Difficult and complicated oral ulceration: an expert consensus guideline for diagnosis

Abstract

The complexity of oral ulcerations poses considerable diagnostic and therapeutic challenges to oral specialists. The expert consensus was conducted to summarize the diagnostic work-up for difficult and complicated oral ulcers, based on factors such as detailed clinical medical history inquiry, histopathological examination, and ulceration-related systemic diseases screening. Not only it can provide a standardized procedure of oral ulceration, but also it can improve the diagnostic efficiency, in order to avoid misdiagnosis and missed diagnosis.

Fig. 1

Typical clinical features of some types of oral ulcers

Fig. 2

Diagnostic work-up for difficult and complicated oral ulcers

Fig. 3

A 22-year-old man with oral ulcers for 3 days. Widespread necrotic ulcers on the left maxillary gingiva, extending to the hard palate, with smooth and thick yellowish-white pseudomembrane. Full blood count showed the percentage of neutrophilic segmented granulocytes decreased significantly (2.0%). Then the bone marrow biopsy and immunotyping revealed acute monocytic leukemia, type M5

Fig. 4

A 25-year-old woman with ulcer for 2 months. Serious erosion and necrosis on the upper labial mucosa, extending to anterior maxillary gingiva covered by yellowish-white pseudomembrane. HE staining and immunohistochemical studies of the biopsy supported the diagnosis of nasal-type extranodal NK/T-cell lymphoma

Fig. 5

A 72-year-old man with palatal ulceration for 3 months. Widespread ulcers and masses on the palate and maxillary palatal gingiva, extending to the posterior part of the soft palate. He denied the history of systemic diseases. HE staining of repeated oral biopsies showed infiltration of neutrophils and chronic inflammation. Further detailed history inquiry revealed that he developed tuberculosis over a decade ago and was cured after the treatment. We suggested him to take specimen to the superior pathologists for consultation. Granulomatous inflammation containing Langhans-type giant cells was identified, raising the possibility of granulomatous infection. Ziehl-Nielsen staining showed acid-fast bacilli. A chest x-ray revealed bilateral upper lobe consolidation and cavitation, consistent with pulmonary tuberculosis. The definitive diagnosis of oral tuberculosis was established. The ulcers healed, and masses gradually resolved after a combination of isoniazid, rifampicin, pyrazinamide, and ethylaminobutanol for 1 month

Fig. 6

A 13-year-old boy with recurrent oral ulcers for 3 years, reappear 1 month. A 1.3 × 1.5 cm ulcer on the left buccal mucosa, covering with yellowish-white pseudomembrane. Inflammatory ulcer was confirmed pathologically. Further detailed history inquiry of intestinal diseases revealed that he had abdominal pain when oral ulcers occurred. Colonoscopy showed irregular ulcers located on ileocecal and terminal ileum. And he was confirmed as Crohn’s disease by intestinal mucosal biopsy. There was no recurrence of oral ulcer after the treatment of Crohn’s disease

Fig. 7

A 72-year-old woman with oral ulcer for 1 month. A 2.0 × 2.4 cm ulcer located on the left buccal mucosa, without apparent inflammation response of surrounding tissues. She was general weakness, and under inoperable conditions, who had the history of angioimmunoblastic T-cell lymphoma, hypertension, diabetes, intracoronary stent implantation and cataract surgery. Due to her high blood glucose level, invasive fungal infection was suspected. The level of 1-3-β-D-glucan and galactomannan increased significantly, probable diagnosis of invasive fungal infection was made. The ulcer healed after infusion of caspofungin