Mouth Ulcers

• Clinical Definition: A mucosal lesion that has broken down through the layers of the mucosa and has revealed its underlying connective tissue and nerve fiber pathways.

• Indications for Immediate Medical Attention: Lesions lasting longer than 14 days, lesions rapidly growing in size, painless lesions with hard edges, high temperature, and difficulty in swallowing.

• Recovery Options: Topical anti-inflammatory gels/products, protective barriers, low-level laser therapy, and nutritional supplementation.

• Risk Factors: Local mechanical trauma, vitamin deficiencies (iron, folate, b-12), stress/psychological stress, and acid/salty/spicy foods/cuisine.

• Visual Appearance: Round/oval crater-like depression in the mucosa with a necrotic/yellowish-grey fibrin center. Surrounding this crater is a raised erythematous halo.

• Sensory/Tactile Response: Sharp burning sensation occurs upon contact with salty/acidic spicy substances.

• Physiological Response: Swelling/mucosal edema increases salivary flow and causes discomfort when the jaw is moved.

• Systemic Signs of Illness: Tender, enlarged submandibular lymph nodes accompanied by mild lethargy during severe outbreaks.

• Non-Healing Duration: Any solitary ulcer persisting continuously for more than 14 days without dimensional reduction requires immediate clinical evaluation.

• Structural Hardening: Ulcers exhibiting firm, raised, or indurated margins upon palpation, which can indicate tissue dysplasia or oral squamous cell carcinoma.

• Extensive Coverage: Outbreaks involving major aphthae patterns exceeding 10 mm in diameter that compromise fluid intake.

• Associated Systemic Symptoms: Lesions accompanied by unexplained weight loss, recurrent gastrointestinal distress, persistent skin rashes, or high fever.

• Mechanical Trauma: Accidental mucosal biting during mastication, sharp broken tooth cusps, ill-fitting removable dentures, or aggressively brushed tissue.

• Chemical and Thermal Stress: Localized thermal burns from extremely hot foods or chemical erosion from aggressive oral hygiene products containing sodium lauryl sulfate (SLS).

• Immunological Reactions: T-cell-mediated immune responses where the mucosal immune system temporarily attacks localized epithelial tissue.

• Nutritional Deficiencies: Inadequate systemic levels of iron, zinc, folic acid, or vitamin B-complex (specifically cyanocobalamin).

• Dietary Triggers: Frequent consumption of highly seasoned or acidic foods common in South Indian cuisine, such as sour tamarind (Puli), green chilies, and fried plantain chips (Nendran).

• Systemic Health Conditions: Underlying autoimmune or gastrointestinal disorders, including Celiac disease, Crohn's disease, and Behçet's syndrome.

• Hormonal Fluctuations: Luteal phase hormonal shifts in women or sudden elevations in cortisol driven by chronic psychological stress.

• Tobacco and Habit Factors: Sudden cessation of smoking (which temporarily alters mucosal keratinization) or sharp micro-trauma from betel nut (Supari) chewing.

• Visual Assessment: Hand washing is performed, inspect your mouth under the bright, natural, or direct white light, then carefully pull back your upper/lower lip/cheek with a clean finger.

• Mapping Location of Ulcer: You will determine if you have an ulcer on non-keratinized tissues (soft palate, inner lips, underside of the tongue) versus keratinized tissues (the attached gums, the roof of the mouth).

• Determining Size: Compare your lesion size to a ruler and classify it based upon size. If less than 10mm in size, it would be classified as minor.

• Palpating Gently: Wash your hands again. Using a clean finger that has been gloved, lightly feel the border around the lesion. Assess whether the base of the ulcer is soft and flexible or firm and hardened. Do not apply pressure to squeeze or remove the ulcer.

• Visual Clinical Exam: Assess the location/distribution of the ulcer's borders and its depth using the direct light and intraoral mirror for clinical evaluation.

• Diagnostic History: Determine how much your diet influences your condition; assess your overall health; evaluate your family history of recurrent aphthous ulcers; evaluate your medical history of medications used.

• Lab Evaluations: Complete Blood Counts (CBC), Serum Ferritin Assays, Vitamin B12, and Red Cell Folate Assay to evaluate for systemic deficiency conditions.

• Biopsy: Excisional or incisional biopsies may need to be taken from chronic/atypical/indurated ulcers persisting beyond 14 days under local anesthesia to eliminate the possibility of malignancy.

• Topical treatments with anti-inflammatory properties are available, prescription-strength triamcinolone acetonide (0.1 %) in a mucoadhesive gel can be placed in the mouth after meals to reduce inflammation in specific areas of the oral cavity.

