Down in the mouth? We've got the measure of mouth ulcers!

Introduction - A common annoyance
Mouth ulcers are very common, and can be very annoying – many of us are only too familiar with the feeling of having painful sores inside the mouth, usually on the inside of the cheek or lips, or on the tongue. In fact, most people in the UK get one or two mouth ulcers a year, and up to 20% of the population say that they suffer regularly with recurrent mouth ulcers. They are commoner in young adults, particularly women,
and in fact it is quite unusual for people to develop their first mouth ulcer after the age of 30. Patients with mouth ulcers usually report painful, round or oval sores which are red and swollen round the edge and which may be red, white, yellow or grey in the middle; the ulcers are usually quite small (half a centimetre in diameter) but can be quite large – the main problem people experience is discomfort which is worse when eating, drinking or brushing teeth. (Ulcers which are painless are less common, and may indicate the possibility of a more serious problem.) Happily, most ulcers are completely harmless, and will heal up naturally by themselves within a week or two. However, some ulcers need proper assessment by a professional.

Many potential triggers and culprits
Most ulcers are “one-off”, single sores which are caused by damage to the inside of the mouth by sharp food, biting the inside of the cheek, or a sharp tooth or filling scraping the inside of the mouth – they can also be caused by poorly fitting false teeth, or even burning from hot food or drinks. Some people seem to get more than their fair share of mouth ulcers, even without any damage to the mouth, and it’s not exactly clear why. There is probably a genetic element, because 40% of people with recurrent mouth ulcers say it runs in the family, and some sort of trigger factor on top of this genetic vulnerability which can start an ulcer off. Examples of trigger factors include stress and anxiety, some foods (such as chocolate, coffee, strawberries, peanuts, almonds, cheese, tomatoes and wheat flour) – and, for some people, the toothpaste additive sodium lauryl sulphate, which is found in some toothpastes. Hormones probably play a part, as women often report that their ulcers are worse around their period and get better in pregnancy. Believe it or not, stopping smoking can cause ulcers to flare up, as the body and mouth get used to not having the poisonous chemicals around – please don’t let this put you off stopping, or use this an excuse to start again, as the ulcers are only temporary and the benefits of stopping smoking trump anything else!

Kissing mouth ulcers goodbye! Treatment and avoidance...
Usually, simple mouth ulcers get better by themselves; if they are being caused by a sharp tooth or filling, dental treatment to resolve this will sort the problem out. If stress is a trigger factor, looking at ways to reduce stress (such as mindfulness) can help prevent ulcers forming and help them heal more quickly. If you have a mouth ulcer, try to avoid any obvious trigger foods or drinks; and try to choose soft, easy-to-chew foods, not sharp foods such as toast! You may even choose to drink through a straw to help with discomfort (but please don’t drink hot drinks this way, as you can burn your throat). Some people find a simple saline mouthwash, made from half a teaspoon of salt mixed in with half a glass of warm water, is effective at soothing ulcers. If, despite trying these ideas, your ulcers are still painful enough to interfere with enjoying life, then there are several things you can try which can all be bought from the pharmacy, or prescribed by your dentist or GP (please check carefully with the pharmacist before buying over-the-counter mouth ulcer medications, especially if the medication is for child, or for someone who is pregnant, trying to become pregnant or breast-feeding). The most commonly used medications for mouth ulcers include steroid tablets such as betametsaone (Betnesol) (some people, who get a warning “tingle” that a mouth ulcer is on its way, can stop it from forming with rapid use of steroid tablets); antibacterial mouthwashes such as chlorhexidine (Cordosyl); or painkillers such as benzydamine (Difflam) or choline salicylate (Bonjela).

Mouth ulcers can sometimes indicate other underlying conditions
Some people with recurrent or severe mouth ulcers, especially those who have their first mouth ulcer after the age of 30, might have an underlying health condition which needs further investigation and treatment. Examples of some underlying conditions which can cause mouth ulcers include: iron, Vitamin B12 or folic acid deficiency; Crohn’s disease (an inflammatory bowel disease); coeliac disease; lichen planus; systemic lupus erythematosus and certain other rare rheumatological (joint) diseases. Viral infections such as the cold sore virus, the chicken pox virus, hand foot and mouth disease, and even (much more rarely) HIV can be the underlying cause of mouth ulcers, and ulcers can also become infected by bacteria, making them take longer to heal. Some medications, such as non-steroidal anti-inflammatory drugs (e.g. ibuprofen), anti-angina drugs such as beta blockers or nicorandil, or cancer treatments such as chemotherapy or radiotherapy, can contribute to mouth ulcers. If you think you might have an underlying medical condition leading to your mouth ulcers, or you know you have an underlying condition and you would like help managing the ulcers, please see your doctor or dentist.

Mouth Cancer - the "worst case scenario"
People often worry that mouth ulcers may be a sign of mouth cancer, and this is certainly the “worst case scenario”. It should be stressed that, while mouth ulcers are extremely common, mouth cancer is relatively rare – although it is on the increase, with about 7,500 new cases of mouth cancer being diagnosed each year in the UK. Mouth cancer (which is, 9 times out of 10, a sort of cancer called a Squamous Cell Carcinoma or SCC; other sorts of mouth cancer, including mouth cancer which has spread from somewhere else in the body, are much less common) is rare in people under 40, more common in men, and much, much more likely in people who both smoke and drink heavily – smoking and drinking in combination can make people up to 40 times at higher risk of developing mouth cancer. Mouth cancer ulcers can often be painless, especially to begin with, so it’s really important (especially for people who drink heavily AND smoke) to have regular dental check-ups, as dentists will assess the whole mouth for any subtle signs of mouth cancer which the patient may not even have noticed. Mouth cancer usually grows quite slowly, and, if it’s detected early, the chances of a complete recovery are good. So please, make sure you have regular dental check-ups and, if you’re worried by a mouth ulcer which has lasted over three weeks, or seems different or much worse than ulcers you have had before, arrange an appointment with your doctor or dentist without delay.

What will your doctor ask? 
If you go to see your GP or dentist because you are worried about a mouth ulcer, you can expect to be asked some questions about how many mouth ulcers you have had in the past, how long this one has lasted for, whether you are a smoker, how much alcohol you drink, and whether anyone in your family has recurrent mouth ulcers. You may also be asked about other symptoms, which may indicate an underlying condition, such as weight loss, rashes, joint pains, temperatures and ulcers anywhere else (including the genitals). Your doctor or dentist will then have a look inside the mouth and feel your neck for any swollen lymph glands. You may need some blood tests to check for iron and vitamin deficiencies, as well as infection and inflammation. If the GP or dentist thinks that your ulcer looks very unusual, or if it has any sinister features, you will be asked to see a hospital specialist called a maxillofacial surgeon. The surgeon may wish to take a small piece of tissue from the ulcer (a biopsy) to see what kind of ulcer it is and what, if any, treatment is needed.

Remember – most ulcers are a nuisance instead of serious. But, if you are concerned, please book an appointment with your GP.