OTC - mouth ulcers

Can be classified into several groups:
Trauma;c, infec;ve, neoplas;c or other (including aphthous)
Recurrent aphthous stoma;;s is extremely common:
Affects as many as one in five people, usual onset between 10 and 19 years
May be a recurrent problem in some
Classified as aphthous (minor or major) or herpe;form ulcers
Occur in all ages, reportedly more common between the age of 10 and 40
Smokers have a lower incidence

Most common non‐traumatic lesion of oral mucosa
~20% of the population affected (peak onset is between 10 and 19 years)
Severity generally declines with age
About 40% of people with recurrent aphthous ulcers will have a positive
family history

Unknown
May be due to a variety of causes including infection, trauma and drug
allergy
Stress, nutritional deficiencies (iron, zinc, vitamin B12), some
preservatives (e.g. benzoic acid)
Occasionally mouth ulcers appear as a symptom of serious disease (e.g.
carcinoma)
In a minority of people, triggers can be identified:
Stress, some foods, hormone imbalance, smoking cessation

-age- child adult
-nature of ulcers
-size, apperance, location, number
-duration
-previous history
-other symptoms
-medications

Patients may describe a history of recurrent ulcera;on, which began in
childhood and has con;nued ever since
Minor aphthous ulcers are more common in women and occur most often
between 10 and 40 years
Occurrence tends to decline over time

Minor aphthous ulcers usually occur in crops of 1‐5
Appear as a white or yellowish centre with an inflamed red outer edge
Common sites are the tongue margin and inside the lips and cheeks
The ulcers tend to last from 5‐14 days and heal without scarring

Major aphthous ulcers are uncommon, severe variants of the minor ones
Can be as large as 30mm in diameter and can occur in crops of up to 10
Sites involved are the lips, cheeks, tongue and palate
More common in pa;ents with ulcerative colitis
They heal slowly over weeks to months and can lead to scarring

Herpe;form ulcers are more numerous, smaller and, in addi;on to the
sites involved with aphthous ulcers, may affect the floor of the mouth and
gums
They are not related to the herpes virus

see picture

major aphthous ulceration

see picture

Minor ulcers normally heal in < 1 week; major ulcers may take longer (10‐30
days)
Where herpe;form ulcers occur, fresh crops of ulcers tend to appear before
the original crop has healed, which may lead pa;ents to believe that the
ulcera;on is con;nuous
Mouth ulcers that persist > 3 weeks require immediate referral to the den;st
or doctor as this may indicate more serious pathology

Oral carcinoma:
More common in smokers than non‐smokers
Smokers at increased risk and more common in people aged > 50 years
O]en painless, and persist despite adequate treatment
Erythema mul;forme (Stevens Johnson syndrome):
Infec;on or drug therapy can cause
Widespread ulcera;on of oral cavity
Annular skin lesions
Conjunctivitis and eye pain common

Recurrent, painful major aphthous ulcers that are slow to heal
Lesions are also located in the genital region and eye involvement is common

O]en a family history is present (1 in 3 cases)
MAU o]en recur, with the same characteris;cs as before
Ill‐fihng dentures may produce ulcera;on in the elderly:
Refer to the dentist if this is the case
Not always the case

In women, MAU o]en precede the start of the menstrual period
The occurrence of these ulcers may cease a]er pregnancy, sugges;ng
hormonal involvement
Vitamin deficiencies may be involved, although this is not proven
May also be associated with IBD

Ulcera;on of other areas:
More serious pathology
If on the edge of the lip and adjacent skin sugges;ve of cold sore
Allergy to food:
Food may be associated
Tomatoes, ‘tangy’ cheese, citrus fruits and chocolate have been implicated
Elimina;on of ‘trigger’ foods may reduce re‐occurrence

Symptoma;c treatment of MAU can reduce pain and healing ;me
Ac;ve ingredients include:
Antiseptics
Corticosteroids
Local anaesthetics
An;‐inflammatories

Applied 2‐4 times per day for up to 5 days
Reduction in pain and healing time
All patient groups can use
Well tolerated, no side‐effects reported
Lack of evidence of safety in pregnancy (Orabase paste may be used alone)
May be used in breast‐feeding
Needs to be ‘dabbed’ on rather than rubbed in

Not recommended < 6 years, category B2, may be used in breast‐feeding

Infants > 6‐months, apply q3h, category A
Benzocaine (Cepacaine, S2) as above but not appropriate for children

> 4 months for teething etc, applied q4h prn, OK in pregnancy and breastfeeding

Antiseptic and disinfectant ‐ can be used to reduce the risk of secondary
bacterial infec;on
Some evidence that chlorhexidine reduces dura;on and severity of ulcera;on
Can stain teeth brown (not usually permanent)
This staining can be reduced by avoiding foods containing tannin (e.g. coffee, tea,
red wine)
Brushing teeth prior to use may help, although need to rinse mouth well with
water before using chlorhexidine
Rinse mouth with water after use

Avoid local trauma (e.g. hard toothbrushes) and acidic food and drinks
Topical therapy with local anaesthe;cs may reduce pain
Local bioadhesives may protect
Best evidence supports the use of Kenalog in Orabase or the use of
chlorhexidine mouthwash
May speed healing and reduce pain

LiEle evidence to support treatments to reduce recurrence
Generally treated in the same way as the ini;al presenta;on in the
absence of causa;ve condi;ons
Zinc deficiency has been proposed as a cause, but evidence does not
support zinc supplementa;on to prevent ulcera;on (RCT trial results
negative)