Difficult and complicated oral ulceration: an expert consensus guideline for diagnosis

A molybdenum sulfide based nitric oxide controlled release oral gel for rapid healing of oral mucosal ulcers

Oral mucosal ulcer is the most prevalent oral mucosal lesion, affecting over 25 % of general population. The current treatment regimens lack efficacy in addressing challenges such as wound bleeding, bacterial infection and inflammation on a continuous basis. Hence, a multi-functional oral gel (termed MPCST) with a long-acting duration is designed. It is based on a tannic acid-thioctic acid (TATA) supramolecular hydrogel which absorbs tissue exudate while exhibiting robust tissue adhesion properties. To form MPCST, TATA is loaded with MPCS, which are composed of polydopamine (PDA)-coated molybdenum disulfide (MoS2) nanoflakes (MoS2@PDA) with high photothermal conversion efficiency, nitric oxide (NO) precursor nitroprusside (SNP) and cerium oxide (CeO2) with high reactive oxygen species (ROS) scavenging rate. Upon exposure to 808 nm near-infrared (NIR) irradiation, MPCS rapidly heats up and releases NO to promote angiogenesis, while exhibiting strong ROS scavenging, antibacterial (including oral common Streptococcus mutans), and anti-inflammatory properties. Animal experiments show that the MPCST oral gel, composed of MPCS and TATA hydrogel, exhibits superior therapeutic efficacy compared to the commonly used dexamethasone patch.

Effective treatment of refractory oral ulcers using a compound Chinese herbal mouthwash: A report of two cases

Oral ulcers are a prevalent oral mucosal disorder, characterized by benignancy and self-limiting progression. However, a subset of these ulcers exhibits resistance to conventional therapeutic interventions, necessitating alternative treatment strategies. In this study, we present two cases of refractory oral ulcers that demonstrated limited responsiveness to standard treatments but achieved significant therapeutic benefits following the application of a compound Chinese herbal mouthwash. Case 1 involved a 60-year-old female patient diagnosed with Behçet's syndrome. Initial treatment with glucocorticoids and immunosuppressants yielded limited improvement in her oral ulcers; however, combination therapy involving the Chinese herbal mouthwash resulted in significant improvement and complete healing after a 2-week period. Case 2 presented a 48-year-old female patient with chronic tongue ulceration pain persisting for one year without any detectable systemic etiology. Despite receiving oral vitamin supplementation and local analgesic jelly, her symptoms remained unalleviated. A 3-week treatment regimen involving the administration of the Chinese herbal mouthwash in conjunction with thalidomide led to the complete resolution of her oral ulcers. The findings from this study suggest that the compound Chinese herbal mouthwash may serve as an adjuvant therapeutic approach for managing chronic oral ulcers that are resistant to conventional treatment.

Mussel-inspired adhesive drug-loaded hydrogels for oral ulcers treatment

Oral aphthous ulcers are common mucosal lesions that cause pain and discomfort. There are diverse biomaterials and drug treatments for oral ulcers used in both research and clinical settings. However, the complex oral environment often results in low adhesion and short drug retention times, which lead to poor drug availability and treatment outcomes. In this study, a mussel-inspired adhesive hydrogel was developed by grafting catechol onto hyaluronic acid (C-HA), and dopamine was added for oxidative pre-polymerization to form modified hyaluronic acid (M-HA), which remarkably increased the adhesion of the hydrogels. Then, M-HA was interpenetrated into the gelatin methacryloyl (GelMA) network. Chlorhexidine gluconate (CHG) was then incorporated into the hydrogel to enhance its availability and therapeutic effect through its sustained-release capability. The GelMA/M-HA hydrogel demonstrated strong adhesion to wet tissues, antibacterial and anti-inflammatory properties, and good biocompatibility. In both rat oral ulcers and infected wounds, the adhesive hydrogel significantly accelerated the healing of the ulcers and infected wounds. These results indicated that this adhesive hydrogel offers a promising new strategy for the treatment of oral ulcers in clinical practice. STATEMENT OF SIGNIFICANCE: Oral ulcers are a common and high-incidence mucosal condition that seriously affect people's daily lives, often making it difficult for patients to chew and speak. However, a dynamic oral environment with various types of bacteria influences drug availability and treatment effects in clinical settings. To address this challenge, an adhesive, mussel-inspired, drug-loaded hydrogel was constructed using natural macromolecules (hyaluronic acid and gelatin) with good biocompatibility. Chlorhexidine gluconate (CHG), with its broad-spectrum antibacterial activity, has been incorporated to synergistically promote oral ulcer healing. The splendid adhesion, antibacterial, and therapeutic effects of this hydrogel demonstrated a new strategy for treating oral ulcers.

