View source for Mouth ulcer

{{Short description|Sore on the mucous membrane of the oral cavity}}
{{Redirect-distinguish|Cancer sore|Canker sore}}
{{Use dmy dates|date=February 2014}}
{{Infobox medical condition (new)
| name          = Mouth ulcer
| synonyms      = Oral ulcer, mucosal ulcer
| image         = Aphthe Unterlippe.jpg
| caption       = A mouth ulcer (in this case associated with [[aphthous stomatitis]]) on the [[labial mucosa]] (lining of the lower lip)
| field         = [[Gastroenterology]]; [[Oral medicine]]
| symptoms      =
| complications =
| onset         =
| duration      =
| types         =
| causes        = Chemicals such as [[Sodium dodecyl sulfate#safety#Oral concerns|SLS]] (a common ingredient in many toothpastes) have been linked to mouth ulcers, and have been recognized by public health agencies such as the NHS as a risk factor.; infections (e.g. [[Herpesviridae|herpes viruses]]); injuries (e.g. biting of the lip, tongue, and cheek, hard foods can scrape the oral tissues, hot foods can cause burns); Nutritional disorders (e.g., vitamin deficiencies); Possibly heavy metals, of which cadmium occurs in phosphate rock; [[Psychological stress|Emotional stress]] is commonly associated with recurrent ulcers.
| risks         =
| diagnosis     = Traumatic ulceration; [[Aphthous stomatitis]]; [[Infection]]; Drug-induced; [[Oral cancer|Malignancy]]; [[Vesiculobullous disease]]; [[Stomatitis#Allergic contact stomatitis|Allergy]]
| differential  =
| prevention    =
| treatment     = Smoothing or removing a local cause of trauma; addressing dry mouth; substituting a problem medication or switching to [[Sodium dodecyl sulfate|SLS-free toothpaste]]; A topical analgesic (e.g. benzydamine mouthwash) to reduce pain
Topical (gels, creams or inhalers) or systemic steroids may be used to reduce inflammation; Topical (gels, creams or inhalers) or systemic steroids may be used to reduce inflammation; an [[antifungal]] drug may be used to prevent [[oral candidiasis]] developing in those who use prolonged steroids; people with mouth ulcers may prefer to avoid hot or spicy foods, which can increase the pain; self-inflicted ulceration can be difficult to manage, and psychiatric input may be required in some people; for recurrent ulcers, [[vitamin B12]] has been shown to be effective; [[benzocaine]]; [[Corbadrine|levonordefrin]]
| medication    =
| prognosis     =
| frequency     =
| deaths        =
}}
A '''mouth ulcer''' ('''aphtha'''), or sometimes called a '''Canker sore''', is an [[Ulcer (dermatology)|ulcer]] that occurs on the [[mucous membrane]] of the [[oral cavity]].<ref name=MedlinePlus>{{cite web|vauthors=Vorvick LJ, Zieve D |title=Mouth ulcers on MedlinePlus|url=https://www.nlm.nih.gov/medlineplus/ency/article/001448.htm|publisher=A.D.A.M., Inc|access-date=27 December 2012}}</ref> Mouth ulcers are very common, occurring in association with many diseases and by many different mechanisms, but usually there is no serious underlying cause. Rarely, a mouth ulcer that does not heal may be a sign of [[oral cancer]]. These ulcers may form individually or multiple ulcers may appear at once (i.e., a "crop" of ulcers). Once formed, an ulcer may be maintained by inflammation and/or secondary infection.
The two most common causes of oral ulceration are local trauma (e.g. rubbing from a sharp edge on a broken filling or braces, biting one's lip, etc.) and [[aphthous stomatitis]] ("canker sores"), a condition characterized by the recurrent formation of oral ulcers for largely unknown reasons. Mouth ulcers often cause pain and discomfort and may alter the person's choice of food while healing occurs (e.g. avoiding acidic, sugary, salty or spicy foods and beverages).{{TOC limit|2}}
== Definition ==
[[File:Erosion excoriation ulcer 2.svg|thumbnail|right|Diagramatic representation of mucosal erosion (left), excoriation (center), and ulceration (right)]]
[[File:CankerProcess.png|thumbnail|right|Simplistic representation of the life cycle of mouth ulcers.]]
