Sir, in reference to the case report letter Oral ulceration with bony sequestration (OUBS), I have seen two similar cases recently.1 Both were over the left mylohyoid region and they healed uneventfully without any intervention other than saline mouthwashes. Both were men, one in his late fifties and the other in his seventies, with no relevant aetiology, although one of the patients was unsure that he might have burnt that site with a hot pudding. They did not have relevant medical history, especially radiotherapy or medications that cause osteonecrosis of the jaw.

They presented as painful, mobile, thin, whitish sequestrum which exfoliated easily during examination revealing irregular ulcers surrounded by erythematous mucosa and bony base. They healed by full mucosal coverage in 3-4 weeks albeit with loss of localised bone volume. I suspect OUBS could be more prevalent than recognised, as the sequestrum could be easily lost and the examining clinician may diagnose it simply as a traumatic ulcer. I agree with R. S. Burrows that the trauma to the thin lingual mucosa overlying the mylohyoid ridge could have resulted in disruption to the local blood supply causing breakdown of the soft tissues and periosteum, and I also agree that clinicians should consider OUBS as a differential diagnosis of mouth ulcers.

Dr Stephen Burrows responds: Thank you for the opportunity to reply to Messrs Maharaj and Majumdar and Mr Chandrasekaran. I agree that caution should be exercised with any oral ulceration especially when it has a protracted history and shows no signs of healing.

An interesting difference was the asymptomatic and potentially insidious nature of the case I presented when a painful symptom picture would have been expected as in the other outlined cases.

Differential diagnosis is of course an important element in the management of oral ulceration and should include recognition of sinister pathology and the need for urgent referral at the outset.

Whilst the medical history included endotracheal intubation (ETI) during recent surgery, the initial signs were of an idiopathic ulcer with a developing bony sequestrum - most likely due to a traumatic incident.

I agree ETI could indeed have been a probable cause and we can be left to speculate on this. However, management of any ulceration should include review to ensure uneventful healing. Two further reviews at short intervals showed this had occurred.

I agree the presence of a recurrent asymptomatic ulcer without any underlying cause could be a reason to refer but again with reviews there were then no indications.