Brief description of condition
Lesions on the lips or oral cavity that are usually, but not always, painful. Ulcers are caused by a number of conditions, most of which are benign (e.g. recurrent aphthous stomatitis, herpes viruses, hand foot and mouth disease). Other causes include include adverse reactions to drugs, nutritional deficiencies, some gastrointestinal diseases and, more seriously, oral cancer.
Key signs and symptoms
- Pain (lips and/or oral cavity)
- Abnormal appearance
If the ulceration is severe, some patients (e.g. children, elderly, infirm) may in addition be:
- Listless or agitated
If a patient presenting with oral ulceration is severely dehydrated, advise the parent/carer to seek emergency medical care.
If there are signs of dehydration (dizziness/lightheaded, tiredness, dry mouth, lips, eyes) advise the patient or parent/carer to seek urgent medical care.
Do not examine with ungloved hands because of potential infection risk with viral ulcers.
Determine how long the ulceration has been present.
If present 3 weeks or more
Refer the patient for urgent care via the local rapid access pathway to investigate potential dysplasia or malignancy.
When ulceration has been present for less than 3 weeks
- If ulceration is recurrent and self-limiting, advise the patient to use 0.2% chlorhexidine mouthwash and to seek non-urgent dental care. For children, recommend optimal analgesia, soft diet and advise that ulcers are likely to resolve within 1-2 weeks.
- If the patient is receiving drug treatment or has an underlying medical condition that might be the cause of the ulcer(s), advise them to seek urgent medical care. Refer to the Medical conditions and Drugs table below.
- If there are multiple ulcers present, advise the patient to seek non-urgent dental care. However, if the patient is also systemically unwell, advise them to seek urgent medical care.
- If ulceration is due to ill-fitting dentures, advise the patient to use 0.2% chlorhexidine mouthwash, to keep dentures out where possible and to seek non-urgent dental care (also refer to Ill-fitting or Loose Dentures).
- If there has been trauma from an adjacent tooth or orthodontic appliance, advise the patient to seek non-urgent dental care (also refer to Orthodontic Problems).
- If ulceration is likely to be due to trauma to anaesthetised tissue following recent treatment using local anaesthesia, advise the patient to avoid smoking, drinking hot liquids and biting the cheek or lip, and to see a dentist only if symptoms persist or worsen.
- If a single ulcer appears not to have been caused by trauma, advise the patient to use 0.2% chlorhexidine mouthwash until symptoms resolve or if the ulcer fails to heal within a week, to see a dentist within 7 days.
- Do not prescribe antibiotics unless there are signs of spreading infection, systemic complications, or for an immunocompromised patient.
In all of the above cases, recommend optimal analgesia, including prescription of topical analgesics (e.g. benzydamine oromucosal spray).
More common underlying medical conditions that may cause oral ulcerations
- Viral infections: Herpetic stomatitis, Chicken pox, Hand, foot and mouth disease, Herpangina, HIV
- Bacterial infections: Syphilis, Tuberculosis
- Mucocutaneous diseases: Lichen planus, Erythema multiforme, Behcet's syndrome, Pemphigus vulgaris, Pemphigoid and variants, Chronic Ulcerative stomatitis
- Haematological diseases: Anaemia, Haematinic deficiencies, Leukaemia, Neutropenia
- Gastrointestinal disease:Coeliac disease, Crohn's disease, Ulcerative colitis
Drugs that might cause oral ulceration include:
- Non-steroidal anti-inflammatories, Nicorandil, Beta blockers, Methotrexate, Cytotoxic drugs, Sulphonamides, Sulfasalazine, Anticonvulsants (such as phenobarbital, phenytoin carbamazepine), Allopurinol, Penicillin , Gold, Penicilamine.
- Fixing ill-fitting dentures if appropriate.
- Prescribing a topical steroid.
- Referring to the local rapid access pathway to investigate potential dysplasia or malignancy if symptoms persist.
- Referral to a dermatologist or an oral medicine specialist if vesiculobullous disorder is suspected.
In cases of primary herpetic gingivostomatatitis or herpes zoster infection, if the symptoms are severe or the patient is immunocompromised, consider prescribing antiviral agents (acyclovir or penciclovir, see SDCEP Drug Prescribing for Dentistry guidance for doses), ideally in the early stages.
Refer to a general medical practitioner if the patient has an underlying medical condition and is receiving a drug that may be the cause of ulceration.
- Scully C, Shotts R. Mouth ulcers and other causes of orofacial soreness and pain. BMJ 2000; 321: 162-5.
- Warnakulasuriya S, Johnson NW, van der Waal I. Nomenclature and classification of potentially malignant disorders of the oral mucosa. J Oral Pathol Med 2007; 36(10): 575-80.
- SDCEP. Drug prescribing for dentistry: dental clinical guidance, 2nd edition. Dundee: Scottish Dental Clinical Effectiveness Programme; 2011
Chlorhexidine mouthwash is not suitable for children under 7 years old.
The maximum recommended dose of painkillers that takes into account the patient's age and is within the normal safe limits.