Mouth ulcer
Introduction
Also known as aphthous ulcers, mouth ulcers are painful, clearly defined, round, or oval sores which form in the mouth.
There are three main types of mouth ulcer which are outlined below.
- Minor ulcer - these are the most common type of ulcer. They account for 80% of all mouth ulcers. They are small (2-8mm in diameter) and normally heal naturally within 10-14 days. A minor ulcer will not cause any scarring.
- Major ulcer - this type of ulcer is deeper and larger than a minor ulcer, and usually has a raised or irregular border. A major ulcer is usually 1cm or more in diameter. This type of ulcer will heal more slowly, over a period of several weeks, and can cause scarring. Approximately 10% of mouth ulcers are major.
- Herpetiform ulcers - these ulcers form as multiple, pinhead sized sores. The number of ulcers can range from 5-100. These tiny ulcers often fuse together to form larger, irregular shaped sores which are extremely painful. Approximately 5-10% of mouth ulcers are herpetiform.
A mouth ulcer is a very common condition, and most people will have at least one in their lifetime. Studies have shown that mouth ulcers are more common in women and people who are under 40 years of age.
Mouth ulcers cannot be passed from person to person. For example, you cannot get an ulcer from kissing someone, or from sharing a glass, or cutlery.
Recurrent ulcers
Most people will only have a mouth ulcer occasionally. However, for some people, mouth ulcers recur on a frequent basis. In the UK, 20% of people (one person in every five) will experience recurrent mouth ulcers. Recurrent mouth ulcers are often caused by different factors than single ulcers. See the 'causes' section for more information.
^^ Back to top
Symptoms
You will usually know if you have a mouth ulcer by looking at its appearance. A mouth ulcer will be:
- round, or oval, in shape,
- white, yellow, or grey in colour, and
- inflamed around the edge.
Most mouth ulcers usually occur on:
- the inside of the lips,
- the inside of the cheeks,
- the floor of the mouth, or
- the under surface of the tongue.
An ulcer can cause pain and discomfort, particularly when eating, drinking or brushing your teeth.
Most mouth ulcers will only last between 10-14 days, although in more severe cases, they may last for several weeks.
If your mouth ulcer gets progressively more painful and inflamed, you should see your GP. You should also see your GP if your mouth ulcer lasts for more than three weeks, or if ulcers appear else where on your body, such as the genitals.
^^ Back to top
Causes
A mouth ulcer cannot be passed from person to person. For example, you will not get a mouth ulcer after kissing, or by sharing drinking glasses and cutlery with someone who has one.
Most minor, single mouth ulcers are caused by damage to the mouth. For example, you may accidentally bite the inside of your cheek while you are eating. Damage to your mouth can also occur if you use a toothbrush incorrectly, or from a sharp tooth, or filling.
Recurrent mouth ulcers
The cause of recurrent mouth ulcers is often unknown. However, there are a number of factors which may increase the chances of you getting recurrent ulcers. Some of these are outlined below.
- Oral trauma - such as excessive tooth brushing, or chewing sharp, or hard, foods.
- Anxiety.
- Stress.
- Certain foods - some people may find that eating certain foods can cause them to develop more ulcers. Foods that have been identified as increasing the risk of ulcers include chocolate, coffee, peanuts, almonds, strawberries, cheese, tomatoes and wheat flour.
- Hormonal changes - many women notice that they are more likely to have an ulcer during their period. This is due to the changes in hormone levels in your body during your menstrual cycle.
Stopping smoking
When you first stop smoking, you may find that you have more mouth ulcers than usual. This is a normal reaction and is part of your body's way of dealing with the change in chemicals in your body.
After quitting smoking, any increase in mouth ulcers will be temporary, and you should not let it deter you from stopping smoking. The long-term health benefits of stopping smoking are far greater than the short-term discomfort of mouth ulcers. Stopping smoking will mean you are at a lower risk of developing smoking-related conditions, such as heart disease and lung cancer. You will also have a greatly improved overall level of fitness.
Family history
Around 40% of people who have recurrent mouth ulcers have a family history of the condition. If both your parents have recurrent mouth ulcers, there is a 90% chance that you will have them too.
Underlying condition
If you have recurrent mouth ulcers, they may be caused by an underlying medical condition, such as those outlined below.
- Vitamin B12 deficiency - Vitamin B12 helps to make red blood cells and keeps your body's nervous system healthy. If you do not have enough vitamin B12, it can cause tiredness, shortness of breath and mouth ulcers.
