Mouth Ulcers/ Oral Stomatitis

One or more painful sores on inner lips, gums, tongue, roof of the mouth or throat that may interfere with eating, such as a canker sore. A mouth ulcer (aphtha) is an ulcer that occurs on the mucous membrane of the oral cavity. Oral ulceration is a common reason for people to seek medical or dental advice. A breach of the oral mucosa probably affects most people at various times during life.

Introduction

An ulcer from Latin  ulcus, "ulcer, sore" is a break in the skin or mucous membrane with loss of surface tissue and the disintegration and necrosis of epithelial tissue.  A mucosal ulcer is an ulcer which specifically occurs on a mucous membrane.

                                             

 
An ulcer is a tissue defect which has penetrated the epithelial-connective tissue border, with its base at a deep level in the submucosa, or even within muscle or periosteum. An ulcer is a deeper breach of epithelium compared to an erosion or excoriation, and involves damage to both epithelium and lamina propria.
An erosion  is a superficial breach of the epithelium, with little damage to the underlying lamina propria. A mucosal erosion is an erosion which specifically occurs on a mucous membrane. Only the superficial epithelial cells of the epidermis or of the mucosa are lost, and the lesion can reach the depth of the basement membrane. Erosions heal without scar formation.
Excoriation is a term sometimes used to describe a breach of the epithelium which is deeper than an erosion but shallower than an ulcer. This type of lesion is tangential to the rete pegs  and shows punctiform (small pinhead spots) bleeding, caused by exposed capillary  loops. Rete pegs are finger-like structures that are formed during the development and wound healing process of the skin and oral mucosa, and they provide better mechanical resistance and nutritional supply between the epithelium and dermis

Diagrammatic representation of mucosal erosion (left), excoriation (center), and ulceration (right)

Glossitis 

Catarrhal Stomatitis: inflammation of a mucous membrane in humans, chronically affecting the human nose and air passages

(i.e. After Drugs (Antibiotics) Stomatitis (Sore Mouth)

Why are mouth ulcers so painful?

Why do they hurt so much? A canker sore is essentially an injury to the inside of your mouth. Unfortunately, the inside of your mouth is full of digestive enzymes and acids that eat into the sore, which is what causes the pain.

Causes

Ulcers and erosions can be the result of a spectrum of conditions including: Aphthous stomatitis and local trauma are very common causes of oral ulceration; the many other possible causes are all rare in comparison.

• Infections : Opportunistic activity by combinations of otherwise normal bacterial flora, such as aerobic streptococci, Neisseria, Actinomyces, spirochetes, and Bacteroides species can prolong the ulcerative process

Infectious causes of oral ulceration

Agent	Example(s)
Viral	Herpes, chickenpox, hand, foot and mouth disease, herpangina, herpetic stomatitis, human immunodeficiency virus, infectious mononucleosis.
Bacterial	acute necrotizing ulcerative gingivitis, gangrenous stomatitis, syphilis, tuberculosis
Fungal	Candida, blastomycosis, cryptoccissosis, histoplasmosis, Para coccidioidomycosis
Parasitic	leishmaniasis

Many infections can cause oral ulceration. The most common are herpes simplex  virus (herpes labialis, primary Herpatic gingivostomatitis ),  Varicella zoster (chicken pox, shingles),  and Coxsackie. A virus (hand, foot and mouth disease), Human immunodeficiency virus  (HIV) creates immunodeficiencies which allow opportunistic infections or neoplasms to proliferate. Bacterial processes leading to ulceration can be caused by Mycobacterium tuberculosis (tuberculosis)  and treponema pallidum (syphilis). 

