Table 1

Causes of oral ulceration and suggested first-line investigations

Causative agentAssociated featuresInitial investigations
 Recurrent ulcersHand foot and mouth disease: Coxsackie A virus or enterovirus 71, Herpes Simplex 1 and 2, HIVTingling 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 ulcersHHV 6, Varicella /Herpes Zoster, CMV, EBV, Syphilis, Tuberculosis
Autoimmune disordersCrohn's disease, Behcet's disease, Systemic Lupus Erythematosus, Coeliac disease, PFAPA syndrome, MAGIC syndromeSystemic features such as weight loss, bleeding, lethargy, cycles of fever, diarrhoea, myalgia, arthralgiaFull blood count, inflammatory markers, ESR, autoantibodies, IgA, tissue transglutaminase.
Immune disordersImmunodeficiency syndromesRecurrent infections, failure to thriveFull blood count, immunoglobulins, lymphocyte subsets, serology for HIV.
TraumaTeething, dental appliancesHistory of trauma
Vitamin deficienciesIron, B12, folate, vitamin C, magnesium, zincPoor diet, weight loss, skin and hair changes, pallor, tongue depapillationFull blood count, haematinics, zinc, magnesium, Vitamin C levels
Neoplastic/haematologicalAnaemia, leukaemia, agranulocytosis, cyclical neutropeniaLethargy, fevers, pallor, tongue depapillationFull blood count, LDH, urate, blood film
Idiopathic recurrent aphthous stomatitisNormal haematologyRecurrent and healing completely between episodesFull 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