A clinical study and management of ulceromembranous lesions of oral cavity

INTRODUCTION

Ulceration of the oral mucosa is common, resulting in painful "aphthae," a term of ancient origins that refers to ulceration of any mucosal surface. Oral mucous membranes are fragile, specialised membranes that are prone to erosion. Painful ulceration results from full thickness epithelial erosion into the lamina propria. Once an ulcer has formed, it is continually irritated by saliva and microflora, and the acute inflammatory stage may be followed by a pattern of chronic inflammation. Although there are many diverse causes, oral ulcers frequently demonstrate similarity both clinically and histologically.

Oral ulcers are one of the predominant complaints of patients visiting ENT OPD. The global prevalence in the general population is predicted to range from 4.9 percent to 64.7 percent. Aphthous ulcers can afflict up to a quarter of the world's population. Oral mucosal lesions affect 4.1 percent of people in South India.¹ A loss or break in the integrity of the surface epithelium or mucous membrane that continues into the lamina propria is known as an ulcer. If the duration of the ulcer is less than 3 weeks, it is called as a short term ulcer, and if the duration is more than or equal to 3 weeks, it is categorised as a long term ulcer. The membranous lesion is an inflammatory disease in which cells on the surface of the mucous membrane are killed, exudate is laid down on the surface, and the entire necrotic layer is connected to the underlying tissue by fibrosis to produce a false membrane, as seen in diphtheria.²

Ulcero-membranous lesions in the oral cavity have a variety of origins, and the disorder can affect mucous membranes in other sections of the body as well as the oral cavity and oropharynx. They could be a symptom of a local or systemic illness. Because of the wide range of symptoms that a single sickness might have, as well as the fact that a variety of diseases can come, the practitioner must approach the diagnosis and treatment in an orderly fashion.³ The morbidity associated with ulcero-membranous lesions in the oral cavity and oropharynx, as well as their impact on an individual's overall health, is significant. An explanation is required when the colour, texture, or consistency of the oral mucosa changes. In certain cases, the history and clinical presentation are sufficient for a definite diagnosis, although biopsy with submission of lesional tissue for histologic assessment is frequently required. A clinician's ability to recognise common oral mucosal lesions and recognise whether a specific lesion requires histologic diagnosis is crucial.²

METHODS

Our study was conducted among patients attending the department of otorhinolaryngology and also patients referred from other departments of DR. B. R. Ambedkar Medical College and Hospital, Kadugondanahalli, Bangalore. The study was conducted for a period of one and half years from November 2019 to May 2021.

Study design

The study was a prospective study.

Inclusion criteria

Patients presenting with ulceromembranous lesions in the oral cavity, aged 18-65 years.

Exclusion criteria

Pregnant women, lactating women, patients below 18 years, patients above 65 years.

Sample size

Patients of ulcero-membranous lesions in the oral cavity by purposive sampling, sample size of 100 was arrived at conducting the study.

Sampling method

The sampling method was purposive sampling.

Ethical approval

The study was done with the patients coming to Department of ENT and also the patients referred from other departments of Dr. B. R. Ambedkar medical college and hospital, Bangalore, was approved by Institutional ethical committee. Informed written consent was taken from the study subjects after explaining to them the plan and intention of the study in the language best known to them.

Statistical methods and tools

Statistical methods and tools included context chart, analysis table.

A specially designed proforma was used to collect data on each individual subject. Patients aged 18 to 65 visiting ENT outpatient department with ulcero-membranous lesion in oral cavity were evaluated. Detailed history regarding tobacco usage such as tobacco chewing, betel nut/quid chewing, smoking and nasal snuff was elicited. History regarding alcohol, drug intake was taken. Patients who have received radiotherapy for head and neck malignancies were also included in the study. History of any drug intake prior to appearance of ulcers was also noted. History was elicited regarding any joint pain or joint stiffness. History of any skin disorders in the family was also noted. Burning sensation in mouth, throat discomfort, dysphagia, odynophagia, foreign body sensation in throat, halitosis, cough, retrosternal burning pain, swelling in the neck, fever, generalised malaise, and weight loss were among the symptoms reported by these patients. Patients exhibiting systemic symptoms that could indicate an autoimmune illness were referred to the department of medicine for additional investigation. Patients with genital ulcers were referred to the Dermatology department for additional assessment.

