MOUTH ULCERS

INTRODUCTION

Mouth ulcers, as the name suggests, are ulcers found in the mouth (they may extend down into the throat). They are also known as Aphthous ulcers or Canker sores.

Who gets mouth ulcers? Anyone can, though the incidence is greater amongst teenagers or women just prior to their period, and also in smokers who have recently given up. Many patients have a family history (up to 46%) of mouth ulcers.

A number of other factors have been implicated in the development of mouth ulcers. These include:

·         Diet: deficiencies of iron, B₁₂ and folic acid as well as diets containing sizeable amounts of tomatoes, chocolate and pineapple juice or other acidic foods.

·         Stress: leading to a feeling of being generally run down.

·         Hormonal changes: especially during the premenstrual phase, sees an increase in incidence, whilst during pregnancy there is often a reduction in incidence.

·         Allergy to foods, hay fever, or asthma.

·         Dentures or braces: when food particles get lodged beneath the dentures and cause friction with the gum, or if dentures are ill fitting. Also teeth with jagged edges causing friction.

·         Toothpaste containing sodium lauryl sulphate (a foaming agent) has been linked to recurrent mouth ulcers.

DIAGNOSIS

Mouth ulcers appear as single or multiple lesions and are generally located on the inside of the cheek or lips or around the edge of the tongue. They may be classified as either minor or major.

1.      MINOR MOUTH ULCERS: These are probably the most common type that affects the inside of the mouth. They are generally less than 1cm in diameter. They are characterised by a whitish /yellow centre with a red border. 

These ulcers generally last for 10-14 days and heal without scarring. The acutely painful stage lasts 3-5 days followed by gradual healing. They are most commonly found on the cheeks and lips as well as on the underside or edges of the tongue.

2.      MAJOR MOUTH ULCERS: These are larger than minor mouth ulcers (>1cm in size). They usually occur singly and may appear on any surface of the mouth, including the back of the mouth. These may persist for weeks to months and will often leave a scar upon healing. If more than one ulcer develops, they may join to form a larger single wound. Often patients may get recurrences so often that they may suffer from continuous ulceration. These can often occur from teeth/ill-fitting dentures and tend to get bigger rather than disappear.

DIAGNOSES TO BE EXCLUDED:

1.      Candidiasis/oral thrush: Appears as white raised patches resembling milk curds with a reddened painful area underneath which may bleed a little. It may occur anywhere, but is most commonly seen on the tongue and inside of the cheeks. From here it can spread to the palate, gums, tonsils, and pharynx.

2.      Herpes: Appears as multiple, small, irregularly shaped lesions of varying size. A large reddened area surrounds the lesions. The oral mucosa and lips are commonly affected sites.

3.      Traumatic ulceration: e.g. with dentures. Adjustment of the denture will be required for long-term resolution.

4.      Dermatological conditions: Some skin conditions are associated with mouth ulcers. Therefore, if the patient has lesions on other areas of the body, they should see a doctor.

5.      Neoplasms (cancer): These are areas of tissue that grow out of control. They may present as a persistent ulcer with or without pain. The margins are often red and raised, and the area is very firm. Prompt referral is necessary.

WHEN TO REFER

·         You are unsure whether the lesion is an ulcer

·         The lesion does not heal significantly within 7 days

·         It is associated with lesions elsewhere on the body

·         There are signs of generalised illness.

TREATMENT OF MOUTH ULCERS

There is no cure for mouth ulcers. Management revolves around relieving the symptoms and protecting the ulcers from further irritation.

Check for food reactions e.g. chocolate and citrus fruits. Also recommend that patients try to avoid stress.

MOUTH ULCER SOLUTION PACK

1.      Kenalog in Orabase: Helps to reduce pain and accelerate healing. It contains a steroidal anti-inflammatory, which relieves the tenderness, pain, and inflammation of the ulcer, in a specially formulated base that forms a protective coating over the ulcer. This coating helps to keep the medication in close contact with the lesion. This product is not to be used if there is an infection in the mouth. If unsure, check with the pharmacist.

Directions: Press a small dab of paste to the lesion until a thick film develops.

                  Do not rub it in as this will result in a gritty sensation. Application is usually best at bedtime but may be used up to 3 to 5 times a day after eating.

If the lesion has not healed significantly within 7 days then consult the pharmacist or a doctor.

2.      Savacol mouthwash: This is a chlorhexidine-based mouthwash that is active against a variety of bacteria. This helps to keep the ulcer from getting infected and prevents worsening of the condition. It also helps soothe the discomfort of mouth ulcers.

Directions: Adults-rinse or gargle 10mL of undiluted Savacol up to 3 times a day.

Children-rinse or gargle 5mL of Savacol, diluted with 5mL of warm water up to 3 times a day.

3.      Tresos B: Contains high dose vitamin B including B₁₂  and folic acid, zinc, and vitamin C, all of which may be lacking in a patient suffering from mouth ulcers. This is a multivitamin, trace mineral antioxidant and amino acid complex. Directions: Take one tablet daily.

4.      Biotene toothpaste: to be used in place of regular toothpaste as it doesn’t contain Sodium Lauryl Sulphate which has been shown to be a cause of recurrent mouth ulcers in some people.