Apthous Ulcers (Mouth Ulcers)

Aphthous ulcers are ulcers that form on the mucous membranes of the mouth or oral cavity. Aphthous ulcers are typically recurrent round or oval sores or ulcers that occur inside the mouth .Aphthous mouth ulcers are very painful sores 

that can occur anywhere inside the mouth. At least 1 in 5 people develop aphthous mouth ulcers at some stage in their life.

There are three types:

• Minor aphthous ulcers are the most common they are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are painful.

• Major aphthous ulcers these are 10 mm or larger. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, and then goes but leaves a scar. They can be very painful – eating may become difficult.

• Herpetiform ulcers’, these are tiny, about 1-2 mm across. Many occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. (These are sometimes called but they have nothing to do with herpes or the herpes virus.)

Aphthous ulcers usually first occur at any age. They then recur from time to time. There can be days, weeks, months, or years between each bout of ulcers. 

The ulcers tend to recur less often as you become older. In many cases, they eventually stop coming back. Some people feel a burning in the mouth for a day or so before an ulcer appears.

Causes of Aphthous ulcers ?

The exact reason why aphthous ulcers develop is not yet clearly defined. Current thinking is that the immune system has been disturbed by some external factor and these results in the development of aphthous ulcers. Also, 

approximately 40% of people who get ulcers have a family history of aphthous ulcers.

Some factors that seem to trigger outbreaks of ulcers include:

• Emotional stress and lack of sleep
• Mechanical trauma, for example self-inflicted bite , improper brushing
• Nutritional deficiencies, particularly vitamins B, iron, and folic acid
• Certain foods including spices, chocolate
• Certain toothpastes and hard tooth brushes
• Smoking, but Some ex-smokers find they develop ulcers only after stopping smoking.
• Changes in hormone levels. Some women find that mouth ulcers occur just before their period. In some women, the ulcers only develop after the menopause.
• Rarely, a food allergy may be the cause.
• A reaction to a medication is a rare cause. For example, anti-inflammatory drugs, and oral nicotine replacement therapy have been reported to cause mouth ulcers in some people.
• Aphthous ulcers are commonly present in certain medical conditions. Many of these conditions are associated with impaired immune systems and include Behcet disease, Crohn disease and inflammatory bowel disease.

Treatments for Aphthous ulcers ?

Treatment aims to ease the pain when ulcers occur, and to help them to heal as quickly as possible. (There is no treatment that prevents aphthous mouth ulcers from recurring.)

• No treatment may be needed. The pain is often mild, particularly with the common ‘minor’ type of aphthous ulcer. Each bout of ulcers will go without treatment.

• General measures include:

• Avoid spicy foods, acidic fruit drinks, and very salty foods (such as crisps) which can make the pain worse.
• Use a straw to drink, to by-pass ulcers in the front of the mouth. (Note: do not drink hot drinks with a straw, as you may burn your throat. Only cold drinks.)
• Use a very soft toothbrush.
• If you suspect a medication is causing the ulcers, then a change may be possible.

• Chlorhexidine mouthwash may reduce the pain. It may also help ulcers to heal more quickly. 

It also helps to prevent ulcers from becoming infected. Chlorhexidine mouthwash is usually used twice a day. 

It may stain teeth brown if you use it regularly. However, the stain is not usually permanent, and can be reduced by avoiding drinks that contain tannin (such as tea, coffee, or red wine), and by brushing teeth before use. Rinse your mouth well after you brush your teeth as some ingredients in toothpaste can inactivate chlorhexidine.

• Steroid lozenges may also reduce the pain, and may help ulcers to heal more quickly. By using your tongue you can keep a lozenge in contact with an ulcer until the lozenge dissolves. A steroid lozenge works best the sooner it is started once an ulcer erupts. If used early, it may ‘nip it in the bud’, and prevent an ulcer from fully erupting. The usual dose is one lozenge, four times a day, until the ulcer goes. In children, use for no more than five days at a time.

• Steroid paste (gel) is an alternative to a lozenge.

• A painkilling oral rinse, gel, or mouth spray may help to ease pain. For example, benzydamine spray, or choline salicylate gel. However, the effect of each dose does not last very long.

• Steroid -Other treatments may be tried if the above do not help or where the pain and ulceration are severe. For example, a course of steroid tablets, strong steroid mouthwashes, colchicine, tetracycline or doxycycline mouthwashes, and some immunosuppressant drugs.

• Cautery with Silver nitrate under local anesthetic is very effective. It destroy the nerve endings under the ulcer base reducing pain and early healing.

• Biopsy to be done if mouth ulcer doesn’t heal after 2-3 weeks, to rule out any malignancy.