Non-Healing Ulcer

• Clinical Definition: A chronic mucosal injury or wound lasting longer than 2 weeks without evidence of re-epithelialization or closure.

• Warning Signs Hardened (indurated) borders, no pain while progressing, unexplained tissue thickening/growth, swollen lymph nodes in the neck, spontaneous bleeding from unknown sources.

• Causes: Mechanical injury due to poorly fitting denture(s)/sharply pointed teeth, chewing/smoking gutka/khaini/betel quid, oral submucous fibrosis (OSMF), malignant transformation.

• Diagnostic Approach: Take incisional biopsy samples and do histopathology evaluations of these biopsies.

• Treatment Plan: Remove the irritating factors, administer topical/systemic steroids, perform surgical excisions, or provide treatment for the cancerous cells.

• Textural Disruptions: The surface of the mucosa appears irregularly disfigured. A cratered appearance will be present at the center.

• Firmness/Induration: The margin or base of an ulcer feels abnormally hard. Rolled margins may also be palpable upon inspection.

• Color Change: Velvety red color (erythroplakia), speckles around the borders (speckled leukoplakia), and dense white (leukoplakia).

• Altered Perception: Sharp pain while eating spicy foods, numbness localized to the site of the ulcer (paresthesia) if nerves have been compromised.

• Bleeding Characteristics: Unprovoked bleeding from the base of an ulcer; Contact bleeding when brushing teeth.

If one of the following occurs immediately seek professional dental examination:

• Duration: An ulcer has shown no improvement in size or healing within fourteen days of onset.

• Hardening: The mucosa surrounding the ulcer is very hard, rigid or firmly attached to deeper tissues.

• Swollen Lymph Nodes: Painless enlargement of lymph nodes located in the neck or near the jawbone.

• Impaired Function: Difficulty in swallowing (dysphagia), difficulty articulating speech (dysarthria), and limited movement of the tongue.

• Weight Loss: Systemic weight loss with ongoing oral discomfort.

• Continuous mechanical micro-trauma from chronic friction due to a sharp enamel cusp, a fractured restorative, or a poorly adjusted removable denture flange.

• Exposure to carcinogens over an extended period through use of smokeless tobacco products containing nitrosamine carcinogens, arecanut/betelnut chewed for long periods of time, and uncooked tobacco quids (paan) placed in the mouth for extended periods of time.

• Placing harsh materials directly on the mouth lining—like resting aspirin tablets against a sore or using abrasive home remedies—can burn and damage the tissue.

• Severe forms of Oral Lichen Planus and Pemphigus Vulgaris causing prolonged mucosal sloughing.

• Progression of dysplastic cells into oral squamous cell carcinoma.

• Habitual Consumption of Tobacco and Arecanuts: High rates of betel quid/arecanut/chewing/tobacco consumption among the regional population greatly increase the likelihood of mucosal dysplasias.

• Inadequate Diet: Significant deficiencies in vitamin B-12/folate/iron leading to mucosal atrophy and increased fragility of tissues.

• Alcohol Consumption: Alcohol consumption over an extended period of time with tobacco synergistically increasing mucosal permeability to potential carcinogens.

• Increasing Age and Decreasing Immunity to Disease: Higher incidence rates seen in individuals > 40 yrs old; individuals who have immune compromising diseases such as diabetes.

Using good lighting and visibility when you are looking inside your mouth for an injury:

• Find a light source. You can use a flashlight or a smartphone light in front of a mirror.

• Clean your hands with soap and water. Wash your hands thoroughly before handling any part of your mouth.

• Pull your lower lip away from your teeth and gently lift up the edges of your cheeks so that you may see inside (the buccal mucosa).

• Look into your mouth to examine your tongue. Stretch your tongue all the way out; then stretch it side-to-side to look at each side (lateral margins). Pull your tongue forward to look at the bottom of your mouth (floor of the mouth).

• Carefully run a clean finger along the edge of the sore spot to feel how firm or soft it is. 

• Don't press too hard on the sore spot or scrape/rub the sore spot.

• Clinical Evaluation: A thorough examination of the appearance and texture of your oral mucosa, as well as visual inspection and physical palpation of the lymph nodes in your neck.

• Vital Toluidine Blue Stain: An office-based diagnostic method using a topical dye to identify areas of high cellular activity and potential dysplastic cell growth.

• Biopsy: The most accurate diagnosis of a lesion. Remove a very small piece of tissue that contains the edge of the lesion and some normal tissue adjacent to the lesion. This is done under local anesthesia for further examination by a pathologist.

• Radiologic Studies: Intraoral x-ray films, an orthopantomogram (OPG) or computed tomography (CT) scan. These studies help determine if there is involvement of underlying bone.

• Eliminating Trauma: This includes smoothing out sharp enamel edges, repairing fractured restorations, or adjusting poorly fitting dentures.

