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Probability diagnosis

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Recurrent aphthous ulceration

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Trauma (e.g. rough tooth, biting)

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Acute herpes gingivostomatitis

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Candidiasis

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Serious disorders not to be missed

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Cancer:

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  • SCC

  • leukaemia

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Agranulocytosis

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HIV

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Syphilitic: chancre or gumma

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Tuberculosis

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Pitfalls (often missed)

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Aspirin burn

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Inflammatory bowel disease (e.g. Crohn)

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Herpes zoster virus

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Glandular fever (EBV)

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Lichen planus

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Coxsackie virus:

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  • herpangina

  • hand, foot and mouth disease

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Epstein–Barr mononucleosis

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Immunosuppression therapy

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Lupus erythematosus

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Rarities:

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  • Behçet syndrome

  • pemphigoid and pemphigus vulgaris

  • erythema multiforme

  • radiation mucositis

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Masquerades checklist

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Diabetes (Candida)

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Drugs (see list)

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Anaemia (iron-deficiency)

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Is the patient trying to tell me something?

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Unlikely.

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Key history

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Take a history of trauma, skin problems, stress, dental problems, drugs, allergy and possible infections, including herpes simplex, Candida albicans, sexually transmitted diseases and Coxsackie virus infection. Consider an immunosuppressive disorder.

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Key examination

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The examination should focus on the patient’s general health, dental status, characteristics of the ulcer, cervical lymphadenopathy and the skin in general

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Key investigations

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Depending on the clinical picture investigations may include:

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  • FBE

  • ESR

  • swabs for M&C

  • autoantibody screen

  • syphilis serology

  • blood sugar

  • vitamin B12 and folate levels

  • biopsy.

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Diagnostic tips

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  • Non-healing ulcers warrant biopsy to exclude squamous cell carcinoma.

  • Remember to enquire about medication such as phenytoin, cytotoxics, immunosuppressants, carbimazole.

  • A blood dyscrasia may be possible.

  • Consider inflammatory bowel disease and coeliac disease in your considerations.

  • Aphthous ulcers are usually 3–5 mm in diameter; minor ones have an erythematous margin.

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