Magnesium metal-organic framework microneedles loaded with curcumin for accelerating oral ulcer healing

Oral ulcers are a common oral mucosal disease that seriously affect the quality of life. Traditional drug treatments have shown unsatisfactory efficacy and potential adverse reactions. In this study, curcumin-loaded multifunctional magnesium metal-organic framework-embedded hyaluronic acid-soluble microneedles patches were developed to optimize treatment strategies for oral ulcers. This microneedles patch achieves efficient release of curcumin and Mg2+ in the ulcer through precisely targeted delivery and controllable release mechanism, significantly regulates inflammation, promotes cell migration and angiogenesis, and accelerates the ulcer healing process. At the same time, the synergistic effect of curcumin and gallic acid effectively alleviated oxidative stress, while the backplate ε-poly-L-lysine and needle tip Mg2+ jointly constructed an antibacterial barrier to effectively inhibit pathogens. Verification using an oral ulcer rat model showed that the microneedles patch exhibited excellent therapeutic effects. This not only opens up a new avenue for clinical oral treatment but also marks a breakthrough in nanobiomaterials science and drug delivery technology and heralds a broad prospect in the field of oral ulcer treatment in the future.

A high-order focus interaction model and oral ulcer dataset for oral ulcer segmentation

Computer-aided diagnosis has been slow to develop in the field of oral ulcers. One of the major reasons for this is the lack of publicly available datasets. However, oral ulcers have cancerous lesions and their mortality rate is high. The ability to recognize oral ulcers at an early stage in a timely and effective manner is a very critical issue. In recent years, although there exists a small group of researchers working on these, the datasets are private. Therefore to address this challenge, in this paper a multi-tasking oral ulcer dataset (Autooral) containing two major tasks of lesion segmentation and classification is proposed and made publicly available. To the best of our knowledge, we are the first team to make publicly available an oral ulcer dataset with multi-tasking. In addition, we propose a novel modeling framework, HF-UNet, for segmenting oral ulcer lesion regions. Specifically, the proposed high-order focus interaction module (HFblock) performs acquisition of global properties and focus for acquisition of local properties through high-order attention. The proposed lesion localization module (LL-M) employs a novel hybrid sobel filter, which improves the recognition of ulcer edges. Experimental results on the proposed Autooral dataset show that our proposed HF-UNet segmentation of oral ulcers achieves a DSC value of about 0.80 and the inference memory occupies only 2029 MB. The proposed method guarantees a low running load while maintaining a high-performance segmentation capability. The proposed Autooral dataset and code are available from  https://github.com/wurenkai/HF-UNet-and-Autooral-dataset .

Genetic Connectivity of Gut Microbiota and Oral Ulcers: A Mendelian Randomization Study

OBJECTIVES

The aim of this study was to reveal the relationship, if any, between gut microbiota and oral ulcers.

