Mouth Ulcers

also termed Apthous Stomatitis

Ulcers appear periodically and heal completely between attacks, before presenting again. Individual Ulcer lasts 7-10days and occurs 3-6 times/year. However, severe forms are virtually constant.

Any non-healing ulcer lasting more than 4 weeks, must be examined by a dentist. This is especially true, if there is no associated pain !

Are they Common?

Affects 20% of the population. They begin in adolescence and last for several years, but gradually disappear. Males and females are affected in an equal ratio, and the peak age of onset between 10 and 19 years. About 80% of people with aphthous stomatitis first develop the condition before the age of 30.

What are they caused by?

The cause is not completely understood, but has something to do with T- cell mediated immunity, that can be triggered by various factors. Different people have different triggers, which may vary from nutritional deficiencies, local trauma, stress, hormonal influences, allergies, genetic predisposition or other factors. There is no causative organism nor are they transmissible (1).

Although this behaviour would lead one to think they are an autoimmune disease, they are not. There is no common autoantibody.

Stress

Stress affects the immune system, which may explain why some cases directly correlate with stress. It is often stated that ulceration is exacerbated during examination periods and lessened during periods of vacation. Alternatively, it may be that cheek chewing and lip biting are more pronounced during stress and hence the mucosa is subjected to more minor trauma.

Nutritional Deficiencies

Vitamin B12, folate and iron deficiencies are also correlated. When these are deficience, the mucosa is thinner and more subject to ulceration.

Interestingly, EVEN if you are not deficient, adding Vitamin B12, folate and iron supplementation IMPROVES healing and symptoms of apthous ulcerations.

Allergens

In some instances, recurrent mouth ulcers may be a manifestation of an allergic reaction. Possible allergens include certain foods (e.g., chocolate, coffee, strawberries, eggs, nuts, tomatoes, cheese, citrus fruits, benzoates, cinnamaldehyde, and highly acidic foods), toothpastes, and mouthwashes. Where dietary allergens are responsible, mouth ulcers usually develop within about 12–24 hours of exposure. Patch testing may reveal the allergic cause and thus diet modification would rectify the solution.

Interestingly, apthous stomatitis in UNCOMMON in smokers and some people report that they present which on nicotine replacement therapy. This is because smoking thickens the mucosa and makes it more resilient to ulceration. Starting to smoke again, however does not prevent them returning.

There is a school of thought that they can also be caused by viral shedding causing immune changes. However, antiviral medication has no effect on aphthous stomatitis and therefore this school of thought becomes redundant.

Systemic Factors

Sometimes, ulcerations can be a sign of other systemic illnesses.

Anemia, Behçet's disease, Coeliac disease and Chrones Disease are the big players.

The link between gastrointestinal disorders and aphthous stomatitis is probably related to nutritional deficiencies caused by malabsorption.

Minor Vs Major Ulcers

Minor ulcers are less than 1cm in size and usually several ulcers appear at the same time, but single ulcers are possible. Healing usually takes seven to ten days and leaves no scar.

Major ulcers are greater than 1cm in size. Healing takes longer, 20-30days (as the ulcers are larger and deeper) and may leave scars. Each episode of ulceration usually produces a greater number of ulcers, and the time between attacks is less than seen in minor ulcers.

2 other classifications exist; herpetiform ulcers (not caused by herpes virus) and those associated with systemic disease.

Treatment

Apply Kenalog in orobase three times a day for 3 days.
Simply apply onto a Q-tip or a clean finger and gently wipe over the ulcer. Do not try to rub it in. The paste won’t stick to the ulcer, so don’t worry if you think it hasn’t been applied, just have confidence that enough medication has reached the area by simply wiping over it.
Cepacaine mouthrinse, three times a day for 3 days.
Avoid Hot and spicy foods

If concerned see a dentist. Sometimes special investigations may be indicated to rule out other causes of oral ulceration. These include blood tests to exclude anemia, deficiencies of iron, folate or vitamin B12 or celiac disease. Screening for celiac disease should form part of the routine work up for individuals complaining of recurrent oral ulceration. Patch testing may also be undertaken if an allergen is the suspected cause.

Advice

If you experience multiple episodes a year, try the following:

Take Vitamin C supplements
Take Vitamin B12, folate and iron supplements, if systemic factors permit. Even in the absence of deficiency, vitamin B12 supplementation may be helpful due to unclear mechanisms.
Drink plenty of water and rest.
Occasionally, in females where ulceration is correlated to the menstrual cycle or to an oral contraceptive, progesterone or a change in oral contraceptive may be beneficial.

(1) Scully C (2013). Oral and maxillofacial medicine: the basis of diagnosis and treatment (3rd ed.). Edinburgh: Churchill Livingstone. pp. 226–234