An ulcer ({{IPAc-en|ˈ|ʌ|l|s|ər}}; from [[Latin]] ''ulcus'', "ulcer, sore")<ref>{{Dictionary.com|ulcer|accessdate=19 July 2015}}</ref> is a break in the skin or mucous membrane with loss of surface tissue and the disintegration and [[necrosis]] of [[epithelium|epithelial tissue]].<ref>{{cite web|title=Ulcer on Merriam-Webster medical dictionary|url=http://www.merriam-webster.com/medlineplus/ulcer|publisher=Merriam-Webster, Inc|access-date=27 December 2012}}</ref> A ''mucosal ulcer'' is an ulcer which specifically occurs on a mucous membrane.
An ulcer is a tissue defect which has penetrated the epithelial-[[connective tissue]] border, with its base at a deep level in the [[submucosa]], or even within muscle or [[periosteum]].<ref name="Loevy 1993" /> An ulcer is a deeper breach of epithelium compared to an erosion or excoriation, and involves damage to both epithelium and [[lamina propria]].<ref name="OMF medicine textbook" />
An ''[[Cutaneous condition#Primary lesions|erosion]]'' is a superficial breach of the epithelium, with little damage to the underlying [[lamina propria]].<ref name="OMF medicine textbook">{{cite book|last=Scully|first=Crispian|title=Oral and maxillofacial medicine : the basis of diagnosis and treatment|year=2008|publisher=Churchill Livingstone|location=Edinburgh|isbn=978-0-443-06818-8|pages=131–39|edition=2nd|chapter=Chapter 14: Soreness and ulcers}}</ref> A ''mucosal erosion'' is an erosion which specifically occurs on a mucous membrane. Only the superficial epithelial cells of the [[epidermis (skin)|epidermis]] or of the mucosa are lost, and the lesion can reach the depth of the [[basement membrane]].<ref name="Loevy 1993" /> Erosions heal without scar formation.<ref name="Loevy 1993" />
''[[Excoriation]]'' is a term sometimes used to describe a breach of the epithelium which is deeper than an erosion but shallower than an ulcer. This type of lesion is tangential to the [[rete pegs]] and shows punctiform (small pinhead spots) bleeding, caused by exposed [[capillary]] loops.<ref name="Loevy 1993">{{cite book|last=Loevy|first=Manfred Strassburg, Gerdt Knolle; translated by Hannelore Taschini|title=Diseases of the Oral Mucosa : A Colour Atlas.|year=1993|publisher=Quintessence Pub. Co.|location=Chicago|isbn=978-0-86715-210-4|edition=2nd|page=32}}</ref>
== Causes ==
Mouth ulcers may be caused by physical means (for example accidental biting of the cheek), certain medical conditions (such as some vitamin deficiencies), or as an [[adverse effect]] of some medications.<ref>{{cite web|url=https://www.nhs.uk/conditions/mouth-ulcers/|title=Mouth ulcers|date=11 March 2024 |publisher=NHS}}</ref>
== Pathophysiology ==
The exact pathogenesis is dependent upon the cause.
Simple mechanisms which predispose the mouth to trauma and ulceration are [[xerostomia]] (dry mouth – as saliva usually lubricates the mucous membrane and controls bacterial levels) and epithelial atrophy (thinning, e.g., after [[radiotherapy]]), making the lining more fragile and easily breached.<ref name="Tyldesley OM textbook">{{cite book|last=Tyldesley|first=Anne Field, Lesley Longman in collaboration with William R.|title=Tyldesley's Oral medicine|year=2003|publisher=Oxford University Press|location=Oxford|isbn=978-0-19-263147-3|pages=7–8, 25, 35, 41, 43–44, 51–56|edition=5th}}</ref>{{rp|7}} [[Stomatitis]] is a general term meaning inflammation within the mouth, and often may be associated with ulceration.<ref name="Cawson Oral Path textbook">{{cite book|author1=RA Cawson |author2=EW Odell |author3=S Porter |title=Cawson's essentials of oral pathology and oral medicine.|url=https://archive.org/details/cawsonsessential00caws |url-access=limited |year=2002|publisher=Churchill Livingstone|location=Edinburgh|isbn=978-0-443-07106-5|pages=[https://archive.org/details/cawsonsessential00caws/page/n183 178]–91|edition=7.}}</ref>
Pathologically, the mouth represents a transition between the gastrointestinal tract and the skin, meaning that many gastrointestinal and cutaneous conditions can involve the mouth. Some conditions usually associated with the whole gastrointestinal tract may present only in the mouth, e.g., [[orofacial granulomatosis]]/oral [[Crohn's disease]].<ref name="Zbar 2012">{{cite journal|author2-link=Shomron Ben-Horin |vauthors=Zbar AP, Ben-Horin S, Beer-Gabel M, Eliakim R | title = Oral Crohn's disease: is it a separable disease from orofacial granulomatosis? A review | journal = Journal of Crohn's & Colitis | volume = 6 | issue = 2 | pages = 135–42 | date = March 2012 | pmid = 22325167 | doi = 10.1016/j.crohns.2011.07.001 | doi-access = free }}</ref>