METHODS

We performed a 2-sample Mendelian randomization (MR) study to estimate the roles of gut microbiota in mouth ulcers. The summary datasets of gut microbiota were from the largest genome-wide association study (GWAS) conducted by MiBioGen, and data of mouth ulcers were obtained from UK Biobank. Random effect inverse variance-weighted, weighted median, MR Egger, simple mode and weighted mode were used to estimate the relationship. Sensitivity analyses were conducted to assess the heterogeneity and pleiotropy of instrumental variables. MR Steiger filtering was also applied to orient the causal direction.

RESULTS

Three gut microbiota taxa were positively associated with mouth ulcers: Holdemania (odds ratio [OR] = 1.005, 95% confidence interval [CI]: 1.001-1.009, P = .019), Oxalobacter (OR = 1.004, 95% CI: 1.000-1.007, P = .032), and Ruminococcaceae UCG011 (OR = 1.006, 95% CI: 1.001-1.011, P = .029), while 4 gut microbiota taxa were negatively associated with mouth ulcers: Actinobacteria (OR = 0.992, 95% CI: 0.985-1.000, P = .042), Lactobacillales (OR = 0.995, 95% CI: 0.990-1.000, P = .034), Oscillospira (OR = 0.990, 95% CI: 0.984-0.997, P = .007) and Phascolarctobacterium (OR = 0.992, 95% CI: 0.986-0.997, P = .003). Sensitivity analyses validated the robustness of the association in between.

CONCLUSIONS

This MR study identified a strong association between the quality of gut microbiota and oral ulcers. The findings are likely to expand the therapeutic targets for mouth ulcers.

Silk Fibroin Microneedles Loaded with Lipopolysaccharide-Pretreated Bone Marrow Mesenchymal Stem Cell-Derived Exosomes for Oral Ulcer Treatment

Oral ulcers, superficial lesions on the surface of the oral mucosa, have a high incidence rate, and their main symptoms include local pain and erosion. Lipopolysaccharide (LPS)-preconditioned bone marrow mesenchymal stem cells and their secreted exosomes (LPS-pre-Exos) have been shown to promote recovery in various inflammatory conditions and wounds. However, studies documenting LPS-pre-Exos as a therapeutic intervention for oral mucosal-like diseases are lacking. In this study, we prepared a silk fibroin microneedle (MN) patch consisting of LPS-pre-Exos and zeolitic imidazolate framework-8 (ZIF-8) that localized at the tip and base, respectively, and used this MN patch for oral ulcer treatment. Upon insertion into the oral mucosa, continuous LPS-pre-Exos release was observed, which promoted macrophage polarization and tissue healing. Additionally, the ZIF-8 framework in the MN patch facilitated the controlled release of Zn2+, which demonstrated potent antimicrobial properties via synergistic effects. The in vitro experimental results showed that the silk fibroin MN patch can continuously release LPS-pre-Exos and Zn2+ for more than 7 days. Thus, the LPS-pre-Exos and ZIF-8-loaded silk fibroin MN patch exhibited good anti-inflammatory and antibacterial properties, promoting oral ulcer healing, and showed good histocompatibility. Hence, it may represent a potentially valuable strategy for facilitating oral ulcer healing.

The Efficacy of Triphala in the Management of Minor Aphthous Ulcers: A Case Report

Aphthous ulcers, also known as canker sores, are the most frequently encountered lesions in the oral cavity by clinicians and particularly by dentists. It might affect populations of all age groups, although common in the younger age group. Though multifactorial causes are known to be associated with the occurrence of aphthae, the most common etiologies are stress, inadequate sleep, and improper digestion. They can appear on the oral mucosa, palate, gingiva, labial mucosa, and tongue. They can be very uncomfortable during mastication, speech, and deglutition. Generally, the management relies on identifying the cause and prescribing medications such as the local application of anesthetic, steroid ointments specifically for refractory cases, and multivitamin tablets to relieve the symptoms. Ayurvedic preparations such as Triphala oral rinse can prove to be really effective in relieving pain and burning sensation and also cause the lesions to subside, although, like other allopathy medications, it is not known to reduce the frequency of episodes. In this article, we present a case of a male patient aged 21 years who came with a complaint of ulcers on the right lateral border of the tongue. He was prescribed Triphala oral rinse and Triphala ingestion for 15 days, and on the follow-up visit, the patient reported the complete resolution of ulcers.