• Nutritional deficiencies :  (e.g., vitamin B12, Folic acid, Iron deficiencies).
• Chemicals such as SLS (a common ingredient in many toothpastes) have been linked to mouth ulcers, and have been recognized by public health agencies such as the NHS as a risk factor.
• Injuries (e.g. biting of the lip, tongue, and cheek, hard foods can scrape the oral tissues, hot foods can cause burns)
• Emotional Stress: Possible triggers of aphthous ulcers include emotional stress. When the body is stressed, the immune symptom may trigger mouth sores
• Those causing auto-immune epithelial damage, damage because of an immune defect (e.g., HIV, leukemia )
• Hematological causes include deficiencies, neutropenia, hyper eosinophilic syndrome, leukemia, myelodysplastic syndromes, other white cell dyscrasias, and gammopathies.. 
• Gastrointestinal causes include celiac disease, Crohn's disease (orofacial celiac disease, Crohn's disease, (orofacial granulomatosis) and ulcerative colitis. 
• Dermatological causes include chronic ulcerative stomatitis, erythema multiforme (Stevens-Johnson syndrome), angina bullosa haemorrhagica and lichen planus.
• Prolong use of steroids
• Aggressive tooth brushing

• History of recent fracture or hospitalization.
• Dehydration : Due to diarrhea or vomiting.
• Dryness of mouth : Antihistamines, Atropine,
• Recurrent ulcers before menstruation : Due to estrogen deficiency.
• Leukoplakia : Rule out malignancy by taking Biopsy of the Patch. 
• Periodic fever

• Due to various factors (saliva, relative thinness of oral-mucosa, trauma from teeth, chewing, etc.), vesicles and bullae which form on the mucous membranes of the oral cavity  tend to be fragile and quickly break down to leave ulcers.
• Traumatic ulceration : Most mouth ulcers that are not associated with recurrent aphthous stomatitis are caused by local trauma. The mucous membrane lining of the mouth is thinner than the skin, and easily damaged by mechanical, thermal (heat/cold), chemical, or electrical means, or by irradiation.
• 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). Eating hard foods can damage the lining of the mouth. Some people cause damage inside their mouths themselves, either through an absent minded habit or as a type of deliberate self harm factitious (ulceration). Examples include biting the cheek, tongue, or lips, or rubbing a fingernail, pen, or toothpick inside the mouth. Tearing (and subsequent ulceration) of the upper labial frenum may be a sign of child abuse (non-accidental injury).
• Iatrogenic ulceration can also occur during dental treatment, where incidental abrasions to the soft tissues of the mouth are common. Some dentists apply a protective layer of petroleum jelly to the lips before carrying out dental work to minimize this.
• Thermal and electrical burn : 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. 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
• 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.  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.
• Irradiation : As a result of radiotherapy  to the mouth, radiation-induced stomatitis may develop, which can be associated with mucosal erosions and ulceration. If the salivary glands are irradiated, there may also be xerostomia  (dry mouth), making the oral mucosa more vulnerable to frictional damage as the lubricating function of saliva is lost, and mucosal atrophy  (thinning), which makes a breach of the epithelium more likely. Radiation to the bones of the jaws causes damage to osteocytes  and impairs the blood supply. The affected hard tissues become hypo vascular (reduced number of blood vessels), hypocellular (reduced number of cells), and hypoxic (low levels of oxygen).  Osteoradionecrosis is the term for when such an area of irradiated bone does not heal from this damage. This usually occurs in the mandible, and causes chronic pain and surface ulceration, sometimes resulting in non-healing bone being exposed through a soft tissue defect. Prevention of osteoradionecrosis is part of the reason why all teeth of questionable prognosis are removed before the start of a course of radiotherapy.
• Aphthous stomatitis : Possible triggers of aphthous ulcers include: Emotional stress. Minor injury to the inside of the mouth, for example from cuts, burns or bites while eating, dental work, hard brushing or ill-fitting dentures. 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 floor of mouth), but less commonly major aphthous ulcers may occur in other parts of the mouth on keratinized mucosal surfaces. The least common type is herpetiform ulceration, so named because the condition resembles primary herpetic gingivostomatitis . Herpetiform ulcers begin as small blisters (vesicles) which break down into 2-3mm sized ulcers. Herpetiform ulcers appear in "crops" sometimes hundreds in number, which can coalesce to form larger areas of ulceration. This subtype may cause extreme pain, heals with scarring and may recur frequently. The exact cause of aphthous stomatitis is unknown, but there may be a genetic predisposition in some people. 
• Other possible causes include hematinic deficiency (folate, vitamin B, iron), stopping smoking, stress, menstruation, trauma, food allergies or hypersensitivity to sodium lauryl sulphate (found in many brands of toothpaste). Aphthous stomatitis has no clinically detectable signs or symptoms outside the mouth, but the recurrent ulceration can cause much discomfort to those affected. Treatment is aimed at reducing the pain and swelling and speeding healing, and may involve systemic or topical steroid, analgesics (pain killers), antiseptics, anti-inflammatories or barrier pastes to protect the raw area(s).
• Allergy :  An example of one common allergen is Balsam of Peru. If individuals allergic to this substance have oral exposure they may experience stomatitis. (inflammation, rash, or painful erosion of the lips, oropharyngeal mucosa, or angles of their mouth). Balsam of Peru is used in foods and drinks for flavoring, in perfumes and toiletries for fragrance, and in medicine and pharmaceutical items for healing properties
• Drug-induced : Antibiotics, Antitubercular drugs. Many drugs can cause mouth ulcers as a side effect. Common examples are alendronate  (a bisphosphonate, commonly prescribed for osteoporosis), cytotoxic drugs  (e.g. methotrexate, i.e. chemotherapy), non-steroid anti-inflammatory drugs, 
• NSAIDs. Mefenamic acid, Diclofenac, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Diflunisal, Piroxicam, Naproxen, Ketoprofen, Etodolac, Flurbiprofen, Meloxicam, Nabumetone, Oxaprozin, Sulindac, Tolmetin.
•  Nicorandil  (may be prescribed for angina) and propylthiouracil (e.g. used for hyperthyroidism). Some recreational drugs can cause ulceration, e.g. cocaine
• Malignancy: Rarely, a persistent, non-healing mouth ulcer may be a cancerous lesion. Malignancies in the mouth are usually carcinomas, Either the tumor arises in the mouth, or it may grow to involve the mouth, e.g. from the maxillary sinus, salivary glands, nasal cavity or peri-oral skin. The most common type of oral cancer is squamous cell carcinoma. The main risk factors are long-term smoking and alcohol consumption (particularly when combined) and betel use. Common sites of oral cancer are the lower lip, the floor of the mouth, and the sides, underside of the tongue and mandibular alveolar ridge, but it is possible to have a tumor anywhere in the mouth. Appearances vary greatly, but a typical malignant ulcer would be a persistent, expanding lesion that is totally red (erythroplasia) or speckled red and white (erythroleukoplakia). Malignant lesions also typically feel indurated (hardened) and attached to adjacent structures, with "rolled" margins or a punched out appearance and bleeds easily on gentle manipulation.

