Causes of oral ulceration and suggested first-line investigations
| Causative agent | Associated features | Initial investigations | |
|---|---|---|---|
| Infection | |||
| Recurrent ulcers | Hand foot and mouth disease: Coxsackie A virus or enterovirus 71, Herpes Simplex 1 and 2, HIV | Tingling prodrome, systemic features such as fever, lethargy, weight loss and recurrent illnesses. | Full blood count, swab for viral diagnostics, serology for HIV and virology. TB testing where appropriate. |
| Persistent ulcers | HHV 6, Varicella /Herpes Zoster, CMV, EBV, Syphilis, Tuberculosis | ||
| Autoimmune disorders | Crohn's disease, Behcet's disease, Systemic Lupus Erythematosus, Coeliac disease, PFAPA syndrome, MAGIC syndrome | Systemic features such as weight loss, bleeding, lethargy, cycles of fever, diarrhoea, myalgia, arthralgia | Full blood count, inflammatory markers, ESR, autoantibodies, IgA, tissue transglutaminase. |
| Immune disorders | Immunodeficiency syndromes | Recurrent infections, failure to thrive | Full blood count, immunoglobulins, lymphocyte subsets, serology for HIV. |
| Trauma | Teething, dental appliances | History of trauma | |
| Vitamin deficiencies | Iron, B12, folate, vitamin C, magnesium, zinc | Poor diet, weight loss, skin and hair changes, pallor, tongue depapillation | Full blood count, haematinics, zinc, magnesium, Vitamin C levels |
| Neoplastic/haematological | Anaemia, leukaemia, agranulocytosis, cyclical neutropenia | Lethargy, fevers, pallor, tongue depapillation | Full blood count, LDH, urate, blood film |
| Idiopathic recurrent aphthous stomatitis | Normal haematology | Recurrent and healing completely between episodes | Full blood count, blood film, haematinics, viral swab for diagnostics |
MAGIC syndrome, mouth and genital ulcers with inflamed cartilage; PFAPA syndrome, periodic fever, aphthous ulcers, pharyngitis and adenitis; TB, tuberculosis; ESR, erythrocyte sedimentation rate; HHV, human herpes virus; CMV, cytomegalovirus; EBV, Epstein–Barr virus; LDH, lactate dehydrogenase