Key history taking questions for patients presenting with oral ulceration
| Number | How many ulcers do you get at one time? |
| Size | How big are the ulcers typically? Use comparison to everyday objects to give frame of reference, for example, pin head, apple pip, pea |
| Site | Which part of the mouth do they affect? Do they occur anywhere other than the mouth, for example, skin, genitals |
| Frequency | How often do you have ulcers? |
| Duration | How long does each ulcer last for? |
| Ulcer-free periods | How long in between ulcer episodes? |
| Pain history | Are 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? |
| Habits | Do 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 symptoms | Have you noticed any other symptoms? Other changes in the mouth? Fever? Malaise? Fatigue? GI issues? |
| Associated features | Does 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 history | Do any other family members have ulceration? Is there a family history of inflammatory bowel disease? |
| Medical history | Relevant 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 |