Mouth Ulcers
Overview
Mouth ulcers are common and can occur on lips, gums, tongue, inside of cheeks, floor, or roof of the mouth and throat.
Mouth ulcers can cause considerable pain. Depending on the severity, mouth ulcers may lead to difficulty in either, eating, drinking, swallowing, or talking. Mouth ulcers can occur due to local causes and diseases confined to the oral cavity or may be a manifestation of an underlying systemic illness. The majority of mouth ulcers are benign but some are cancerous.
Traumatic factors including mechanical, thermal, and chemical injuries are common causes of mouth ulcers. Mechanical trauma could be in form of an ill-fitting denture or braces, rough fillings, misaligned or fractured sharp tooth, hard brushing, and habitual biting; thermal injuries can occur due to hot liquids or food; whereas, chemical injuries can be a result of smoking, tobacco, and acidic liquids or certain medications. Traumatic ulcers usually resolve within a few weeks after removal of the cause, however, a long standing traumatic ulcer due to persistence of the physical or chemical factor, has the potential to evolve into oral cancer.
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Aphthous ulcer commonly known as canker sores, which are frequently recurrent, are the most prevailing innocuous oral ulcers affecting approximately 20% population. They are three types of aphthae: Minor aphthae are 1-6 in number, small <5mm>1cm, healing takes several weeks and may leave behind a scar. Herpetiform aphthae are the least common, 10-50 in number, which begins as small blisters progressing to tiny 2-3mm sized ulcers, resolving over a course of 10-14 days. Aphthous ulcers are multifactorial, the various factors implicated in causation are familial or genetic tendency, psychological stress, menstruation, smoking, trauma, food or drug allergies or sensitivity to some chemical in toothpaste and Iron or vitamin deficiencies, Verily, a systemic disease such as immunodeficiency, celiac disease, Cohn’s disease and Behcet’s syndrome (wherein aphthae not only involve mouth but also genital area) may underlie oral aphthae.
Mouth ulcers can also be caused by several infections mostly viruses such as Herpes, chickenpox (Shingles), Herpangina, hand-foot, and mouth disease, Fungal (Candida), rarely tuberculosis and syphilis. Herpes infection, also called as cold sore, is the most common of all oral infections and most people are infected by early adulthood. Herpes infection can spread from person to person through saliva via close contacts such as kissing and sharing cosmetics, razors, towels, or other items. After the first infection, the virus remains dormant and gets reactivated to cause recurrences, which are triggered by stress, menstruation or pregnancy-related hormonal changes, infection, fever, or cold, weakened immunity, and sun exposure. It usually stars as pain, tingling, or burning preceding the formation of a fluid-filled blister, followed by rupture to form a shallow ulcer, which usually heals on its own in 1-2 weeks. The outbreak of cold sore may also be accompanied by low fever, body ache, sore throat, swollen, and painful neck lymph nodes. In presence of eczema or atopic dermatitis and immunodeficiency, Herpes infection can be very severe and complicated, necessitating medical care under specialist.
Mouth ulcers may also be a manifestation of underlying disorders of the skin, blood, connective tissue or autoimmunity, and digestive system. There are various skin diseases that present as mouth ulcers, the commonest being lichen planus, and pemphigus. Mouth ulcers may also be the presenting feature of gastrointestinal diseases such as Celiac disease and Crohn’s disease. Connective tissue or autoimmune diseases associated with mouth ulcers include lupus erythematosus and Bechet’s syndrome. Blood disorders such as anemia and leukemia (blood cancer) can also lead to mouth ulcers. Vitamin deficiencies (B12, Folate), and mineral deficiencies (iron and Zinc), can also cause mouth ulcers. Intake of certain drugs such as Aspirin and anticancer medication is associated with mouth ulcers.
A persistent non-healing or an unusual non-painful ulcer may signify oral cancer, mostly a squamous cell carcinoma. Smoking and tobacco are the causative agents in the majority of the cases, the others being consumption of betel nut or alcohol; Human Papillomavirus (HPV) infection, long-standing trauma (such as due to ill-fitting denture or rough filling); and immunodeficiency. Oral cancer is usually preceded by a precancerous stage in the form of white patches or leukoplakia. In the initial stages oral cancer may be painless, therefore, may remain unnoticed. Apart from ulcer and pain, it may also present as jaw stiffness, weight loss, bleeding, and swollen lymph nodes in the neck. Oral cancer locally infiltrates the structures in the oral cavity and also has the potential to spread to the throat, lymph nodes, and distant organs such as lungs and bones.