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A mouth ulcer (from Latin ulcus) is the name for the appearance of an open sore inside the mouth caused by a break in the mucous membrane or the epithelium on the lips or surrounding the mouth. The types of mouth ulcers are diverse, with a multitude of associated causes including: physical or chemical trauma, infection from microorganisms or viruses, medical conditions or medications, cancerous and sometimes nonspecific processes. Once formed, the ulcer may be maintained by inflammation and/or secondary infection. Two common mouth ulcer types are aphthous ulcers (canker sores) and cold sores caused by the herpes simplex virus.••
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Symptoms
The symptoms preceding the ulcer may vary according to the cause of the ulcerative process.
Some mouth ulcers may begin with a tingling or burning sensation at the site of the future mouth ulcer. In a few days, they often progress to form a red spot or bump, followed by an open ulcer. Sometimes this takes a little bit longer, depending on the cause of the ulcer.
The mouth ulcer appears as a white or yellow oval with an inflamed red border. Sometimes a white circle or halo around the lesion can be observed. The grey, white, or yellow coloured area within the red boundary is due to the formation of layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is often extremely painful, especially when agitated, may be accompanied by a painful swelling of the lymph nodes below the jaw, which can be mistaken for toothache.
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Causes
There are many processes which can lead to mouth ulceration. In some cases they are caused by an overreaction by the body's own immune system. Factors that appear to provoke them include stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies and deficiencies in vitamin B12, iron and folic acid. Some drugs, such as nicorandil, have been linked with mouth ulcers.
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Minor physical injuries
Trauma to the mouth is a common cause of mouth ulcers. A sharp edge of a tooth, accidental biting (this can be particularly common with sharp canine teeth), sharp food, poorly fitting dentures, dental braces or trauma from a tooth brush may injure the mucosal lining of the mouth resulting in an ulcer. These ulcers usually heal rapidly if the source of the injury is removed (for example, if poorly fitting dentures are removed or replaced).•
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Chemical injuries
Chemicals such as Aspirin or alcohol that are held or that come in contact with the oral mucosa may cause tissues to become necrotic and slough off creating an ulcerated surface.
Sodium Lauryl Sulfate (SLS), one of the main ingredients in most toothpastes, has been implicated in increased incidence of mouth ulcers.
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Infection
Viral, fungal and bacterial processes can lead to oral ulceration.
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Viral
The most common is Herpes simplex virus which causes recurrent herpetiform ulcerations preceded by usually painful multiple vesicles which burst. Herpes Zoster (shingles), Varicella Zoster (chicken pox), Coxsackie A virus and its associated subtype presentations, are some of the other viral processes that can lead to ulceration. HIV creates immunodeficiencies which allow opportunistic infections or neoplasms to proliferate.•
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Bacterial
Bacterial processes leading to ulceration can be caused by Mycobacterium tuberculosis (tuberculosis) and treponema pallidum (syphilis).
Opportunistic activity by combinations of otherwise normal bacterial fauna, such as aerobic streptococci, Neisseria, Actinomyces, spirochetes, and bacteroides can prolong the ulcerative process.[*] According to small-scale experiments by at least one patent applicant (Hau, US Patent No. 6,248,718), topical preparations of high doses of penicillin resulted in accelerated healing of mouth ulcers.
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Fungal
Coccidioides immitis (valley fever), cryptococcus neoformans (cryptococcosis), Blastomyces dermatitidis ("North American Blastomycosis") are some of the fungal processes causing oral ulceration.
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Immune system
Many researchers view the causes of aphthous ulcers as a common end product of many different disease processes, each of which is mediated by the immune system.
Aphthous ulcers are thought to form when the body becomes aware of and attacks chemicals which it does not recognize. The presence of the unrecognized molecules garners a reaction by the lymphocytes, which trigger a reaction that causes the damage of a mouth ulcer.
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Immunodeficiency
Repeat episodes of mouth ulcers can be indicative of an immunodeficiency, signalling low levels of immunoglobulin in the mucous membrane of the mouth. Chemotherapy and HIV are both causes of immunodeficiency with which mouth ulcers become a common manefestation.
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Autoimmunity
Autoimmunity is also a cause of mouth ulceration. Mucous membrane pemphigoid, an autoimmune reaction to the epithelial basement membrane, causes desquamation/ulceration of the oral mucosa.
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Allergy
Contact with allergens can lead to ulcerations of the mucosa.
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Dietary
Vitamin C deficiencies may lead to scurvy which impairs wound healing, which can contribute to ulcer formation.[ Similarly deficiencies in vitamin B12, iron, zinc][*] and folic acid has been linked to oral ulceration.
Too much ascorbic acid (Vitamin C) or citric acid may cause ulcers. In this case the sores disappear after intake decreases (for example, by substituting ascorbate salts for ascorbic acid).
A common cause of ulcers is Coeliac disease, in which case consumption of wheat, rye, or barley can result in chronic mouth ulcers. If gluten intolerance is the cause, prevention means taking most breads, pastas, cakes, pies, cookies, scones, biscuits, beers etc. out of the diet and substituting gluten-free varieties where available. Artificial sugars, such as those found in diet cola and sugarless gum, have been reported as causes of mouth ulcers as well.
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Cancer
Oral cancers can lead to ulceration as the center of the lesion loses blood supply and necroses. Squamous cell carcinoma is just one of these.
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Medical conditions associated with mouth ulcers
The following medical conditions are associated with mouth ulcers:
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Palliative treatment for severe cases
Treatments based on antibiotics and steroids such as Dexamethasone Elixir are reserved for severe cases, and should be used only under medical supervision. Tetracycline suspension is a common antibiotic prescribed for mouth ulcers. Some doctors may also prescribe a local anesthetic, such as lidocaine, for cases of multiple or severe mouth ulcers. If it does not heal within a week, a doctor or dentist may cauterize it using a silver nitrate applicator or laser. This procedure immediately burns off the ulcer, causing it to completely disappear within a few hours or two to three days.
In very severe cases, a doctor may prescribe a steroid treatment. One such steroid is methylprednisolone (usually in a dose-pack), taken orally for a period of 7 days. Alternatively, the doctor may directly inject a steroid into the site of the ulcer (this treatment is performed with kenalog. Between 0.2 and 0.4 cc of kenalog is injected into the site of the ulcer, which will usually be completely healed 72 to 96 hours after the injection).
Some dentists recommend a sulfuric acid solution for treating mouth ulcers, such as debacterol.
Another choice doctors have is to prescribe Aphthasol (amlexanox oral paste, 5%), the only Food and Drug Administration (FDA) approved treatment specifically indicated for Aphthous ulcers.
The miracle cures that are advertised should be viewed with skepticism. However, aqueous sulphuric acid products as listed above can provide significant pain relief, if not treating the underlying causes.
One home remedy is to wet a tea bag and use it as a compress on the area.
Some people benefit from using the over-the-counter topical gel Bonjela, which contains choline salicylate. Choline salicylate is a local analgesic that helps to reduce the pain and inflammation associated with mouth ulcers.
Some people have reported great benefit from eating milk products such as yogurt and buttermilk that contain the active cultures L. Acidophilus.
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Prevention
The majority of the types of ulceration, require treatment of the underlying cause of the oral ulceration for successful prevention; Controlling imbalances in vitamins and minerals related to ulceration, managing or restricting the disease processes has shown to reduce the ulcerative process. For trauma related cases, avoiding the offending source will prevent ulceration, but since such trauma is usually accidental, this type of prevention is not usually practical.
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See also
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