Oral Ulceration
On this page
Direct answer
Any oral ulcer that persists beyond three weeks demands a biopsy, because that single rule separates the several self-limiting ulcerative conditions from squamous cell carcinoma, the diagnosis no one can afford to watch. The commonest cause overall is recurrent aphthous stomatitis, of which the minor form accounts for the great majority: small, painful ovals on non-keratinized mucosa healing within a fortnight. Traumatic ulcers follow sharp teeth, ill-fitting dentures and habits; infective ulcers accompany tuberculosis and other systemic infections; and a handful of characteristic syndromes — Behçet's, PFAPA, cyclic neutropenia — announce themselves through the mouth. Diagnosis rests on site, duration, character of the edges and response to removing the suspected cause.
What you must remember
- Minor aphthous ulcers: under about 1 cm, on labial and buccal mucosa, floor of mouth and soft palate, heal in 10–14 days without scarring and account for roughly 80 per cent of recurrent aphthae.
- Major aphthae (Sutton's disease): over 1 cm, last weeks to months, heal with scarring, and involve movable mucosa including the soft palate and tonsillar fossa.
- Herpetiform aphthae: crops of 10 to 100 pinpoint ulcers, mostly in older patients, heal without scarring despite the herpes-sounding name and have no relation to herpes simplex virus.
- Screen every recurrent aphthous patient for haematinic deficiency (iron, folate, vitamin B12), coeliac disease and, with genital ulcers and uveitis, Behçet's disease.
- PFAPA syndrome — periodic fever, aphthae, pharyngitis and cervical adenitis — is the paediatric classic; cyclic neutropenia recurs on an almost clockwork 21-day cycle with ulcers appearing as counts fall.
- Traumatic ulcers: ragged, yellow-based, minimally indurated lesions near an obvious cause; remove the cause and they heal within about two weeks — persistence beyond that window mandates biopsy.
- Riga-Fede ulceration is traumatic ulceration of the ventral tongue from natal or neonatal teeth; necrotizing sialometaplasia is the painless, deep, self-healing palatal ulcer that mimics carcinoma and must be biopsied to avoid radical overtreatment.
How to work through a non-healing ulcer
Take a 52-year-old with a three-month ulcer on the lateral tongue. Step one, the history: site, duration, habits — tobacco, areca nut, alcohol — and any prior episodes of healing ulcers at the same spot. Step two, examination: measure and map the ulcer, palpate for induration, roll the edges between fingers, examine the cervical nodes and check the teeth and denture flanges adjacent to the lesion. Step three, act on the rule: three weeks of persistence, or induration or fixed nodes at any time, means incisional biopsy including the ulcer margin and adjacent normal tissue with underlying connective tissue — never a swab, never a wait-and-watch. If the biopsy shows only a non-specific ulcer with a cause you can see, remove the cause and review at two weeks. For the patient with recurrent crops of small ulcers instead, the pathway turns investigative: complete blood picture with haematinics, coeliac serology where suggestive, and a symptom diary to catch periodicity; most minors need only topical steroids and reassurance, while haematinic correction in deficient patients halves the recurrence rate in a gratifying proportion of cases.
The three-week trap
The trap is not ignorance but impatience dressed as reassurance. A dentist attributes a tongue ulcer to a sharp tooth, smooths the cusp, and reviews in one week; the ulcer improves slightly, so the review extends; three months later the node appears. The correct discipline is to give any traumatic hypothesis exactly one two-week trial after removing the cause — then biopsy regardless of the appearance of healing, because carcinoma can crater and partially epithelialize while continuing to advance. The mirror-image error is panicking over every aphthous ulcer: recurrent, multi-site, non-indurated ulcers that heal completely between episodes in a young patient are not cancer, and biopsying each one adds nothing but scarring.
Frequently asked questions
What are the three types of recurrent aphthous stomatitis?
Minor (under 1 cm, 10–14 days, no scarring, the great majority), major (over 1 cm, weeks, scarring) and herpetiform (crops of pinpoints, older patients, no scarring).
Which deficiencies are classically linked to recurrent aphthae?
Iron, folate and vitamin B12 deficiency, with coeliac disease and Behçet's disease to exclude when ulcers are severe, recurrent or paired with systemic features.
How long may an oral ulcer be observed before biopsy?
Roughly three weeks — the standard red-flag interval in Indian teaching; induration, fixation or node enlargement mandates immediate biopsy irrespective of duration.
What is necrotizing sialometaplasia?
A painless, deep ulcer of the hard palate from ischaemic necrosis of minor salivary lobules that heals spontaneously in weeks; it mimics carcinoma clinically and histologically requires an expert eye.
Which ulcer occurs on the ventral tongue of infants?
Riga-Fede ulceration, caused by repetitive trauma from natal or neonatal teeth; management ranges from smoothing the tooth edges to extraction if feeding is severely disturbed.
What is PFAPA syndrome?
Periodic fever, aphthae, pharyngitis and cervical adenitis in young children, with episodes every few weeks; tonsillectomy is considered in refractory cases and corticosteroids abort individual flares.