Table 1

Key history taking questions for patients presenting with oral ulceration

NumberHow many ulcers do you get at one time?
SizeHow big are the ulcers typically? Use comparison to everyday objects to give frame of reference, for example, pin head, apple pip, pea
SiteWhich part of the mouth do they affect? Do they occur anywhere other than the mouth, for example, skin, genitals
FrequencyHow often do you have ulcers?
DurationHow long does each ulcer last for?
Ulcer-free periodsHow long in between ulcer episodes?
Pain historyAre the ulcers painful? Are they constantly painful or occasionally? Does anything bring on the pain or make the pain worse, for example, certain food groups?
HabitsDo you clench or grind your teeth? Do you tongue thrust? Do you put non-food items in your mouth for example, pen biting?
Other symptoms/extraoral/systemic symptomsHave you noticed any other symptoms? Other changes in the mouth? Fever? Malaise? Fatigue? GI issues?
Associated featuresDoes the onset of ulceration correlate with any other significant event, for example, dental treatment, stressful life experience? Any other known associated factors, for example, menstruation, following eating certain foods
Family historyDo any other family members have ulceration? Is there a family history of inflammatory bowel disease?
Medical historyRelevant medical history may include inflammatory bowel disease, deficiencies, malnutrition, Pica, learning difficulties, neoplastic conditions/recent chemo or radiotherapy.
Enquire about current medications both generally and those used to manage oral ulceration