Similarly, cutaneous (skin) conditions can also involve the mouth and sometimes only the mouth, sparing the skin. The different environmental conditions (saliva, thinner mucosa, trauma from teeth and food) mean that some cutaneous disorders which produce characteristic lesions on the skin produce only nonspecific lesions in the mouth.<ref name="Burket OM textbook">{{cite book|last=Glick|first=Martin S. Greenberg, Michael|title=Burket's oral medicine diagnosis & treatment|url=https://archive.org/details/burketsoralmedic00burk|url-access=limited|year=2003|publisher=BC Decker|location=Hamilton, Ont.|isbn=978-1-55009-186-1|pages=[https://archive.org/details/burketsoralmedic00burk/page/n63 50]–79|edition=10th}}</ref> The vesicles and bullae of blistering mucocutaneous disorders progress quickly to ulceration in the mouth, because of moisture and trauma from food and teeth. The high bacterial load in the mouth means that ulcers may become secondarily infected. Cytotoxic drugs administered during chemotherapy target cells with fast turnovers such as malignant cells. However, the epithelia of the mouth also has a high turnover rate and makes oral ulceration ([[mucositis]]) a common side effect of chemotherapy.{{citation needed|date=July 2017}}
Erosions, which involve the epithelial layer, are red in appearance since the underlying lamina propria shows through. When the full thickness of the epithelium is penetrated (ulceration), the lesion becomes covered with a [[fibrin]]ous [[exudate]] and takes on a yellow-grey color. Because an ulcer is a breach of the normal lining, when seen in cross section, the lesion is a crater. A "halo" may be present, which is a reddening of the surrounding mucosa and is caused by inflammation. There may also be [[edema]] (swelling) around the ulcer. Chronic trauma may produce an ulcer with a [[keratosis|keratotic]] (white, thickened mucosa) margin.<ref name="OMF medicine textbook" /> Malignant lesions may ulcerate either because the tumor infiltrates the mucosa from adjacent tissues, or because the lesion originates within the mucosa itself, and the disorganized growth leads to a break in the normal architecture of the lining tissues. Repeat episodes of mouth ulcers can be indicative of an [[immunodeficiency]], signaling low levels of [[immunoglobulin]] in the oral mucous membranes. [[Chemotherapy]], [[HIV]], and [[Infectious mononucleosis|mononucleosis]] are all causes of immunodeficiency/immunosuppression with which oral ulcers may become a common manifestation. [[Autoimmunity]] is also a cause of oral ulceration. [[Mucous membrane pemphigoid]], an autoimmune reaction to the epithelial [[basement membrane]], causes [[desquamation]]/ulceration of the oral mucosa.
Numerous aphthous ulcers could be indicative of an inflammatory autoimmune disease called [[Behçet's disease]]. This can later involve skin lesions and [[uveitis]] in the eyes. [[Vitamin C]] deficiency may lead to [[scurvy]] which impairs wound healing, which can contribute to ulcer formation.<ref name="Contemp Oral path" /> For a detailed discussion of the pathophysiology of aphthous stomatitis, see [[Aphthous stomatitis#Causes]].
== Diagnosis ==
Diagnosis of mouth ulcers usually consists of a medical history followed by an oral examination as well as examination of any other involved area. The following details may be pertinent: The duration that the lesion has been present, the location, the number of ulcers, the size, the color and whether it is hard to touch, bleeds or has a rolled edge. As a general rule, a mouth ulcer that does not heal within 2 or 3&nbsp;weeks should be examined by a health care professional who is able to rule out oral cancer (e.g. a [[dentist]], [[oral medicine|oral physician]], [[oral surgeon]], or [[maxillofacial surgeon]]).<ref name=MedlinePlus /><ref  name="Scully 2000">{{cite journal |vauthors=Scully C, Shotts R | title = ABC of oral health. Mouth ulcers and other causes of orofacial soreness and pain | journal = BMJ (Clinical Research Ed.) | volume = 321 | issue = 7254 | pages = 162–65 | date = 15 July 2000 | pmid = 10894697 | pmc = 1118165 | doi = 10.1136/bmj.321.7254.162 }}</ref>  If there have been previous ulcers that have healed, then this again makes cancer unlikely.
