Mouth ulcer

• Chemicals such as SLS (a common ingredient in many toothpastes^[6]) have been linked to mouth ulcers,^[7] and have been recognized by public health agencies such as the NHS as a risk factor.^[8]
• Infections (e.g. herpes viruses)
• Injuries (e.g. biting of the lip, tongue, and cheek, hard foods can scrape the oral tissues, hot foods can cause burns)
• Nutritional disorders (e.g., vitamin deficiencies).
• Possibly heavy metals,^[9] of which cadmium occurs in phosphate rock^[10]
• Emotional stress is commonly associated with recurrent ulcers.^[11][12]

Pathophysiology

The exact pathogenesis is dependent upon the cause.

Simple mechanisms which predispose the mouth to trauma and ulceration are

Pathologically, the mouth represents a transition between the gastrointestinal tract and the skin, meaning that many gastrointestinal and cutaneous conditions can involve the mouth. Some conditions usually associated with the whole gastrointestinal tract may present only in the mouth, e.g., orofacial granulomatosis/oral Crohn's disease.^[15]

Similarly, cutaneous (skin) conditions can also involve the mouth and sometimes only the mouth, sparing the skin. The different environmental conditions (saliva, thinner mucosa, trauma from teeth and food) mean that some cutaneous disorders which produce characteristic lesions on the skin produce only nonspecific lesions in the mouth.^[16] The vesicles and bullae of blistering mucocutaneous disorders progress quickly to ulceration in the mouth, because of moisture and trauma from food and teeth. The high bacterial load in the mouth means that ulcers may become secondarily infected. Cytotoxic drugs administered during chemotherapy target cells with fast turnovers such as malignant cells. However, the epithelia of the mouth also has a high turnover rate and makes oral ulceration (mucositis) a common side effect of chemotherapy.^{[citation needed]}

Erosions, which involve the epithelial layer, are red in appearance since the underlying lamina propria shows through. When the full thickness of the epithelium is penetrated (ulceration), the lesion becomes covered with a

Diagnosis

Diagnosis of mouth ulcers usually consists of a medical history followed by an oral examination as well as examination of any other involved area. The following details may be pertinent: The duration that the lesion has been present, the location, the number of ulcers, the size, the color and whether it is hard to touch, bleeds or has a rolled edge. As a general rule, a mouth ulcer that does not heal within 2 or 3 weeks should be examined by a health care professional who is able to rule out oral cancer (e.g. a

An ulcer that keeps forming on the same site and then healing may be caused by a nearby sharp surface, and ulcers that heal and then recur at different sites are likely to be RAS. Malignant ulcers are likely to be single in number, and conversely, multiple ulcers are very unlikely to be oral cancer. The size of the ulcers may be helpful in distinguishing the types of RAS, as can the location (minor RAS mainly occurs on non-keratinizing mucosa, major RAS occurs anywhere in the mouth or oropharynx). Induration, contact bleeding and rolled margins are features of a malignant ulcer. There may be nearby causative factor, e.g. a broken tooth with a sharp edge that is traumatizing the tissues. Otherwise, the person may be asked about problems elsewhere, e.g. ulceration of the genital mucous membranes,[19] eye lesions or digestive problems, swollen glands in neck (lymphadenopathy) or a general unwell feeling.^{[citation needed]}

The diagnosis comes mostly from the history and examination, but the following special investigations may be involved: blood tests (vitamin deficiency, anemia, leukemia, Epstein-Barr virus, HIV infection, diabetes) microbiological swabs (infection), or urinalysis (diabetes). A biopsy (minor procedure to cut out a small sample of the ulcer to look at under a microscope) with or without immunofluorescence may be required, to rule out cancer, but also if a systemic disease is suspected.^[5] Ulcers caused by local trauma are painful to touch and sore. They usually have an irregular border with erythematous margins and the base is yellow. As healing progresses, a keratotic (thickened, white mucosa) halo may occur.^[13]: 52

Differential diagnosis

Due to various factors (saliva, relative thinness of oromucosa, trauma from teeth, chewing, etc.),

Aphthous stomatitis and local trauma are very common causes of oral ulceration; the many other possible causes are all rare in comparison.^{[citation needed]}

Traumatic ulceration

Most mouth ulcers that are not associated with

Common causes of oral ulceration include rubbing on sharp edges of teeth, fillings, crowns, false teeth (dentures), or braces (orthodontic appliances), or accidental biting caused by a lack of awareness of painful stimuli in the mouth (e.g., following local anesthetic used during dental treatment, which the person becomes aware of as the anesthetic wears off).^{[citation needed]}

Eating hard foods (e.g., potato chips) can damage the lining of the mouth. Some people cause damage inside their mouths themselves, either through an absentminded habit or as a type of deliberate