RESULTS

A total of 22147 patients attended ENT OPD during the study period from November 2019 to May 2021, of which there were 100 patients with ulcero- membranous lesions in oral cavity which accounted to 0.45%. Among these patients 40 were males (40%) and 60 were females (60%).

The highest number of ulcero-membranous lesions was seen in female patients in the age group 36-45 years (17%) and male patients in the age group 46-55 years (17%). Least age of the patient encountered in this study was 22 years male. Highest age of the patient in this study was 65 years. Mean age in this study was 47.7 years.

Most common site affected in our study is mucous membrane followed by hard palate and then tongue.

In our study, the most common cause for ulcero-membranous lesions in oral cavity was aphthous ulcer which accounts for 15%. Neoplastic conditions altogether constitute 27% of total cases, among which carcinoma tongue was most common followed by floor of mouth, lips and buccal mucosa. Carcinoma tongue accounts to 14%, carcinoma floor of mouth constitute 6%. Traumatic etiology accounts to 12%.

22 patients among 100 study subjects had history of risk factors such as smoking and 13 with alcoholism. Among 100 patients highest number of patients 39 gave history of tobacco chewing.

History of alcohol intake was present in 13 patients and 8 patients had history of both smoking and alcohol. 48 did not have any risk factors. Out of 27 patients with malignant ulcers, smoking, alcohol, history was present in 8 patients, history of alcohol intake was present in 13 patients and history of both smoking and alcohol intake was present in 6 patients.

DISCUSSION

Local reasons (bacterial or viral), systemic disorders, drug-related reactions, or lifestyle variables such as tobacco, betel-quid, and alcohol usage can all produce oral ulceromembranous lesions. During the study period, ulcero-membranous lesions in the oral cavity accounted for 0.45 percent of the cases examined in ENT services.

The most typically affected age group for ulcero-membranous lesions in the oral cavity was 36-55 years (57 percent), which is also same according to a study published in 2008 by Isaac U and Isaac JS et al. The study's youngest patient was a 22-year-old boy, and the oldest patient was a 65-year-old man.

Most common site affected in our study is mucous membrane followed by hard palate and then tongue. In our study, the most common cause for ulcero-membranous lesions in oral cavity was aphthous ulcer which accounts for 15%. Neoplastic conditions altogether constitute 27% of total cases, among which Carcinoma tongue was most common followed by floor of mouth, lips and buccal mucosa. Carcinoma tongue accounts to 14%, carcinoma floor of mouth constitute 6%. Traumatic etiology accounts to 12%.8 patients. Among 100 patients highest number of patients (39) gave history of tobacco chewing. 13 patients had a history of alcohol consumption, and 8 patients had both a smoking and an alcohol consumption history. 48 patients out of a total of 100 had no risk factors. Tobacco chewing history was found in 26 of the 27 patients with malignant ulcers, history of alcohol intake was present in 13 patients, and history of both smoking and alcohol intake was present in 8 patients. In our study, 68 patients (68%) were treated conservatively. Six (six percent) of the 27 patients with malignant ulcers chose radiotherapy, while one patient with a malignant ulcer had both radiotherapy and surgical treatment. Most of the patients showed improvement following treatment (46%), 42% fully recovered and 2 patients with Carcinoma buccal mucosa expired due to complications.

All 27 patients who presented with malignant ulcers had history of either tobacco usage (smoking/tobacco chewing) or alcohol consumption for more than 10 years which is also seen in studies by Isaac et al, Saintrain et al and Phelan et al.^4-6 The most common symptoms in our study were ulceromembranous lesions in the oral cavity and discomfort followed by pain and burning sensation.

Infectious disease was the most common cause of ulcero-membranous lesions in the oral cavity (44.62 percent), followed by inflammatory disease (29.23 percent). Thimmappa et al and Goyal et al found that 50 percent of the cases were caused by inflammation.^9,10 Diphtheria was the most prevalent bacteria recovered from ulcero-membranous lesions in the oral cavity and oropharynx, according to Sridhar et al.⁷

Recurrent aphthous stomatitis was detected in 15 patients, the majority of which were between the ages of 25 and 55, with a female preponderance (F:M=2:1). There were no predisposing variables in 11 of the 15 patients. Crispian et al and Goyal et al showed that recurrent aphthous ulcers were the most common entity, accounting for almost half of all cases.^8,9

Malignant ulcers in the oral cavity accounted for about 27% in our study, which is similar to Manjunath et al and Mahavar et al.¹¹