Multifunctional hyaluronic acid/gelatin methacryloyl core-shell microneedle for comprehensively treating oral mucosal ulcers

Oral ulceration is the most common oral mucosal disease. Oral mucosal ulcers are extremely painful, may interfere with eating and speaking, and potentially complicate systemic symptoms in severe cases. The humid and highly dynamic environment of the oral cavity makes local drug administration for treating oral mucosal ulcers challenging. To overcome these challenges, we designed and prepared a novel dissolving microneedle (MN) patch containing multiple drugs in a core-shell to promote oral ulcer healing. The MNs contained a methacrylate gelatin shell layer of basic fibroblast growth factor (bFGF), a hyaluronic acid (HA) core loaded with dexamethasone (DXMS), and zeolite imidazoline framework-8 (ZIF-8) encapsulated in the HA-based backplane. Progressive degradation of gelatin methacryloyl (GelMA) from the tip of the MN patch in the oral mucosa resulted in sustained bFGF release at the lesion site, significantly promoting cell migration, proliferation, and angiogenesis. Moreover, the rapid release of HA and, subsequently, DXMS inhibited inflammation, and the remaining MN backing after the tip dissolved behaved as a dressing, releasing ZIF-8 for its antimicrobial effects. This novel, multifunctional, transmucosal core-shell MN patch exhibited excellent anti-inflammatory, antimicrobial, and pro-healing effects in vivo and in vitro, suggesting that it can promote oral ulcer healing.

Wet adhesive hydrogels based on niobium carbide for experimental research of oral mucosal impairment

Oral mucosal impairment is a prevalent oral disease that frequently causes pain for patients. Conventional treatments have limited effectiveness and can cause adverse reactions. Furthermore, the moist and dynamic nature of the oral mucosal environment makes persistent adherence of conventional materials challenging, which can affect treatment efficacy. In this study, we investigated the potential of a NbC/TA-GelMA hydrogel system, where niobium carbide (NbC) and tannic acid (TA) were added to gelatin methacryloyl (GelMA), for repairing oral mucosal impairment. The wet adhesion properties of NbC/TA-GelMA hydrogels were confirmed by the inclusion of TA with a catechol-rich group. In addition, the photothermal effect of NbC/TA-GelMA hydrogel under near-infrared light, synergizing with TA, provided sustained antibacterial action. Furthermore, the NbC/TA-GelMA hydrogel effectively healed damaged oral mucosa of rats.

A double-layer thin oral film for wet oral mucosa adhesion and efficient treatment of oral ulcers

Oral ulceration (OU), a prevalent oral mucosal condition causing significant pain and hindering eating and speaking, adversely impacts the patient's quality of life. Topical medications are preferred for their minimal side effects and convenient administration. However, existing formulations generally present discomfort and insufficient drug retention due to the thick formulations and poor adhesion, which considerably restrict their therapeutic effectiveness. In this study, a thin and lightweight double-layer oral film based on FDA approved excipients with excellent adhesion under wet oral conditions and outstanding biocompatibility is successfully developed by a simple method. It consists of an adhesive layer for anchoring in situ to delivery drugs and a hydrophobic layer to isolate the saliva for unidirectional drug delivery. The double-layer oral film with extremely thin appearance (only 0.11 mm thick) offers excellent adhesion (up to 150 min on an SD rat oral ulceration), which was also matched with its drug release time (87.47% release in 2 h). Animal experiments confirmed that the double-layer oral film carrying dexamethasone sodium phosphate achieved satisfactory efficacy in the SD rat oral ulcer model. Hence, this biologically friendly double-layer thin oral film holds great promise for clinical application in topical drug therapy for oral mucosal conditions.