Thermal burns usually result from placing hot food or beverages in the mouth. This may occur in those who eat or drink before a local anesthetic has worn off. The normal painful sensation is absent and a burn may occur. Microwave ovens sometimes produce food that is cold externally and very hot internally, and this has led to a rise in the frequency of intra-oral thermal burns. Thermal food burns are usually on the palate or posterior buccal mucosa, and appear as zones of erythema and ulceration with necrotic epithelium peripherally. Electrical burns more commonly affect the oral commissure (corner of the mouth). The lesions are usually initially painless, charred and yellow with little bleeding. Swelling then develops and by the fourth day following the burn the area becomes necrotic and the epithelium sloughs off.[20]

Electrical burns in the mouth are usually caused by chewing on live electrical wiring (an act that is relatively common among young children). Saliva acts as a conducting medium and an electrical arc flows between the electrical source and the tissues, causing extreme heat and possible tissue destruction.^[20][22]

Chemical injury

Caustic chemicals may cause ulceration of the oral mucosa if they are of strong-enough concentration and in contact for a sufficient length of time. The holding of medication in the mouth instead of swallowing it occurs mostly in children, those under psychiatric care, or simply because of a lack of understanding. Holding an aspirin tablet next to a painful tooth in an attempt to relieve pulpitis (toothache) is common, and leads to epithelial necrosis. Chewable aspirin tablets should be swallowed, with the residue quickly cleared from the mouth.^{[citation needed]}

Other caustic medications include eugenol and chlorpromazine. Hydrogen peroxide, used to treat gum disease, is also capable of causing epithelial necrosis at concentrations of 1–3%. Silver nitrate, sometimes used for pain relief from aphthous ulceration, acts as a chemical cauterant and destroys nerve endings, but the mucosal damage is increased. Phenol is used during dental treatment as a cavity sterilizing agent and cauterizing material, and it is also present in some over-the-counter agents intended to treat aphthous ulcerations. Mucosal necrosis has been reported to occur with concentrations of 0.5%. Other materials used in endodontics are also caustic, which is part of the reason why use of a rubber dam is now recommended.^[20]

Irradiation

As a result of

Aphthous stomatitis (also termed recurrent aphthous stomatitis, RAS, and commonly called "canker sores") is a very common cause of oral ulceration. 10–25% of the general population have this non-contagious condition. Three types of aphthous stomatitis exists based on their appearance, namely minor, major and herpetiform major aphthous ulceration. Minor aphthous ulceration is the most common type, presenting with 1–6 small (2-4mm diameter), round/oval ulcers with a yellow-grey color and an erythematous (red) "halo". These ulcers heal with no permanent scarring in about 7–10 days. Ulcers recur at intervals of about 1–4 months. Major aphthous ulceration is less common than the minor type, but produces more severe lesions and symptoms. Major aphthous ulceration presents with larger (>1 cm diameter) ulcers that take much longer to heal (10–40 days) and may leave scarring. The minor and major subtypes of aphthous stomatitis usually produce lesions on the non-keratinized oral mucosa (i.e. the inside of the cheeks, lips, underneath the tongue and the

Rarely, a persistent, non-healing mouth ulcer may be a

Some of the viral infections mentioned above are also classified as

Rarely, allergic reactions of the mouth and lips may manifest as erosions; however, such reactions usually do not produce frank ulceration. An example of one common

The conditions eosinophilic ulcer and necrotizing sialometaplasia may present as oral ulceration.

Macroglossia, an abnormally large tongue, can be associated with ulceration if the tongue protrudes constantly from the mouth.^[20] Caliber persistent artery describes a common vascular anomaly where a main arterial branch extends into superficial submucosal tissues without a reduction of diameter. This commonly occurs in elderly people on the lip and may be associated with ulceration.^[20]

Treatment

Treatment is cause-related, but also symptomatic if the underlying cause is unknown or not correctable. It is also important to note that most ulcers will heal completely without any intervention. Treatment can range from:

• Smoothing or removing a local cause of trauma
• Addressing dry mouth
• Substituting a problem medication or switching to SLS-free toothpaste
• Maintaining good oral hygiene and use of an antiseptic mouthwash or spray (e.g. chlorhexidine), which can prevent secondary infection and therefore hasten healing
• A topical analgesic (e.g. benzydamine mouthwash) to reduce pain
• Topical (gels, creams or inhalers) or systemic steroids may be used to reduce inflammation
• An
  antifungal drug may be used to prevent oral candidiasis developing in those who use prolonged steroids^[5]
• People with mouth ulcers may prefer to avoid hot or spicy foods, which can increase the pain[1]
• Self-inflicted ulceration can be difficult to manage, and psychiatric input may be required in some people^[13]: 53
• For recurrent ulcers, vitamin B12 has been shown to be effective^[34]

Epidemiology

Oral ulceration is a common reason for people to seek medical or dental advice.^[13]: 52 A breach of the oral mucosa probably affects most people at various times during life. For a discussion of the epidemiology of aphthous stomatitis, see the epidemiology of aphthous stomatitis.

See also

• Sodium dodecyl sulfate

References