1. Oral Ulcers

1.1 Epidemiology

• Aphthous ulcers are the most common cause of oral ulceration.
• Occur in up to one-third of the normal population, often recurrent.
• More severe cases may be associated with systemic diseases.

1.2 Aetiology

• Aphthous (Recurrent) Ulcers:
  • Typically superficial breaches of the oral mucosa (lips, tongue, gums, buccal membranes).
  • Can be triggered by minor trauma, stress, or spontaneously.
• Other Causes (when there are systemic features or atypical patterns):
  • Crohn’s disease
  • Coeliac disease
  • Behçet’s syndrome (characterised by oral ulcers, genital ulcers, and uveitis)
  • Erythema multiforme
  • Lichen planus
  • Herpes simplex, syphilis, Vincent’s angina

1.3 Risk Factors

• General risk factors for aphthous ulcers include:
  • Emotional or physical stress
  • Minor mucosal trauma
  • Possibly immunological predisposition
• Systemic conditions (e.g. inflammatory bowel diseases, coeliac disease, Behçet’s) can predispose to more frequent or severe ulceration.

1.4 Clinical Features

• Painful, shallow ulcers in the oral mucosa (e.g. lips, tongue, buccal membranes).
• Lesions typically have a greyish base surrounded by erythema.
• May present as single or multiple ulcers.
• In recurrent or severe ulcers, consider underlying systemic disease if additional symptoms (e.g. GI, skin, ocular) are present.

1.5 Diagnostic Approach

1. Clinical Examination
   • Usually diagnosed by characteristic appearance.
   • Evaluate for potential systemic disease if presentation is atypical or if ulcers are severe and recurrent.
2. Consider Further Tests if:
   • Ulcers are persistent beyond 3 weeks (biopsy to exclude malignancy).
   • Systemic features suggest an underlying condition (e.g. coeliac disease, Crohn’s).

1.6 Immediate Management

• Mouth Care:
  • Antiseptic mouthwashes (e.g. chlorhexidine) to prevent secondary infection.
  • Topical salicylates or topical corticosteroids to reduce pain and inflammation, enabling rapid healing.
• Symptomatic Relief:
  • Use of topical analgesic preparations.
  • Avoid acidic or abrasive foods/drinks that aggravate discomfort.

1.7 Long-Term Management

• Most mild ulcers heal spontaneously and need no further intervention.
• Severe or recurrent ulcers:
  • Oral steroids in rare, severe cases to induce remission.
  • Assess and manage any underlying systemic illness (e.g. coeliac, Crohn’s, Behçet’s).
• Lifestyle measures:
  • Minimise oral trauma (gentle toothbrushing, soft diet if necessary).
  • Reduce stressors if possible.

1.8 Prognosis / Complications

• Simple aphthous ulcers typically resolve spontaneously within 1–2 weeks.
• Frequent recurrences can impact quality of life, cause pain, and interfere with eating/drinking.
• Malignancy is very rare, but any ulcer persisting beyond 3 weeks should be biopsied to exclude possible cancer.

2. Oral Cancer

2.1 Epidemiology

• Oral cancer (typically squamous cell carcinoma) is increasing in incidence.
• Common worldwide, with higher rates in regions where tobacco or betel nut chewing is prevalent.

2.2 Aetiology

• Squamous cell carcinoma is most often linked to mucosal surfaces of the oral cavity.
• Key aetiological factors:
  1. Smoking or tobacco chewing
  2. Alcohol excess
  3. Malnutrition
  4. Betel nut chewing (particularly in Asian populations)

2.3 Risk Factors

• Tobacco use (cigarettes, cigars, chewing tobacco)
• Alcohol (especially when combined with tobacco)
• Poor nutritional status
• Chronic irritation (potentially from betel nuts)
• Leukoplakia or erythroplakia in the mouth (pre-malignant lesions)

2.4 Clinical Features

1. Presentation
   • Lump in the mouth or jaw
   • Ulcerated lesion on the oral mucosa
   • White patch in the mouth (leukoplakia), which may represent dysplasia
   • Occasionally red patch (erythroplakia) – often more suspicious than leukoplakia
2. Cervical lymphadenopathy
   • Often a sign of late presentation or metastatic spread

2.5 Diagnostic Approach

1. Clinical Examination
   • Detailed inspection and palpation of the oral mucosa, tongue, and floor of mouth
   • Note any non-healing ulcers or suspicious white/red patches
2. Biopsy of suspicious lesions
   • Confirms squamous cell carcinoma or its precursors (dysplasia)
3. Additional Imaging (e.g. CT, MRI)
   • Assesses local extent and any regional lymph node involvement

2.6 Immediate Management

• Referral to a specialist (ENT or maxillofacial surgeon) if malignancy is suspected.
• Biopsy and staging investigations if not already performed.
• Nutritional support if intake is compromised by pain or ulceration.

2.7 Long-Term Management

• Radical Radiotherapy is often the primary treatment for localised disease, especially when aiming to preserve structure and function.
• Surgical Resection may be required, which can be extensive and involve complicated reconstruction.
• Combined Modalities (surgery + radiotherapy ± chemotherapy) depending on stage and location.
• Follow-up for detection of recurrences and management of sequelae (e.g. swallowing difficulties, speech issues).

2.8 Prognosis / Complications

• Late presentation with nodal involvement significantly worsens prognosis.
• Metastatic spread typically to cervical lymph nodes.
• Potential for local invasion causing difficulty in speaking, eating, or significant cosmetic impact.
• Early detection is crucial for better outcomes.