• Pharmacologic Therapy with Topicals: The use of high potency topical corticosteroids (i.e. triamcinolone acetonide; clobetasol) to suppress auto-immune mucosal erosion.

• Excising Lesions: Removing completely localised benign or dysplastic lesions through either routine cold steel excision or advanced Diode laser therapy.

• Oncologic Therapy: In cases where there is malignant involvement, treatment can include surgical excision, neck dissection, radiation and/or chemotherapy provided by a multidisciplinary Oral Oncology Team.

As far as cost is concerned, diagnostic and treatment costs in Kerala can vary depending on both clinical complexity and which type of healthcare provider you see:

• Diagnostic Evaluation/Incisional Biopsy: A typical diagnostic evaluation that would include an incisional biopsy could run anywhere from 1500 rupees to 4500 rupees in a private clinic, but many of the same diagnostics can be had at no charge, or significantly less expensive than those private options through our public dental college programs.

• Removal/Laser Treatment of Minor Lesions: Removal of minor lesions via minor surgical excision or laser therapy can range anywhere from 3500 rupees to 12000 rupees dependent upon the size of the lesion being treated and the equipment being utilized.

• Complex Procedures/Hospital-based Interventions: As might be expected, these interventions may require hospitalization and therefore carry much greater financial risk. These procedures also qualify for reimbursement if they are part of your state sponsored health insurance plans or private health insurance policies.

• General Dental Practitioner: The general dental practitioner provides an initial assessment for a patient with a traumatic ulcer. Smoothing the edges of sharp tooth cusps will help to reduce irritation. A basic approach to managing traumatic ulcers is through topical application and removal of debris from the area.

• Oral Medicine Specialist (OMR): An Oral Medicine Specialist has expertise in non-surgical diagnosis and treatment of autoimmune diseases that affect the mucosa of the mouth. Clinical evaluation of all mucosal lesions are part of their responsibilities.

• Oral & Maxillofacial Surgeon (OMFS): The OMFS surgeon performs surgical biopsies when needed. They can also surgically remove dysplastic lesions. In addition, they perform complex reconstructive surgery on the maxilla and mandible, including bone grafts, implants and other forms of reconstructive techniques.

• Urgent (within 24 hrs): Any ulcer that creates extreme and unmanageable pain within 24-48 hours, which results in high fever, swelling that is increasing rapidly, and difficulty swallowing or airway obstruction.

• Within Weeks: If an ulcer does not show obvious signs of healing after 2 weeks, it should be evaluated formally by an Oral Medicine Specialist (OMR) and a biopsy scheduled.

• Routine/Elective Following a biopsy: Routine follow-up visits as required to monitor the post-operative site, smoothing of the minor sharp cusps of teeth.

1. My mouth ulcer has been open for over two weeks. Why hasn't it healed yet?

Any mouth ulcer lasting longer than two weeks is outside the time frame for complete mucosa repair. The most common reasons are an area of your mouth being repeatedly traumatized from contact with a pointed tooth; you may be suffering from one of the many forms of autoimmune disease; or your cells have changed in such a way that they need to be biopsied.

2. Do all non-healing mouth ulcers represent oral cancer?

Many mouth ulcers become chronic due to long-term mechanical irritation from eating habits, nutritional deficiencies, or localized autoimmune disorders. Oral cancers often present as a painless, non-healing ulcer and should therefore be ruled out through an early clinical assessment.
 

3. What foods should I stay away from while I am experiencing an ongoing oral ulcer?

You should try to limit or eliminate very spicy food, hot drinks, citrus fruits which have an acidic nature, crunchy fried foods, and uncooked spices that could irritate or mechanically damage the uncovered layers of your mucosa.

• Oral Lichen Planus: An autoimmune disorder where the body attacks the mucus membrane. This results in small white lacy patches on the inside of the cheeks, gums, etc., but also can produce large erosions/ulcers.

• Oral Submucous Fibrosis (OSMF): Areca Nut use leads to scarring of the sub-mucosa and creates fibrosis. It makes areas of the mouth feel stiff and sore. Some people develop ulcers.

• Erythroleukoplakia (Speckled Leukoplakia): White and red dysplastic lesions of the oral mucosa that carry a high risk of malignant transformation and chronic ulceration.

• Coronoplasty: Grind and smooth sharp or jagged edges of an enamel cusp for elimination of mucosal friction.

• Oral Professional Prophylaxis: Regularly remove bacteria and plaque with an ultrasonic scaler which is also able to help in reduction of local mucosal inflammation. 

• Topical Barrier Pastes: Bioadhesive oral gel that will protect exposed raw ulcer areas from irritation caused by contact with saliva and food and provide a method for delivery of topical medications to the area.

Any oral wound remaining unhealed beyond 14 days warrants mandatory clinical investigation and histopathological evaluation to ensure timely diagnosis and therapeutic intervention.