Bryan C. Ego-Osuala and Duane Sewell

Diagnosis of lesions in the oral cavity can usually be made clinically, with biopsy reserved for suspected malignant lesions. A proper history and physical exam, however, are essential. To distinguish between the various causes of ulcers and lesions, several aspects of the history must be elucidated. History of lesion/ulcer: onset, duration, progression, pain, bleeding, changes in appearance. Other factors: trauma (eg, from poorly fitting dentures), risk factors for malignancy (EtOH and tobacco use), autoimmune disease, history of previous lesion, taste or sensory disturbances, hoarseness, sore throat, trismus, fever, or malaise.

Lesions That Present as Ulcers

Pemphigus vulgaris: Autoimmune disease. Can affect mucosa of oral cavity, nasal cavity, pharynx and larynx. Typically seen in older adults in the fifth decade and above. It is a chronic illness, and typically presents as erosions, blisters, and ulcerations. The blisters tend to be short lived, and as old blisters rupture and collapse, new ones form. These ruptured lesions ulcerate and cause pain.

Cicatricial pemphigoid or mucous membrane pemphigoid: Also an autoimmune disease. Can affect the oral cavity, nasal cavity, pharynx, and larynx. These usually present as patchy distribution of erythematous vesicles and bullae, usually beneath a collapsed bulla as an ulcer. The lesions have a predilection for the palate and gingiva. It is less commonly seen on the buccal mucosa.

Bullous pemphigoid: Chronic autoimmune skin disease involving the formation of blisters below the surface of the skin and antibodies against the type XVII collagen component of hemidesmosomes. It can also involve the mucous membranes in the head and neck, but only rarely.

Herpes simplex virus: This will be covered in the inflammation section but these very shallow painful ulcers present as small vesicles on the oral mucosa that are short lived and quickly become ulcers with a surrounding erythematous ring.

Aphthous stomatitis (canker sores): Usually seen on the labial, buccal, ventral tongue, floor of mouth, lateral tongue, soft palate, and tonsillar pillars. According to studies, this is prevalent in people of high socioeconomic status, nonsmokers, and members of professional groups. They can be very painful, but they typically last 7 to 10 days. They heal without scarring.

Erythema multiforme (EM): This is a self-limiting mucocutaneous hyper-sensitivity reaction characterized by cutaneous or oral cavity ulcerations. Usually involves the mucosa in a symmetrical distribution. On close examination, you will see target or iris lesions that are usually irregular in size.

Malignancy: Any nonhealing ulceration could potentially represent carcinoma and should be biopsied or referred to an otolaryngologist for biopsy and definitive diagnosis. The most common cancer in the oral cavity is squamous cell carcinoma. Risk factors include smoking and drinking alcohol.