Tongue Ulcer

Diagnosis

• Medical history :  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.
• Oral examination as well as examination of any other involved area. 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, eye lesions or digestive problems, swollen glands in neck (lymphadenopathy) or a general unwell feeling.

The diagnosis comes mostly from the history and examination, but the following special investigations may be involved: 

• Blood tests : For sugar to rule out diabetes. Complete Blood Count (CBC ) i.e.  for Red blood cells, (RBC), Hemoglobin, total white blood cells (WBC), Eosinophil count, to rule out (vitamin deficiency, anemia, leukemia, Epstein-Barr virus, HIV infection)
• Microbiological Swabs (for infection)  
• Urine Analysis (for diabetes).   
• Biopsy:  for Leucoplakia  (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. 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.

 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 dentist, oral physician, oral surgeon or maxillofacial surgeon). If there have been previous ulcers that have healed, then this again makes cancer unlikely.

Mudra

Prithvi Mudra 

 पृथ्वी मुद्रा Quickens healing Wounds

• Prithvi mudra is good for Aphthous ulcer.

Prithvi mudra increases the earth

Diet

Folic acid : All leafy green vegetables. 

• Sunflower seeds are the source of folic acid

Vitamin B12

Deficiency of vitamin B12 or Cobalamin can cause mouth ulcers. Sources of vitamin B12 : Food

Vitamin B12 is naturally present in foods of animal origin, including fish, meat, poultry, eggs, and dairy products. In addition, fortified breakfast cereals and fortified nutritional yeasts are readily available sources of vitamin B12 that have high bioavailability.

Iron

Green vegetables.

