Sir, I am writing to report a rather unusual case of oral ulceration I came across recently that required a certain amount of detective work to finally establish a cause. The patient, a 68-year-old gentleman, attended with severe oral ulceration of two weeks duration. The ulceration was unilateral, involving the floor of mouth, gingivae and buccal mucosa on the right side. The affected areas were very large and painful with multiple coalesced ulcers in all areas. The patient's medical history revealed medication for hypertension and high cholesterol but nothing of any further significance. The unilateral nature of the ulceration seemed to be significant but as to its cause I couldn't come to a firm diagnosis. The patient was prescribed Benzydamine Hydrochloride and was reviewed two weeks later. At review the ulceration was still present with little change. I applied Propolis and instructed the patient to rinse regularly with Propolis tincture. The patient was reviewed one week later at which time the ulceration had improved considerably. At this review appointment the patient asked whether holding anything in his teeth would give rise to the problem. On questioning it appears that he is a very keen gardener and the week before the ulceration appeared he was staking out dahlias with plant ties, which he held in his mouth. On further questioning he was holding anything up to 400 ties during this process, which were re-used ties from other plants. I asked him whether the plants were sprayed with anything and it was revealed he used both insecticide and fungicide regularly on the plants and of course the ties.

The cause of the ulceration then became clear. The insecticide contained permethrin and malathion and the fungicide contained myclobutanil. All these chemicals are highly toxic if ingested causing multiple problems especially mucosal damage to mouth, oesophagus and stomach lining. The patient was naturally told to desist from this practice in future and was reviewed regularly with no further problems.

This is an example of how a commonplace presentation may have a much more complex history than first thought.