risk factors such as tobacco and alcohol, or other recognised risk factors (e.g., human papillomavirus infection, poor diet, immunosuppressive condition); sore mouth; symptoms of more advanced disease: bleeding, loosening of teeth, difficulty wearing dentures, dysphagia, dysarthria, odynophagia, development of neck mass

non-specific white, red, or red and white mucosal changes with or without ulceration; most commonly affected sites are ventrolateral border of tongue, floor of mouth, and soft palate

rapid growth or a sudden growth spurt; pain and neural involvement

firm, nodular lesions; can be fixed to adjacent tissue, often with a poorly defined periphery

fever, drenching night sweats, weight loss, malaise, loss of appetite, red patches on skin, severely itchy skin, often affecting legs/feet

cachexia, lymphadenopathy (most commonly cervical and supraclavicular, but also inguinofemoral and axillary)

history of immunocompromise (e.g., HIV); cutaneous lesions are usually painless and non-pruritic; oral lesions can bleed, ulcerate, and affect mastication, speech, and swallowing

skin lesions are papular, nodular, plaque-like, bullous-like, or fungating with skin ulceration and secondary infection; multifocal and asymmetrically distributed, vary in size (from several millimetres to centimetres in diameter) and colour (pink, red, purple, brown, or blue); long-standing lesions may become indurated (woody) and hyperkeratotic; oral lesions affect the hard palate, gingiva, and dorsum of tongue; present as macules, papules, nodules, and exophytic masses of varying size and colour; advanced lesions may become ulcerated from masticatory trauma and secondary infection; lymphadenopathy

asymptomatic in early stages; loosening of teeth, bleeding, ulceration, and pain may occur in later stages

pigmented or amelanotic lesion (white, red, or mucosa-coloured) of varying size (1 mm to ≥1 cm) in oral cavity; usually macular; predominantly affecting the palate and maxillary gingiva

a characteristic rash that typically progresses in sequential stages (from macules, to papules, vesicles, and pustules); anorectal symptoms have been reported (e.g., severe/intense anorectal pain, tenesmus, rectal bleeding, or purulent or bloody stools, pruritus, dyschesia, burning and swelling) in recent outbreaks, and may occur in the absence of a rash; fever may be a symptom of the prodromal period (usually preceding the appearance of the rash), but may present after the rash or not at all; other common symptoms may include myalgia, fatigue, asthenia, malaise, headache, sore throat, back ache, cough, nausea/vomiting, oral/oropharyngeal ulcers; there may be a history of recent travel to/living in endemic country or country with outbreak, or contact with suspected, probable, or confirmed case within the previous 21 days before symptom onset

rash or skin lesion(s) are usually the first sign of infection; physical examination may reveal a rash or lesion(s), and possibly lymphadenopathy; rash generally starts on the face and body and spreads centrifugally to the palms and soles (it may be preceded by a rash affecting the oropharynx and tongue in the 24 hours prior that often passes unnoticed); lesions simultaneously progress through four stages - macular, papular, vesicular, and pustular - with each stage lasting 1-2 days, before scabbing over and resolving; lesions are typically 5-10 mm in diameter, may be discrete or confluent, and may be few in number or several thousand; vesicles are well-circumscribed and located deep in the dermis; the rash may appear as a single lesion in the genital or perioral areas without a prodromal phase; perianal/rectal lesions and proctitis may be present​; lymphadenopathy typically occurs with onset of fever preceding the rash or, rarely, with rash onset, may be submandibular and cervical, axillary, or inguinal, and occur on both sides of the body or just one side; inguinal lymphadenopathy has been commonly reported