Saidala 24: Mouth ulcers

Introduction
Mouth ulcers, also known as aphthous ulcers, are painful lesions that develop on the mucous membrane inside the oral cavity. They are typically small, round or oval, with a white or yellow base surrounded by an erythematous (red) halo. Most are benign and self-limiting, but recurrent or unusually severe ulcers can indicate underlying systemic disease.

Epidemiology

Common worldwide; prevalence estimated at 5–25% of the population.
Recurrent aphthous stomatitis (RAS) often begins in childhood or adolescence.
Slightly more common in females.

Etiology and Risk Factors

Local and Systemic Causes

Minor trauma: biting the cheek, sharp teeth, ill-fitting dentures, aggressive tooth brushing.
Nutritional deficiencies: iron, folate, vitamin B12, zinc.
Food hypersensitivity: chocolate, coffee, strawberries, tomatoes, cheese, nuts, acidic foods.
Stress and hormonal changes.
Viral infections: herpes simplex virus (usually in herpetiform ulcers).
Autoimmune diseases: Behçet’s disease, inflammatory bowel disease, systemic lupus erythematosus.
Drug-induced: NSAIDs, nicorandil, beta-blockers, cytotoxic drugs.
Immunosuppression: HIV/AIDS.

Classification

Minor Aphthous Ulcers
- Diameter <10 mm.
- Heal within 7–14 days without scarring.
- Most common type.
Major Aphthous Ulcers (Sutton’s Disease)
- Diameter >10 mm.
- Deeper lesions, last several weeks.
- May scar on healing.
Herpetiform Ulcers
- Multiple small ulcers (1–3 mm) that may coalesce.
- Resemble herpes simplex lesions but are not caused by herpes virus.

Clinical Features

Round or oval ulcer with a white, yellow, or grey base and red margin.
Pain worsens with eating, drinking, and speaking.
Usually occur on non-keratinized mucosa (inside cheeks, lips, soft palate, floor of mouth).
Associated symptoms in severe cases: fever, malaise, lymphadenopathy (if secondary infection).

Diagnosis

Diagnosis is usually clinical, based on history and examination.
Investigations may be indicated in recurrent or severe cases:

Full blood count (FBC).
Ferritin, folate, vitamin B12, zinc levels.
ESR/CRP for inflammatory conditions.
HIV testing if immunosuppression is suspected.

Management

General Principles

Aim to reduce pain, promote healing, and prevent recurrence.
Identify and treat underlying cause where present.

1. Non-Pharmacologic Measures

Avoid known trigger foods and trauma.
Maintain good oral hygiene with a soft-bristled toothbrush.
Use alcohol-free mouthwash.
Manage stress with relaxation techniques.

2. Pharmacologic Treatment

Topical Analgesics & Anti-inflammatory Agents

Lidocaine 2% oral gel: Apply thinly to ulcer up to 4 times daily before meals.
Benzydamine mouthwash (0.15%): Rinse for 30 seconds, up to 4 times daily.

Topical Corticosteroids (reduce inflammation, speed healing)

Hydrocortisone buccal tablets 2.5 mg: Dissolve one tablet in mouth 4 times daily.
Triamcinolone acetonide 0.1% dental paste: Apply directly to ulcer 2–4 times daily after meals.
Fluocinonide 0.05% gel: Apply thin layer to ulcer 2–4 times daily.

Antiseptic Mouthwashes (reduce risk of secondary infection)

Chlorhexidine gluconate 0.2%: Rinse for 1 minute twice daily.

Systemic Treatments (for severe or recurrent cases)

Prednisolone: Short course 20–30 mg daily, tapered over 5–7 days (severe inflammation).
Colchicine: 0.5–1.5 mg daily for recurrent aphthous stomatitis.
Dapsone: 50–100 mg daily in selected refractory cases.
Thalidomide: 50–100 mg daily (restricted to specialist use in severe immunosuppression-related ulcers).

Complications

Secondary bacterial infection.
Nutritional compromise due to painful eating.
Scarring (mainly in major ulcers).
Underlying systemic disease missed if ulcers are recurrent and unexplained.

Prognosis

Minor ulcers usually heal spontaneously in 1–2 weeks.
Major ulcers may take weeks to months to resolve.
Recurrence is common, particularly in recurrent aphthous stomatitis.

Saidala 24

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Monday, August 11, 2025

Mouth ulcers