An ulcer that keeps forming on the same site and then healing may be caused by a nearby sharp surface, and ulcers that heal and then recur at different sites are likely to be recurrent aphthous stomatitis (RAS). Malignant ulcers are likely to be single in number, and conversely, multiple ulcers are very unlikely to be oral cancer. The size of the ulcers may be helpful in distinguishing the types of RAS, as can the location (minor RAS mainly occurs on non-keratinizing mucosa, major RAS occurs anywhere in the mouth or oropharynx). Induration, contact bleeding and rolled margins are features of a malignant ulcer. There may be nearby causative factor, e.g. a broken tooth with a sharp edge that is traumatizing the tissues. Otherwise, the person may be asked about problems elsewhere, e.g. ulceration of the genital mucous membranes,<ref name="Keogan 2009">{{cite journal | author = Keogan MT | title = Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet's syndrome | journal = Clinical and Experimental Immunology | volume = 156 | issue = 1 | pages = 1–11 | date = April 2009 | pmid = 19210521 | pmc = 2673735 | doi = 10.1111/j.1365-2249.2008.03857.x }}</ref> eye lesions or digestive problems, swollen glands in neck ([[lymphadenopathy]]) or a  general unwell feeling.{{citation needed|date=July 2017}}
The diagnosis comes mostly from the history and examination, but the following special investigations may be involved: blood tests (vitamin deficiency, anemia, leukemia, Epstein-Barr virus, HIV infection, diabetes) microbiological swabs (infection), or [[urinalysis]] (diabetes). A [[biopsy]] (minor procedure to cut out a small sample of the ulcer to look at under a microscope) with or without [[immunofluorescence]] may be required, to rule out cancer, but also if a systemic disease is suspected.<ref name="OMF medicine textbook" /> Ulcers caused by local trauma are painful to touch and sore. They usually have an irregular border with erythematous margins and the base is yellow. As healing progresses, a keratotic (thickened, white mucosa) halo may occur.<ref name="Tyldesley OM textbook" />{{rp|52}}
=== Differential diagnosis ===
Due to various factors (saliva, relative thinness of oromucosa, trauma from teeth, chewing, etc.), [[Skin condition|vesicles and bulla]]e which form on the [[mucous membrane]]s of the [[oral cavity]] tend to be fragile and quickly break down to leave ulcers.
Aphthous stomatitis and local trauma are very common causes of oral ulceration; the many other possible causes are all rare in comparison.{{citation needed|date=July 2017}}
==== Traumatic ulceration ====
[[File:Trauma of the lower mouth lining.png|thumbnail|right|150px|A "crop" of trauma-induced ulcers on the [[labial mucosa]]]]
Most mouth ulcers that are not associated with [[recurrent aphthous stomatitis]] are caused by local trauma. The mucous membrane lining of the mouth is thinner than the skin, and easily damaged by mechanical, thermal (heat/cold), chemical, or electrical means, or by irradiation.
