How do I Manage a Patient with a Chronic Non-healing Solitary Ulcer?

May 16, 2016

Chronic non-healing solitary ulcer

A chronic, solitary non-healing ulcer is a fairly uncommon lesion. A non-healing solitary ulcer is present for more than 3 weeks without any identifiable cause. Clinically, these lesions present a challenge for diagnosis and treatment.

Presentation

Population

These ulcers can occur in any age group or population; however, they are mainly seen in elderly, immunocompromised or immunosupressed individuals (e.g., patients with HIV or patients undergoing transplantation).

Signs

  • Sloping edge found in ulcers that are healing (growth of the epithelium from the borders).
  • Undermined edge found in tuberculous ulcers (the ulcer spreads and destroys the subcutaneous tissue faster than the skin).
  • Punched out edge found in syphilitic ulcers (the edges of the ulcers are at right angles to the skin surface).
  • Rolled out edge found in patients with cancer; granulomatous lesions, such as deep fungal infections; oral lesions of Wegener granulomatosis; Crohn disease; and chronic traumatic ulcers (growing portion of the edge of the ulcer heaps up and spills over the normal skin).
  • Pain severity may range from mild to severe depending on the cause of the lesion and the presence of secondary infection. On palpation, margins will be tender because of inflammation. Pain is more severe when there is secondary or superadded infection.

Symptoms

  • Ulceration with or without pain
  • Exposure of the underlying tissues, mucosa or bone
  • Halitosis
  • Occasionally associated with bleeding

Investigation

  1. Obtain a detailed history:
    • Ask about the onset and progression of the ulcer.
    • If it is a painful condition, ask about the onset and nature of the pain.
    • Ask about history of continuous or persistent trauma.
    • Ask about the history of tobacco, alcohol and drug use.
    • Ask about fever.
    • Ask about any medical illnesses or conditions (infections, lung disease or any other systemic disease).
    • Ask about history of medications.
  2. Perform a complete extraoral and intraoral examination (examine all oral mucosal surfaces): Extraoral exam:
    • Perform a complete head and neck lymph node examination.
    • Look for any extraoral draining sinuses or scars.

    Intraoral exam:

    • Inspect the ulcer and make a note about its size, shape, location, borders, margins, floor and surrounding areas.
    • Palpate the ulcer and surrounding area with a gloved finger to check for any tenderness and indurations (firmness).
    • Check for numbness or sensations (loss occurs in patients with malignancies owing to invasion).
  3. Biopsy, chest radiography and other specific tests may be advised, depending on the patient history.

Diagnosis

Based on the clinical examination and biopsy, if available, a diagnosis of a chronic non-healing solitary ulcer is determined.

  • If the ulcer is caused by trauma, usually it will have an irregular border. The traumatic factor should be identified and removed. Following removal of the cause, the lesion should regress. If the lesion persists, biopsy should be recommended.
  • If the ulcer is caused by infection (deep fungal infections), usually it exposes the underlying bone and has necrotic slough. There may be signs of lung disease or systemic involvement.
  • Malignant ulcers usually have rolled out edges with induration in the surrounding area (firmness because of invasion into the surrounding tissues).
  • Chemotherapeutic ulcers may be seen in individuals undergoing chemotherapy and may have added necrosis because of suppressed neutrophil counts.
  • Fixed drug eruptions are inflammatory alterations of the mucosa or skin that recur at the same site after the administration of any allergen, mostly a medication. These appear as localized areas of inflammation and erythema and are often caused by barbiturates, co-trimoxazole, dapsone, salicylates, sulfonamides and tetracyclines.
  • Ulcers with exposure of underlying bone may be caused by osteoradionecrosis (in patients with a history of radiation treatment) or bisphosphonate-related osteonecrosis (in patients taking oral or intravenously administered bisphosphonates).
  • Patients with a non-healing solitary chronic ulcer need to be referred to an oral medicine specialist for complete examination and diagnostic follow-up.

As per the clinical history and signs there may be need for special microbial cultures and stains. Most commonly, a biopsy needs to be done to establish a diagnosis. A solitary non-healing ulcer may require advanced care, including referral to an oral medicine specialist and hospitalization.

Treatment

Common Initial Treatments

  • Identify the cause of the ulcer. If it is chronic trauma, then treat the cause; if it is due to an underlying medical condition like syphilis, tuberculosis (TB) or deep fungal infection, refer the patient to a specialist for treatment in consultation with a medical doctor.
    • For patients with syphilis, usually penicillin is prescribed.
    • For patients with TB, multidrug therapy is required (isoniazid, rifampin, ethambutol).
    • For patients with deep fungal infections, usually the following medications are prescribed: ketoconazole, 200 mg (1 tablet daily for 20 days); fluconazole, 100 mg (2 tablets to be taken as soon as possible, then 1 tablet daily for 18 days); or amphotericin B (usually not prescribed by a general dentist because it is highly toxic, particularly to the kidneys; side effects are relatively common; and hospitalization is required for monitoring renal function).
  • If pain is mild and the cause is local, topical anesthetics (benzocaine gel, 20% strength; Orabase-B, maximum strength) and anesthetic mouthwashes, which contain benzydamine hydrochloride, can be suggested. Alternatively, for mild to moderate pain, prescribe analgesics (acetaminophen, 325 mg, 6 times daily). The maximum cumulative dose of acetaminophen is 4 g in 24 hours). Patients will require opioid analgesia (oxycodone 5 mg with acetaminophen 325 mg [Percocet®]; 1 tablet 4–6 times daily) if pain is severe.
  • Antibacterial mouthwashes (chlorhexidine 0.12%) may be given to avoid secondary infection and to facilitate healing.
  • Surgery is only required in patients who are not responding to antimicrobials.
  • Malignancies may require chemotherapy, radiotherapy, surgery or a combination of these therapies.
  • For bisphosphonate-related osteonecrosis of the jaw, please refer to consult.

Advice

  • Avoid spicy food, rinse with over-the-counter mouthwashes, maintain proper oral hygiene and apply nonprescription topical anesthetics.
  • Patients with suspected tuberculosis must be referred to a medical doctor for chest radiography, sputum analysis, skin, chest and other examinations.
  • Patients with suspected syphilis must be referred to a medical doctor for serological investigations and follow-up.
  • Patients who have these diseases may be infectious and should practise rigorous infection control and prevention to avoid transmitting infections to family and colleagues.

Suggested Resources

  1. Neville BW, Damm DD, Allen CM, Bouquot JE, editors. Oral and maxillofacial pathology. 3rd ed. St. Louis: Saunders Elsevier; 2009.
  2. Regezi JA, Sciubba JJ, Jordan RC. Oral pathology clinical and pathological correlations. 6th ed. St. Louis: Saunders Elsevier; 2012.
  3. Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins and Cotran Pathologic basis of disease.8th ed. St. Louis: Saunders Elsevier; 2010.

THE AUTHOR

 

 

Dr. Auluck is a clinician research fellow with the British Columbia Oral Cancer Prevention Program, Vancouver, BC.

 

Acknowledgement: I am grateful to Dr. Michele Williams for her help in creating and revising this article. Michele was an oral medicine specialist and clinical professor in dentistry at the  University of British Columbia and an oral medicine leader at the BC Oral Cancer Prevention Program. She passed away in January 2015.

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