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Aphthous ulcer - Management
When should I refer?

  • Refer people with suspected malignancy:
    • Anyone with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made should be referred or followed up until the symptoms and signs disappear. An urgent referral should be made if the symptoms and signs have not disappeared after 6 weeks.
    • An urgent referral should be made for anyone who presents with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful, swollen, or bleeding.
    • An urgent referral should be made for anyone with unexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks.
    • A non-urgent referral should be made for anyone with unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are not painful, swollen, or bleeding. If oral lichen planus is confirmed the patient should be monitored for oral cancer as part of routine dental examination.
  • Refer people with a suspected underlying cause of aphthous-like ulceration, suggested by history, examination, or results of investigations (see Differential diagnosis).
  • Refer people if ulceration is particularly painful and disabling, or if recurrences are frequent and severe and not adequately relieved by symptomatic treatments.
  • Refer to a dentist anyone with a suspected localized dental cause of recurrent ulceration, such as poorly-fitting dentures or a damaged tooth. This may be suggested by recurrent ulceration in the same place.
Clarification / Additional information
  • Referral routes may vary depending on locality, but would usually be to an oral medicine department or to an oral and maxillofacial department.
Basis for recommendation
  • The recommendations for referral of people with suspected malignancy are based on the referral guidelines for suspected cancer published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2005]. A biopsy should be considered for solitary or multiple ulcers that last more than 3 weeks [Scully, 2006].
  • Referral is recommended for people with a suspected underlying cause of aphthous-like ulceration, to identify and manage any underlying disease [Scully et al, 2003].
  • For people whose symptoms are not adequately relieved by topical corticosteroids, antimicrobial mouthwashes, and local analgesia, experts recommend referral to an oral medicine specialist for further treatment (e.g. more potent topical corticosteroids, doxycycline mouthwash, systemic corticosteroids, or immunosuppressants) [Scully et al, 2003].

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