Studies by Thimmappa et al shows only 6.5% were malignant.¹⁰ The most common site of malignancy in oral cavity in this study was tongue followed by floor of mouth and lips. Study done by Mathur et al showed that the most common site was buccal mucosa.¹²

Malignant ulcers (27 out of 100 subjects) were most commonly seen in the age group of 40-65 years in female patients. In this study, female preponderance (14 female patients out of 27 patients with malignant ulcers) was found in patients having malignant ulcers, which is comparable to study by Saintrain et al showed female preponderance of oral malignant lesions.⁵

Studies done by Thimmappa et al, Manjunath et al, Isaac et al showed male preponderance.^10,11,16 Only 13 male patients were encountered in malignant ulcer group in our study.

Miscellaneous causes for ulcero-membranous lesions in oral cavity found in our study were oral pemphigus vulgaris (6), leukoplakia (8), mucositis (7), oral candidiasis (7), mucormycosis (5), herpes simplex (3), aspergillosis (4), fixed drug eruption (6). These are seen most commonly in the age group of 36-55 years with male to female ratio of 7:9.

In our study 68 out of 100 cases were managed conservatively. Patients with recurrent apthous stomatitis were treated symptomatically with multivitamins, antioxidants, antacids, topical anaesthetic agents, and antiseptic gargling solution.³ Patients with viral etiology were treated with oral acyclovir and topical anesthetic agents. 7 patients with oral candidiasis were treated with oral fluconazole, topical clotrimazole and topical antiseptic gargling solution. 6 patients received radiotherapy and 21 patients underwent surgery. Studies by Crispian et al and Patil et al also shows that majority of them were managed conservatively.^13,14

In a prospective study of 60 patients with ulcero-membranous lesions in the oral cavity and oropharynx, Thimmappa et al discovered that 50% of cases were non-specific ulcers, 15% were apthous ulcers, 8.3% were traumatic ulcers, 6.5 percent were malignant ulcers, 6.5 percent were dental ulcers, 3.2 percent were HIV infection and AIDS, 3.2 percent were tuberculosis ulcers, and 6.5 percent Low socioeconomic position, lack of education, poor dental hygiene, and unhealthy habits formed in childhood are all predisposing factors, according to the author. As a result, in all cases of ulcers, early identification and treatment are recommended.¹⁰

In India, Mehta et al studied the epidemiology and histology of oral cancer and leukoplakia in 50,915 villagers. Patients were chosen based on the types of chewing and smoking behaviours they had. The prevalence of epithelial atypia ranged from 3.0 percent to 12.4 percent in biopsies from 723 leukoplakias, according to histological analyses. Epithelial atypia was observed in 8.4% of homogeneous leukoplakias and 59.1% of speckled leukoplakias. The author found that leukoplakia was the most frequent precancerous oral lesion in India, with speckled form leukoplakia being more likely to progress to malignancy.¹⁵

Limitations

Relative risk and attributable risk of smoking, tobacco chewing and alcohol consumption for malignant ulcers needs to be calculated in two separate cohort groups with or without malignant ulcers. Long term follow up needs to be done to determine the frequency of recurrence, predisposing factors and evaluation of recurrent aphthous stomatitis.

CONCLUSION

A descriptive study of ulcero-membranous lesions in oral cavity presenting to ENT department from November 2019 to May 2021 was done. In this study out of 22147 patients who attended ENT OPD during study period, 100 patients presented with ulcero-membranous lesions in oral cavity which accounted for 0.45%. Mostly females of the age group 36 to 45 years were affected in our study. A variety of etiological factors were found in these patients with ulcero-membranous lesions in oral cavity, the foremost being malignant in nature, which accounted for 27%, followed by inflammatory etiology (22%). In infective etiology ulcero-membranous lesions caused by fungus were most common (11%), and viral infection constitute 3%. If considering single most common condition, recurrent Aphthous ulcer is the most common condition seen in our study. In our study, patients presented with ulcerative lesion in oral cavity and pain were the most common complaints. History of tobacco chewing was present in majority of patients with malignant lesions. Most of the patients (conservative management–68%) were treated symptomatically with oral and topical agents. 21 patients were treated surgically and 6 patients received radiotherapy.

ACKNOWLEDGEMENTS

The authors are thankful to Dr. S.V. Divakar, MD, Principal, DR B. R. Ambedkar Medical College and Hospital, Bangalore for permitting the use of the facilities in the college.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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