Mouth Ulcers

Introduction

Mouth ulcers has 3 main clinical presentations.

• Minor aphthous ulcers (MAUs)
• Most cases of mouth ulcers (80%) are minor aphthous ulcers, which are self-limiting (last from 5 to 14 days).
• The cause is unknown.
• The lesions (usually 5-6 mm in diameter) appear as a white or yellowish centre with an inflamed red outer edge.
• Pain is the key presenting symptom and can make eating and drinking difficult, although pain subsides after 3 or 4 days.
• Major aphthous ulcers
• Characterized by large (>1 cm in diameter) numerous ulcers, occurring in crops of 10 or more.
• Herpetiform ulcers
• Are pinpoint, often occur in large crops of up to 100 at a time, and can be extremely painful.

Any mouth ulcers that have persisted for longer than 3 weeks requires immediate referral to the dentist or doctor because an ulcer of such long duration may indicate serious pathology, such as carcinoma.

NOTE: In children under 10 years, hand, foot and mouth disease should be ruled out.

• Hand, foot and mouth disease patients usually present with a maculopapular/vesicular rash on the extremities (predominantly the hands and to a lesser extent the feet) and painful oral lesions, which is often preceded by a 12-36 hour prodrome that may include fever. The rash may also involve the knees, elbows, buttocks and/or genital areas. It is highly contagious, and good hygiene is required to prevent it from spreading to others.

Drugs Causing Ulcers

The oral mucosa is particularly vulnerable to ulceration in patients treated with cytotoxic drugs, e.g. methotrexate. Other drugs capable of causing oral ulceration include ACE inhibitors, gold, nicorandil, NSAIDs, pancreatin, penicillamine, proguanil hydrochloride and protease inhibitors.

OTC Medications for Minor Aphthous Ulcers

A wide range of products are used for the temporary relief and treatment of mouth ulcers.

• Topical corticosteroids
• Acts locally to reduce inflammation and pain.
• Local analgesics or anaesthetics (e.g. benzydamine mouthwash, choline salicylate dental gel and lidocaine)
• Producing temporary pain relief.
• In 2009, the CHM has advised that topical oral pain relief products containing salicylate salts should not be used in children under 16 years, as a cautionary measure due to the theoretical risk of Reye's syndrome.
• Topical hyaluronic acid (e.g. Aloclair and Gengigel)
• It coats the oral mucosa, enhances tissue hydration and accelerates healing.
• Antibacterials (e.g. chlorhexidine mouthwash)
• There is some evidence that chlorhexidine mouthwash reduces duration and severity of ulceration.
• Side effects associated with chlorhexidine mouthwash use include reversible tongue and tooth discolouration, burning of the tongue and taste disturbances.

External Links

• Use of steroids in treatment of aphthous ulceration, 1968
  
• Hexetidine mouth rinse in the management of minor aphthous ulceration and as an adjunct to oral hygiene, 1991
  
• Oral salicylate gels: not for use in those younger than age 16 years, 2014
• Systematic review: the efficacy of topical hyaluronic acid on oral ulcers, 2017