Deep learning algorithms for classification and detection of recurrent aphthous ulcerations using oral clinical photographic images

Background/purpose

The application of artificial intelligence diagnosis based on deep learning in the medical field has been widely accepted. We aimed to evaluate convolutional neural networks (CNNs) for automated classification and detection of recurrent aphthous ulcerations (RAU), normal oral mucosa, and other common oral mucosal diseases in clinical oral photographs.

Materials and methods

The study included 785 clinical oral photographs, which was divided into 251 images of RAU, 271 images of the normal oral mucosa, and 263 images of other common oral mucosal diseases. Four and three CNN models were used for the classification and detection tasks, respectively. 628 images were randomly selected as training data. In addition, 78 and 79 images were assigned as validating and testing data. Main outcome measures included precision, recall, F1, specificity, sensitivity and area under the receiver operating characteristics curve (AUC).

Results

In the classification task, the Pretrained ResNet50 model had the best performance with a precision of 92.86%, a recall of 91.84%, an F1 score of 92.24%, a specificity of 96.41%, a sensitivity of 91.84% and an AUC of 98.95%. In the detection task, the Pretrained YOLOV5 model had the best performance with a precision of 98.70%, a recall of 79.51%, an F1 score of 88.07% and an AUC of Precision-Recall curve 90.89%.

Conclusion

The Pretrained ResNet50 and the Pretrained YOLOV5 algorithms were shown to have superior performance and acceptable potential in the classification and detection of RAU lesions based on non-invasive oral images, which may prove useful in clinical practice.

Combination therapy using multifunctional dissolvable hyaluronic acid microneedles for oral ulcers

Oral ulcers are common in the oral mucosa. Frequent occurrences of oral ulcers commonly afflict patients, seriously impacting their daily life. Treatments with good anti-inflammatory and antibacterial properties are important for promoting the healing of oral ulcers. In this study, a multifunctional, soluble hyaluronic acid (HA) microneedle (MN) patch was prepared to promote oral ulcer healing. The tip layer of the MN patch was loaded with triamcinolone acetonide (TA) and epidermal growth factor (EGF) to inhibit inflammation and promote angiogenesis. Zeolitic imidazolate framework-8 (ZIF-8) was loaded onto the base layer of the MN patch, which effectively released Zn2+ to mediate antibacterial effects. In addition, HA exerts a protective effect on the mucous membrane. Owing to these properties, the multifunctional MN patches were found to have good anti-inflammatory, antibacterial, and tissue-healing abilities, indicating that the multifunctional MN patch design successfully promoted the healing of oral ulcers.

Identification of the causal relationship between sleep quality, insomnia, and oral ulcers

BACKGROUND

Multiple epidemiological studies have posited a potential association between sleep quality and the risk of oral diseases, yet the resulting conclusions have remained contentious, and the presence of a causal link remains equivocal. In this study, we aimed to investigate the causal relationship between sleep duration, insomnia, and common oral diseases.

METHODS

We utilized genetic correlation and two-sample Mendelian randomization analyses based on summary statistics from genome-wide association studies of sleep duration (N = 460,099), insomnia (N = 462,341), mouth ulcer (N = 385,026), oral cavity cancer (N = 4,151), and periodontal disease (N = 527,652).

RESULTS

Our results revealed a negative genetic correlation between sleep duration and mouth ulcer (genetic correlation: -0.09, P = 0.007), while a positive genetic correlation between insomnia and mouth ulcer was observed (genetic correlation: 0.18, P = 2.51E-06). Furthermore, we demonstrated that longer sleep duration is significantly associated with a reduced risk of mouth ulcers (OR: 0.67, 95% CI: 0.54-0.83, P = 2.84E-04), whereas insomnia is nominally associated with an increased risk of mouth ulcers (OR: 1.40, 95% CI: 1.01-1.95, P = 0.044). In contrast, no significant association was detected between sleep quality and periodontal disease or oral cavity cancer.

