Mouth ulcers may be benign and self-limiting, and seen in all age groups but sometimes they can signal a systemic disorder. In this article. Dr YK Amdekar talks about the causes and treatment of such lesions that may be seen in all the parts of the mouth, including the base gums.

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Mouth ulcers are common in the community and seen in all age groups. While most of them are benign and self-limiting, one must be cautious to rule out any systemic disease in the background. The mucus membrane of the mouth is very delicate and is easily damaged even by trivial factors. They are painful and cause difficulty in eating, drinking and speaking.

Causes

1. The most common causes include local trauma and aphtous ulcers. Local mechanical injury may be induced by accidental biting of the cheeks or lips while chewing hard food items, a sharp tooth, poorly fitting dentures or braces, chemical injury from spicy food or thermal injury from hot drinks. Ulcers caused by local injury heal within 1 to 2 weeks.
2. Apthous ulcers are also localised to the mouth but they recur every few months and may take longer to heal. While the exact cause is not known, it is likely to be triggered by genetic predisposition, stress, vitamin or iron deficiency and hypersensitivity to toothpaste or smoking. Both causes are restricted to the mouth only, without many systemic symptoms.
3. The next common cause includes infections and vitamin/iron deficiency. Viral infections such as coxasackie A (hand, foot, mouth disease), herpes, varicella, EB virus, HIV, bacterial infections such as scarlet fever, fungal infections, syphilis etc. Deficiency disorders include vitamin B12, folate and other B complex vitamins and iron deficiency.
4. Rare but serious causes include autoimmune disorders such as SLE, juvenile idiopathic arthritis, dermatomyositis, vasculitis syndromes, inflammatory bowel disease, drug reactions such as Steven-Johnson syndrome and occasionally leukaemia. Some of these disorders may start with mouth ulcers before other manifestations appear and in such situations, correct diagnosis is difficult in the initial stages. However, such patients are often disproportionately sick.

The mouth represents the transition between the skin and GI tract and hence mouth ulcers are often associated with skin lesions or GI disturbances.

Clinical approach

The first step is to differentiate between localised benign lesions and mouth ulcers representing a probable systemic disorder. Systemic disorders generally present with sickness besides other symptoms such as fever, skin rash, joint involvement etc. Sickness is different from the discomfort caused by painful lesions and though it is a subjective impression, an experienced physician can make out a difference between well-being and sickness.

However, at times it could be tricky and so one has to be cautious in pronouncing a benign lesion. Once a benign disorder is considered, detailed history may suggest local injury and if not, one may look at family history to consider apthous ulcers and also assess probable vitamin B12 or folate deficiency (knuckle pigmentation) and iron deficiency. Past history of similar disease favours the diagnosis of apthous ulcers as they are recurrent.

History of drug therapy may be a clue to the cause of mouth ulcers. However, one must be cautious to keep in mind that isolated mouth ulcers may be the only initial presentation of systemic disorders and so one must look for evidence of systemic disease on physical examination such as evidence of viral infection, skin rash, nail abnormalities, joint swelling, restriction of joint movements or pain, pallor, lymphadenopathy, hepatosplenomegaly and signs of other organ involvement.

Investigations

1. Isolated mouth ulcers without evidence of any other physical findings in an otherwise normal child does not call for any investigations. In case of accompanying pallor, peripheral blood smear along with CBC can suggest deficiency anemia. Apthous ulcers in a clinical diagnosis based on circumstantial evidence and do not justify any tests.
2. If mouth ulcers don’t heal within two weeks or in case of doubt about probability of systemic disorder, CBC, ESR / CRP are initial tests that may support a systemic disease – either infective, autoimmune or malignant diseases. Further investigations depend on initial test results.
3. In case of suspected fungal infection, workup for immune deficiency including HIV is necessary as fungal mouth ulcers are seen in immune-compromised individuals with an exception of a neonate or an individual on long term antibiotic therapy.

Treatment

Benign lesions are self-limiting and don’t need any specific drug therapy.

• It is best to avoid spicy and hot food, drink plenty of fluids, keep the mouth clean and rinse with warm water with a pinch of salt by keeping water in the mouth for a few minutes
• Local application may be tried such as ghee or butter or local anaesthetic agents; local steroids are not helpful but analgesics may be tried
• Withdrawal of probable offending drug is necessary if suspected to be drug-induced mouth ulcers
• Replacement therapy is necessary for vitamin and iron deficiency disorder
• Viral infections are also self-limiting and don’t need any specific treatment, however, disseminated herpes infection needs to be treated with acyclovir or gancyclovir
• Streptococcal infection is treated with first-generation cephalosporin or amoxicillin
• Fungal infection is treated with a local anti-fungal drug unless it is disseminated, which then needs systemic therapy
• Treatment of other serious disorders must be left to a specialist

In summary, mouth ulcers are usually benign and self-limiting but we must look for any systemic disorder in the background that may not be initially evident unless especially looked for. However, if lesions persist beyond two weeks, we must investigate to rule out a systemic disorder. Local lesions heal on their own and while the local application may be tried, healing takes a natural course.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.