{{citation needed|date=July 2017}}
==== Mechanical ====
[[File:Oral ulcer.jpg|thumbnail|left|A small ulcer on the [[frenum]] on the lower inside lip]]
Common causes of oral ulceration include rubbing on sharp edges of teeth, fillings, crowns, false teeth (dentures), or braces ([[dental braces|orthodontic appliances]]), or accidental biting caused by a lack of awareness of painful stimuli in the mouth (e.g., following [[local anesthetic]] used during dental treatment, which the person becomes aware of as the anesthetic wears off).{{citation needed|date=July 2017}}
Eating hard foods (e.g., potato chips) can damage the lining of the mouth. Some people cause damage inside their mouths themselves, either through an absentminded habit or as a type of deliberate [[self-harm]] ([[Factitious disorder|factitious]] ulceration). Examples include biting the cheek, tongue, or lips, or rubbing a fingernail, pen, or toothpick inside the mouth. Tearing (and subsequent ulceration) of the [[Frenulum labii superioris|upper labial frenum]] may be a sign of [[child abuse]] (non-accidental injury).<ref name="OMF medicine textbook" />
Iatrogenic ulceration can also occur during dental treatment, where incidental [[abrasion (medical)|abrasions]] to the soft tissues of the mouth are common. Some dentists apply a protective layer of [[petroleum jelly]] to the lips before carrying out dental work to minimize this.{{citation needed|date=July 2017}}
The [[lingual frenum]] is also vulnerable to ulceration by repeated friction during [[Cunnilingus|oral sexual activity]] ("[[cunnilingus tongue]]").<ref name="OMF path textbook">{{cite book|author1=BW Neville |author2=DD Damm |author3=CM Allen |author4=JE Bouquot |title=Oral & maxillofacial pathology|url=https://archive.org/details/oralmaxillofacia00nevi |url-access=limited |year=2002|publisher=W.B. Saunders|location=Philadelphia|isbn=978-0-7216-9003-2|pages=[https://archive.org/details/oralmaxillofacia00nevi/page/n265 253]–84|edition=2.}}</ref> Rarely, infants can ulcerate the tongue or lower lip with the teeth, termed [[Riga-Fede disease]].<ref>{{cite journal|last1=Li|first1=J|last2=Zhang|first2=YY|last3=Wang|first3=NN|last4=Bhandari|first4=R|last5=Liu|first5=QQ|title=Riga-Fede disease in a child.|journal=Clinical and Experimental Dermatology|date=April 2016|volume=41|issue=3|pages=285–86|doi=10.1111/ced.12728|pmid=26307375|s2cid=204986006}}</ref>
==== Thermal and electrical burn ====
Thermal burns usually result from placing hot food or beverages in the mouth. This may occur in those who eat or drink before a local anesthetic has worn off. The normal painful sensation is absent and a burn may occur. Microwave ovens sometimes produce food that is cold externally and very hot internally, and this has led to a rise in the frequency of intra-oral thermal burns. Thermal food burns are usually on the palate or posterior buccal mucosa, and appear as zones of erythema and ulceration with necrotic epithelium peripherally. Electrical burns more commonly affect the oral commissure (corner of the mouth). The lesions are usually initially painless, charred and yellow with little bleeding. Swelling then develops and by the fourth day following the burn the area becomes necrotic and the epithelium sloughs off.<ref name="OMF path textbook" />
Electrical burns in the mouth are usually caused by chewing on live electrical wiring (an act that is relatively common among young children). Saliva acts as a conducting medium and an electrical arc flows between the electrical source and the tissues, causing extreme heat and possible tissue destruction.<ref name="OMF path textbook" /><ref name=Toon>{{cite journal |vauthors=Toon MH, Maybauer DM, Arceneaux LL, Fraser JF, Meyer W, Runge A, Maybauer MO | title = Children with burn injuries-assessment of trauma, neglect, violence and abuse | journal = Journal of Injury and Violence Research | volume = 3 | issue = 2 | pages = 98–110 | year = 2011 | pmid = 21498973 | pmc = 3134932 | doi = 10.5249/jivr.v3i2.91 }}</ref>
==== Chemical injury ====
Caustic chemicals may cause ulceration of the oral mucosa if they are of strong-enough concentration and in contact for a sufficient length of time. The holding of medication in the mouth instead of swallowing it occurs mostly in children, those under psychiatric care, or simply because of a lack of understanding. Holding an [[aspirin]] tablet next to a painful tooth in an attempt to relieve [[pulpitis]] (toothache) is common, and leads to epithelial necrosis. Chewable aspirin tablets should be swallowed, with the residue quickly cleared from the mouth.{{citation needed|date=July 2017}}