Probiotics

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 : Keep your self well hydrated. Drink at least 8-10 glasses of water.
• Substituting a problem medication or SLS- free toothpaste : 

* Bentodent Toothpaste 

*Sensodyne Fresh Mint Toothpaste

*  Splat PS Green Tea Toothpaste

*  Lever Ayush Anti Cavity Clove Oil Toothpaste

*  Dabur Red Paste

*   Mamaearth Kids 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 candidysis developing in those who use prolonged steroids
• People with mouth ulcers may prefer to avoid hot or spicy foods, which can increase the pain.
• Self-inflicted ulceration can be difficult to manage, and psychiatric input may be required in some people.
• For recurrent ulcers, vitamin B12 (Cobalamine) has been shown to be effective
• Maintain your immunity level high by taking adequate amount of vitamin C in form of citrous fruits. As it helps in wound healing.

Candidiasis (Thrush)

• For Oral Thrush : Treatment of Candida infection (which is common) Candid Mouth Paint  or Candid Lotion

• Saturated solution of Soda bicarb for mouth wash
• Gentian violet 1% solution in water. Paint the patches with the solution.

Chronic Candidiasis

• Oral leision may respond only to IV Amphotericin with or without flucytosine, fluconazole or ketoconazole.

Leucoplakia

Glossitis - Stomatitis (Sore Mouth)

• Bland Diet
• Glycerine Borax- Apply locally 3-4 times a day.
• B-complex forte tablets 2 daily.
• Or Inj B-complex withB12 1ml IM daily for 10 days.
• Avoid Spices,, tobacco, hot food.

Aphthous Ulcer

• Eliminate suspect foods
• Good Oral hygiene
• Aqueous chlorhexidine 0.2% mouth wash.
• Povidone Iodine Mouth wash
• Kamilosan N spray
• Dequadin paint.. Apply locally to ulcer3-4 times a day

For Recurrent Ulcers

• For recurrent ulcers, Vitamin B12  has been shown to be effective

For Multiple leisions

• Tetracycline cap 250 mg, dissolve 1 cap in water and rinse the mouth three times a day.
• Tetracycline oral suspension 250mg is held in the mouth for 2-5 minutes to coat the ulcers before swallowing.
• Lignocaine (Gesicain) viscous 2% in 5 ml (1tsp) as oral rinse q3h or Benadryl elixir 5 ml as oral rinse q2h
• Sodabicarb mouth wash 2.5 ml in 80& warm water soothes and cleans.
• Lexanox oral paste.
• Or Apply Aloe vera gel oral get directly to the ulcers before sleeping.

• Tab Folic acid 5 mg once a day for a week.

• Tab (iron) Ferrous sulphate OD for a week

If Pain

• Tab Paracetamol 1-1-1
• Tab Lynoral (Ethinyl oestradiol) 2 mg daily if recurrent ulcers before menstruation. 
• Gelora or Zytee or Hexigel or Mucopain.

                                               

What are some ways to treat mouth ulcers?

• using a rinse of saltwater and baking soda.
• placing milk of magnesia on the mouth ulcer.
• covering mouth ulcers with baking soda paste.
• using over-the-counter benzocaine (topical anesthetic) products like Orajel or Anbesol.
• applying ice to canker sores.

Note : Patient with oral ulcers must be reviewed within 3 weeks to ensure that  healing has occurred. Otherwise the ulcer must  be biopsied.

Viral (Primary Herpatic gingivostomatitis)

Same as Catarrhal. 

• Rebagen Tab TDS for 7 days. (used for peptic ulcer)

Herpatic Labialis

• 5% Acyclovir Cream (Zovirax) cream
• Dettolin or Povidone gargles several times a daily (to prevent secondary infection)

For Frequent Cold Sores  (As prophylaxis)

• Oral Acyclovir 400-800 mg/day for 12 months or more

Leukoplakia :Rule out malignancy by taking Biopsy of the patch.

Eliminate associated cause :

• Stop smoking
• Alcohol
• Betel
• Sharp tooth
• Spices
• Anemia
• Spirits
• Syphilis
• Kidney failure
• HIV Infection

Herb

Liquorice / मुलेठी

A small quantity of licorice is an effective natural balm.

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