CONCLUSIONS

This work provides robust evidence to support the notion that enhanced sleep quality may confer a decreased risk of oral ulcers, thereby bearing considerable clinical relevance.

A Case Report of Extreme Oral Lesions: A Rare Indicator of Bullying-Associated Non-suicidal Self-Injury

Bullying has reached epidemic proportions, affecting one in three students worldwide. A pervasive issue that carries profound physical, mental, and social consequences, significantly increasing the risk of non-suicidal self-injury (NSSI) and suicidal behaviors among those who experience this type of harassment and hazing. While physicians and most caregivers are fully aware and competent in identifying signs of self-harming behavior such as scratching, cutting, or burning the skin, oral self-injury is often overlooked as a potential indicator and is associated with unintentional soft tissue biting or specific conditions. We present a rare case of a 14-year-old male who sought medical attention due to severe bilateral tongue ulcers, leading to his admittance to the emergency department (ED) with excruciating pain and feeding difficulties. In the reported case, although the traumatic biting of the tongue emerged as the most probable etiological factor, a specific underlying motive and contextual comprehension were initially absent. It was only after successfully establishing a foundation of trust with the patient, enabling an honest response, that it became evident that the observed lesions represented a manifestation of bullying-induced non-suicidal self-injury. However, patients rarely openly acknowledge intentional self-inflicted lesions and/or their experiences of bullying, underscoring the necessity to maintain vigilance for alternative indicators such as behavioral changes or a noticeable decline in academic productivity. The significance of this case also goes beyond its presentation, highlighting the largely unexplored issue of how a patient's dentofacial features can serve as substantial catalysts for bullying. Therefore, it is only through equally prioritizing awareness of uncommon signs, symptoms, and context that one can expedite early diagnosis and intervention, emphasizing the essential need for comprehensive and timely management of such cases.

Probiotic-loaded calcium alginate/fucoidan hydrogels for promoting oral ulcer healing

Probiotics are beneficial bacteria located in the oral cavity which exhibit antimicrobial properties and contribute to the regulation of immune function and the modulation of tissue repair. Fucoidan (FD), a marine prebiotic, may further enhance the ability of probiotics to promote ulcer healing. However, neither FD nor probiotics are attached to the oral cavity and neither are well-suited for oral ulcer healing owing to the wet and highly dynamic environment. In this study, probiotic-loaded calcium alginate/fucoidan composite hydrogels were developed for use as bioactive oral ulcer patches. The well-shaped hydrogels exhibited remarkable wet-tissue adhesion, suitable swelling and mechanical properties, sustained probiotic release, and excellent storage durability. Moreover, in vitro biological assays demonstrated that the composite hydrogel exhibited excellent cyto/hemocompatibility and antimicrobial effects. Importantly, compared to commercial oral ulcer patches, bioactive hydrogels show superior therapeutic capability for promoting ulcer healing in vivo by enhancing cell migration, inducing epithelial formation and orderly collagen fiber deposition, as well as facilitating neovascularization. These results demonstrate that this novel composite hydrogel patch demonstrates great potential for the treatment of oral ulcerations.

Soluble epoxide hydrolase inhibitor promotes the healing of oral ulcers

OBJECTIVE

Oral ulcers are a lesion in the oral mucosa that impacts chewing or drinking. Epoxyeicosatrienoic Acids (EETs) have enhanced angiogenic, regenerative, anti-inflammatory, and analgesic effects. The present study aims to evaluate the effects of 1-Trifluoromethoxyphenyl-3-(1-Propionylpiperidin-4-yl) Urea (TPPU), a soluble epoxide hydrolase inhibitor for increasing EETs level, on the healing of oral ulcers.