Other caustic medications include [[eugenol]] and [[chlorpromazine]]. [[Hydrogen peroxide]], used to treat gum disease, is also capable of causing epithelial necrosis at concentrations of 1–3%. [[Silver nitrate]], sometimes used for pain relief from aphthous ulceration, acts as a chemical cauterant and destroys nerve endings, but the mucosal damage is increased. [[Phenol]] is used during dental treatment as a cavity sterilizing agent and cauterizing material, and it is also present in some over-the-counter agents intended to treat aphthous ulcerations. Mucosal necrosis has been reported to occur with concentrations of 0.5%. Other materials used in [[endodontics]] are also caustic, which is part of the reason why use of a [[Dental dam|rubber dam]] is now recommended.<ref name="OMF path textbook" /><!-- all this section supported by OMF path textbook, pp&nbsp;259–260 -->
==== Irradiation ====
As a result of [[radiotherapy]] to the mouth, radiation-induced [[stomatitis]] may develop, which can be associated with mucosal erosions and ulceration. If the salivary glands are irradiated, there may also be [[xerostomia]] (dry mouth), making the oral mucosa more vulnerable to frictional damage as the lubricating function of saliva is lost, and mucosal [[atrophy]] (thinning), which makes a breach of the epithelium more likely. Radiation to the bones of the jaws causes damage to [[osteocyte]]s and impairs the blood supply. The affected hard tissues become hypovascular (reduced number of blood vessels), hypocellular (reduced number of cells), and hypoxic (low levels of oxygen). [[Osteoradionecrosis]] is the term for when such an area of irradiated bone does not heal from this damage. This usually occurs in the [[mandible]], and causes chronic pain and surface ulceration, sometimes resulting in non-healing bone being exposed through a soft tissue defect. Prevention of osteradionecrosis is part of the reason why all teeth of questionable prognosis are removed before the start of a course of radiotherapy.<ref name="OMF path textbook" /><!-- all this section supported by OMF path textbook, pp&nbsp;263–264 -->
==== Aphthous stomatitis ====
[[File:Mouth sore.JPG|thumb|An [[aphthous ulcer]] on the [[labial mucosa]] (note [[erythematous]] "halo" surrounding lesion)]]
{{main|Aphthous stomatitis}}
Aphthous stomatitis (also termed recurrent aphthous stomatitis, RAS, and commonly called "canker sores") is a very common cause of oral ulceration. 10–25% of the general population have this non-contagious condition. Three types of aphthous stomatitis exists based on their appearance, namely minor, major and herpetiform major aphthous ulceration. Minor aphthous ulceration is the most common type, presenting with 1–6 small (2-4mm diameter), round/oval ulcers with a yellow-grey color and an erythematous (red) "halo". These ulcers heal with no permanent scarring in about 7–10&nbsp;days. Ulcers recur at intervals of about 1–4&nbsp;months. Major aphthous ulceration is less common than the minor type, but produces more severe lesions and symptoms. Major aphthous ulceration presents with larger (>1&nbsp;cm diameter) ulcers that take much longer to heal (10–40&nbsp;days) and may leave scarring. The minor and major subtypes of aphthous stomatitis usually produce lesions on the non-keratinized oral mucosa (i.e. the inside of the cheeks, lips, underneath the tongue and the [[floor of mouth]]), but less commonly major aphthous ulcers may occur in other parts of the mouth on keratinized mucosal surfaces. The least common type is herpetiform ulceration, so named because the condition resembles [[primary herpetic gingivostomatitis]]. Herpetiform ulcers begin as small blisters (vesicles) which break down into 2-3mm sized ulcers. Herpetiform ulcers appear in "crops" sometimes hundreds in number, which can coalesce to form larger areas of ulceration. This subtype may cause extreme pain, heals with scarring and may recur frequently.{{citation needed|date=July 2022}}