- Iron deficiency - if you do not get enough iron in your diet, your red blood cells will not be able to carry as much oxygen. This can make you tired, lethargic, and dizzy. Although not as common as other symptoms, an iron deficiency can also cause mouth ulcers.
- Coeliac disease - this is a condition where the small intestine becomes inflamed, and it is caused by intolerance to a protein called gluten, which is found in wheat, rye and barley. Mouth ulcers are a common symptom in adults with the disease.
- Crohn's disease - this is a condition which causes inflammation of the gut. This inflammation can cause ulcers in both your stomach and your mouth.
- Reiter's syndrome - this is a reaction to another infection within your body. It can cause inflammation, which sometimes spreads to your mouth.
- Immunodeficiency - any condition which attacks, or suppresses, your body's immune system (which protects the body against infection and illness) can cause you to get mouth ulcers. HIV is an example of an immunosuppressant illness.
Medication
Occasionally, mouth ulcers can also be caused by a reaction to a medicine that you are taking. Some of the medicines which can cause mouth ulcers are listed below.
- Non-steroidal anti-inflammatory drugs (NSAIDs)- painkilling medication, such as ibuprofen and aspirin. Children under 16 should not be given aspirin.
- Nicorandil - a medicine that is used to treat angina (chest pain caused by reduced blood flow to the heart).
- Beta-blockers - a medicine used to treat a variety of conditions which affect the heart and blood flow, such as angina, heart failure, high blood pressure, and abnormal heart rhythms.
You may notice that your mouth ulcers start when you increase the dosage of your medication, or when you first start taking the medicine. However, this is often a temporary effect of the medication.
Speak to your GP if you find that you are experiencing more mouth ulcers as a result of your medication. They may be able to prescribe an alternative medicine for you. However, you should never stop taking medication unless your GP advises you to do so.
^^ Back to top
Diagnosis
If you are suffering from a mild mouth ulcer you will not require any formal diagnosis from your GP. You will also not require any specific treatment, but there are some self-care tips you can follow to help the ulcer heal faster (see 'treatment' section).
If your ulcer is causing you significant pain, or you get mouth ulcers on a recurrent basis, then you should see your GP. You should also see your GP if your mouth ulcer has lasted for more than three weeks.
Your GP will normally be able to diagnose a mouth ulcer from its appearance and position in your mouth. They will also look at your medical history to help them work out what might be causing your ulcer.
Recurring ulcers
If you are having recurrent mouth ulcers, your GP may ask you a series of questions to help determine whether your mouth ulcers have any underlying cause. You may be asked about:
- the frequency of your ulcers (how often they occur),
- how long your ulcers last for,
- how severe the pain is, and
- what treatments you have used (either prescribed or over-the-counter).
If your GP is unsure of the diagnosis, they might want to rule out any conditions which may be causing your ulcers to recur. To do this, your GP may refer you for a series of blood tests. Some of the tests may include those outlined below.
- Full blood count - this is a common type of blood test which will help to determine your general health. It will show whether there is an infection in your body and will also indicate whether you have been exposed to any toxic substances.
- Erythrocyte sedimentation rate (ESR) - this test will not confirm a specific condition. Instead, it shows whether there is inflammation in your body. If your GP knows that there is inflammation, they will be able to conduct further tests to try and work out what condition may be causing it.
- Ferritin - this test measures how much iron is being stored in your body. A lack of iron in your body can often be a cause of recurrent mouth ulcers (see 'causes' section).
- Vitamin B12 - this test checks to see whether you have enough vitamin B12 in your body. A lack of vitamin B12 can also be a cause of recurrent mouth ulcers (see 'causes' section).
Referral
If you have had a severe mouth ulcer for more than three weeks, your GP will usually have to refer you to a specialist. You may require a biopsy (where a small tissue sample is taken for further examination) to help determine the cause of your ulcer.
You will also be referred to a specialist if your mouth ulcers are abnormal in appearance. For example, some people develop large red and white patches in their mouth, which often bleed and are painful. If this is the case, you may be referred for further examination.
It is very important that you see your GP if your ulcer has lasted for more than three weeks, or is abnormal in appearance - for example, if your ulcers are made up of large red and white patches, which often bleed. This is because in a small number of cases, a severe, long-lasting mouth ulcer may be a sign of mouth cancer. You are more at risk of getting mouth cancer if you are:
- male,
- over 45 years of age,
- a heavy smoker, or
- a heavy alcohol drinker.
If mouth cancer is spotted early on, the chances of a complete recovery are good. This is why it is always important to have regular check-ups with your dentist, as they will carry out a thorough assessment of both your teeth and mouth, and will be able to spot any possible signs of mouth cancer.