• Mucosal protective agents can provide a barrier to protect damaged nerve endings from irritation. These agents include hyaluronic acid-based gels and bio-adhesive rinse products designed to promote healing.

• Low-level laser therapy (LLLT), using diode lasers will be provided as an in-office treatment modality.

• Anesthetics can be applied topically by a dentist before meals to prevent painful sensations while eating. Benzocaine and Lidocaine are two topical anesthetic medications commonly prescribed.

• A general consultation and diagnosis in a dental office may cost anywhere from Rs 300-Rs 800. Prices vary depending upon whether you live in a city such as Kochi, Thiruvananthapuram or Kozhikode, etc.

• Prices for prescription topical gels/supplements may range from Rs 150-Rs 600 for standard courses of treatment for anti-inflammatory pastes, antiseptic agents, etc., and B-complex supplements.

• Prices for LLLT (laser) treatment of aphthous ulcers may range from Rs 1,500-3,500 per treatment session. Depending upon which clinic you choose to use, how many lesions you have, what type of equipment is being used, etc.

• Prices for biopsy/histopathological procedures may range from Rs 2500-Rs 6,000 depending upon your physician's clinical judgment regarding the necessity of performing these tests.

• Dentists (General Dentist): A General Dentist is a good starting point for an initial assessment and/or minor treatment including trauma-related damage removal, minor aphthae management and other local issues.

• Oral Medicine/Radiologists: When you require advanced diagnostic testing or need a systemic work-up for persistent/recurrent/atypical ulcers, you should seek the services of an Oral Medicine Specialist.

• Periodontists: If the ulcerations directly affect the attached gingiva/periodontal tissues/deep sulcus area, then you would want to see a Periodontist.

• Oral and Maxillofacial Surgeons: If you need to have a formal surgical biopsy performed/tissue removed/surgically correct any sharp anatomical obstructions, then you will need to visit an Oral and Maxillofacial Surgeon.

• Emergency/Urgent: Mucosal tears due to sharp objects; large aphtha lesions which create severe swallowing difficulty & lead to dehydration.

• Same Day Care: Larger than usual aphthae creating significant discomfort/pain, facial swelling, and/or interfere with ability to speak.

• Routine/Regular Office Appointments: Recurring mild aphthae that resolve by day 7, typically scheduled for routine office visits.

1. I have developed recurring mouth sores when I eat spicy South Indian foods. What could be the reason? 

The irritation in your mouth is likely caused by one of three types of spices contained in many South Indian dishes including capsicum, tamarind, and concentrated mustard seeds. These irritants will damage your already sensitive lining and cause discomfort in a few hours. This is a common problem and usually resolves quickly once you stop consuming those irritating spices.
 

2. Will having a sharp point on a tooth cause a mouth sore permanently? 

If you continuously bite against the sharp edge of a tooth, it will continually traumatize the area causing the development of an ulcer. While the actual ulcer may eventually go away, if this continues for extended periods of time, you may develop cellular abnormalities in the area. Once the tooth edge is smoothed out or removed, the area should begin healing quickly (within days).
 

3. Is it possible to spread aphthous ulcers to other people through sharing utensils? 

Aphthous ulcers are a non-transmissible condition. They can't be spread through kissing or through sharing eating utensils. Viral infections such as primary herpetic gingivostomatitis are transmittable and need to be differentiated medically.

• Oral Lichen Planus: An inflammatory mucosal disorder that presents as white streaks or erosive lesions in the mouth.

• Gastrointestinal Disorders: Chronic inflammatory bowel diseases such as Crohn’s disease and celiac disease that may include aphthous-like oral lesions.

• Oral Candidiasis: Oral thrush is a fungal infection that grows on mucous membranes. It commonly occurs in individuals who use inhalers long term and/or are immunocompromised.

• Tooth Smoothening & Occlusal Readjustment: Resurfacing sharp fractured tooth enamel (or restorative margins) to eliminate mechanical sources of friction.

• Dental Cleaning: Removing loose calculus and plaque biofilm that can promote inflammation in areas of soft tissues.

• Modification of Prosthesis: Remaking, reshaping or replacing poorly fitting partial or complete dentures which cause soreness on the mucosa

While recurrent oral mucosal ulcers often will respond to symptomatic treatment as well as nutritional support, all atypical or chronic ulcers must be clinically evaluated to determine if there is an identifiable underlying etiology such as malnutrition, systemic autoimmune disease or dysplasia. The combination of early clinical evaluation with use of photobiomodulation has been shown to reduce pain associated with the ulcers and restore the tissue's healthy state.