METHODS

The chemically-induced oral ulcers were established in Sprague Dawley rats. The ulcer area was treated with TPPU to evaluate the healing time and pain threshold of ulcers. The expression of angiogenesis and cell proliferation-related protein in the ulcer area was detected using immunohistochemical staining. The effects of TPPU on migration and angiogenesis capability were measured with scratch assay and tube formation.

RESULTS

Compared with the control group, TPPU promoted wound healing of oral ulcers with a shorter healing time, and raised pain thresholds. Immunohistochemical staining showed that TPPU increased the expression of angiogenesis and cell proliferation-related protein with reduced inflammatory cell infiltration in the ulcer area. TPPU enhanced cell migration and tube-forming potential in vitro.

CONCLUSIONS

The present results support the potential of TPPU with multiple biological effects for the treatment of oral ulcers by targeting soluble epoxide hydrolase.

Use of Artificial Intelligence in the Classification of Elementary Oral Lesions from Clinical Images

OBJECTIVES

Artificial intelligence has generated a significant impact in the health field. The aim of this study was to perform the training and validation of a convolutional neural network (CNN)-based model to automatically classify six clinical representation categories of oral lesion images.

METHOD

The CNN model was developed with the objective of automatically classifying the images into six categories of elementary lesions: (1) papule/nodule; (2) macule/spot; (3) vesicle/bullous; (4) erosion; (5) ulcer and (6) plaque. We selected four architectures and using our dataset we decided to test the following architectures: ResNet-50, VGG16, InceptionV3 and Xception. We used the confusion matrix as the main metric for the CNN evaluation and discussion.

RESULTS

A total of 5069 images of oral mucosa lesions were used. The oral elementary lesions classification reached the best result using an architecture based on InceptionV3. After hyperparameter optimization, we reached more than 71% correct predictions in all six lesion classes. The classification achieved an average accuracy of 95.09% in our dataset.

CONCLUSIONS

We reported the development of an artificial intelligence model for the automated classification of elementary lesions from oral clinical images, achieving satisfactory performance. Future directions include the study of including trained layers to establish patterns of characteristics that determine benign, potentially malignant and malignant lesions.

Follicular lymphoma manifests as multiple erosive and proliferative lesions of the oral mucosa: case report and brief literature review

Background

Erosion is one of the most common and basic lesions of oral mucosal diseases. Long-term refractory oral erosions, induced by autoimmune blistering diseases, infectious diseases, malignant diseases, and some rare conditions, may substantially reduce the quality of life of patients or even constitute a life-threatening condition, resulting in a clinical dilemma regarding the accurate diagnosis and precise management of these diseases. As a special type of malignant lymphoma, most lesions of follicular lymphoma (FL) in the oral mucosa present as masses or swelling of the oral mucosa, while emerging novel presentations lead to intractable diagnoses. Hence, diagnostic algorithms for such diseases are clinically required. 

Case presentation

A 55-year-old female patient presented to the clinic with long-lasting oral mucosal erosions and proliferative lesions. Blood tests, pathological examinations of oral lesions including haematoxylin–eosin (HE) staining, and direct immunofluorescence precluded all of the potential diagnoses described previously. Unexpectedly, positron emission tomography/computed tomography (PET/CT) and abdominal CT of the patient revealed a dense mass in the retroperitoneal area, and the final diagnosis of the retroperitoneal mass was FL. After three courses of chemotherapy conducted by the haematologist, the erosion and proliferative lesions in the patient's oral mucosa had significantly improved. HE and immunohistochemical staining results of intraoral lesions also confirmed it as oral FL. The successful diagnosis of FL in this case is of great clinical significance, as the oral and abdominal FL were treated in a timely manner to avoid unfavourable outcomes.

Conclusions

To the best of our knowledge, this is the first case of FL that exhibited widespread erosions interspersed with proliferative lesions. Clinicians should be aware of oral FL or seek systemic factors in the presence of similar refractory oral erosions when treatment is non-responsive and the diagnosis is intractable.