^^ Back to top
Treatment
Most mouth ulcers will often not require specific treatment. Mouth ulcers will normally heal naturally without the need for treatment, or medication, if they are:
- infrequent,
- mild, and
- do not interfere with your daily activities (such as eating).
However, if you have a mild mouth ulcer, there are some self-care tips you can follow which may help your ulcer to heal quicker.
- Use a soft toothbrush when brushing your teeth.
- Avoid eating hard foods, such as toast. Try to stick to foods which are softer and easier to chew.
- Try to reduce your stress levels, perhaps by doing something that you find relaxing, such as yoga, meditation, or exercise.
- Many people find that eating certain foods, such as chocolate, coffee and peanuts can make them more prone to developing an ulcer. If you know that eating a particular food provokes an ulcer for you, avoid eating that food until your ulcer has completely healed.
If your ulcer has a specific cause, such as a sharp tooth, then it will normally heal naturally once the cause has been treated. If you suspect a sharp tooth is causing your ulcer, visit your dentist, who should be able to repair the tooth, allowing the ulcer to heal by itself.
Medication
If your ulcer is causing you significant pain and discomfort, your GP will prescribe you medication to help ease your symptoms. If you prefer, many of the medicines used to treat ulcers can also be purchased over-the-counter (OTC), at your local pharmacy. Speak to your pharmacist about which medicine would be most suitable for you.
Some of the different types of medicine you can purchase, or be prescribed are outlined below.
Corticosteroids
A corticosteroid is a type of medicine that helps reduce inflammation. By reducing the inflammation of your ulcer, you should also find that it is less painful.
The two most commonly prescribed corticosteroids are triamcinolone and hydrocortisone. Triamcinolone comes in the form of a paste, which you apply directly to the ulcer between 2-4 times a day.
Hydrocortisone comes in the form of a lozenge which slowly dissolves in your mouth. You will usually have to take a lozenge four times a day.
It is best if you can use these medicines as soon as the ulcer appears. These medicines only contain a low dose of corticosteroid, as it is usually enough to reduce inflammation in a mouth ulcer.
Antimicrobial mouthwash
Antimicrobial mouthwash helps to kill any micro-organisms, such as bacteria, viruses, or fungi that may cause a mouth infection if you cannot brush your teeth properly.
The mouthwash most commonly prescribed is chlorhexidine gluconate. You will usually have to use this mouthwash twice a day.
You may notice that after using chorhexidine gluconate, your teeth are covered in a brown stain. This staining is not permanent, and your teeth should return to their normal colour once you finish your treatment.
The best way to prevent staining is to brush your teeth before using the mouthwash. However, if you do brush your teeth prior to using chorhexidine, you should make sure that you rinse your mouth thoroughly with water before you use the mouthwash.
Analgesics
Analgesics are more commonly known as painkillers. If your mouth ulcer is very painful, your GP may prescribe an analgesic, which you can apply directly to your ulcer.
Your GP will normally prescribe benzydamine, which can either be taken in the form of a mouthwash or a spray. You will not be able to use benzydamine for more than seven days in a row.
Some people find that the mouthwash form of benzydamine stings when using it. If it does, you can dilute the mouthwash using an equal measure of water before using it. When using sprays, or mouthwashes, always make sure that you follow the manufacturer's dosage instructions.
^^ Back to top
Complications
Mouth ulcers rarely cause any complications. Most will heal naturally with time, and those that do not can usually be treated using medication (see 'treatment' section).
A mouth ulcer may be an indication of an underlying condition - but the ulcer itself will not be the cause of any illness.
The only complication mouth ulcers can cause is a bacterial infection, although this is very rare. In some cases, an infected ulcer can cause the bacteria to spread to other areas of your mouth, such as your teeth. If your ulcer does become infected, you may require antibiotic treatment.
^^ Back to top
Prevention
To prevent getting mouth ulcers,try to avoid becoming run down by making sure you eat a balanced diet, take regular exercise and learn to effectively manage stress.
If you are prone to recurrent ulcers, avoid damage to the inside of your mouth by using a softer toothbrush and avoiding hard, brittle, or sharp-edged foods.
Make sure that your teeth are in good order by regularly visiting your dentist. Your dentist will advise you about how often you should have a check-up appointment. The time to your next check-up could be as short as three months, or as long as two years, depending on your oral health. The better your oral health, the longer the longer the gap will be before your next appointment.
If you attend regular check-up appointments, this will help to ensure that no sharp edges of your teeth, or fillings, can cause damage to the inside of your mouth.
^^ Back to top