The exact cause of aphthous stomatitis is unknown, but there may be a genetic predisposition in some people. Other possible causes include [[hematinic]] deficiency ([[folate]], [[vitamin B]], [[iron]]), stopping smoking, [[stress (psychological)|stress]], [[menstruation]], trauma, food [[allergy|allergies]] or hypersensitivity to [[sodium lauryl sulphate]] (found in many brands of [[toothpaste]]). Aphthous stomatitis has no clinically detectable signs or symptoms outside the mouth, but the recurrent ulceration can cause much discomfort to those affected. Treatment is aimed at reducing the pain and swelling and speeding healing, and may involve systemic or topical [[steroid]]s, [[analgesic]]s (pain killers), [[antiseptic]]s, [[anti-inflammatory|anti-inflammatories]] or barrier pastes to protect the raw area(s).<ref name="OMF medicine textbook" />
==== Infection ====
{| class="wikitable" style="float: right; width:400px;"
|+ Infectious causes of oral ulceration<ref name="OMF medicine textbook" />
|-
| Agent|| Example(s)
|-
| [[virus|Viral]] || [[chickenpox]], [[hand, foot and mouth disease]], [[herpangina]], [[herpetic stomatitis]], [[human immunodeficiency virus]], [[infectious mononucleosis]]
|-
| [[Bacteria]]l || [[acute necrotizing ulcerative gingivitis]], [[Noma (disease)|gangrenous stomatitis]], [[syphilis]], [[tuberculosis]]
|-
| [[fungi|Fungal]] || [[blastomycosis]], [[cryptococcosis]], [[histoplasmosis]], [[paracoccidioidomycosis]]
|-
| [[Parasite|Parasitic]] || [[leishmaniasis]]
|}
Many infections can cause oral ulceration (see table). The most common are [[herpes simplex]] virus ([[herpes labialis]], [[primary herpetic gingivostomatitis]]), [[Varicella zoster virus|varicella zoster]] ([[chicken pox]], [[shingles]]), and [[coxsackie A virus]] ([[hand, foot and mouth disease]]). [[Human immunodeficiency virus]] (HIV) creates immunodeficiencies which allow opportunistic infections or neoplasms to proliferate. Bacterial processes leading to ulceration can be caused by  ''[[Mycobacterium tuberculosis]]'' ([[tuberculosis]]) and ''[[Treponema pallidum]]'' ([[syphilis]]).{{citation needed|date=July 2017}}
Opportunistic activity by combinations of otherwise normal bacterial flora, such as aerobic streptococci, ''Neisseria'', ''Actinomyces'', spirochetes, and ''Bacteroides'' species can prolong the ulcerative process. Fungal causes include ''Coccidioides immitis'' ([[valley fever]]), ''Cryptococcus neoformans'' ([[cryptococcosis]]), and ''[[Blastomyces dermatitidis]]'' ("North American [[Blastomycosis]]").<ref name="Contemp Oral path">{{cite book|last=Sapp|first=J. Phillip|author2=Lewis Roy Eversole |author3=George W. Wysocki |title=Contemporary Oral and Maxillofacial Pathology|url=https://archive.org/details/contemporaryoral0000sapp_w9z1|url-access=registration|publisher=[[Mosby (publisher)|Mosby]]|year=2004|isbn=978-0-323-01723-7}}{{Page needed|date=September 2010}}</ref> [[Entamoeba histolytica]], a [[parasite|parasitic]] [[protozoa]]n, is sometimes known to cause mouth ulcers through formation of [[cysts]].{{Citation needed|date=October 2012}} [[Epstein-Barr virus-associated lymphoproliferative diseases#Epstein-Barr virus-positive mucocutaneous ulcer|Epstein-Barr virus-positive mucocutaneous ulcer]] is a rare form of the [[Epstein-Barr virus-associated lymphoproliferative diseases]] in which infiltrating, [[Epstein-Barr virus]] (i.e. EBV)-infected B cells cause solitary, well-circumscribed ulcers in [[mucous membrane]]s and skin.<ref name="pmid29885408">{{cite journal | vauthors = Rezk SA, Zhao X, Weiss LM | title = Epstein-Barr virus (EBV)-associated lymphoid proliferations, a 2018 update | journal = Human Pathology | volume = 79 | pages = 18–41 | date = September 2018 | pmid = 29885408 | doi = 10.1016/j.humpath.2018.05.020 | s2cid = 47010934 }}</ref>
==== Drug-induced ====
Many drugs can cause mouth ulcers as a side effect. Common examples are [[alendronate]]<ref name="Kharazmi 2012">{{cite journal |vauthors=Kharazmi M, Sjöqvist K, Warfvinge G | title = Oral ulcers, a little known adverse effect of alendronate: review of the literature | journal = Journal of Oral and Maxillofacial Surgery | volume = 70 | issue = 4 | pages = 830–36 | date = April 2012 | pmid = 21816532 | doi = 10.1016/j.joms.2011.03.046 }}</ref> (a [[bisphosphonate]], commonly prescribed for [[osteoporosis]]), [[cytotoxic drug]]s (e.g. [[methotrexate]], i.e. [[chemotherapy]]), [[non-steroidal anti-inflammatory drug]]s, [[nicorandil]]<ref name="Healy 2004">{{cite journal |vauthors=Healy CM, Smyth Y, Flint SR | title = Persistent nicorandil induced oral ulceration | journal = Heart | volume = 90 | issue = 7 | page = e38 | date = July 2004 | pmid = 15201264 | pmc = 1768343 | doi = 10.1136/hrt.2003.031831 }}</ref> (may be prescribed for [[angina]]) and [[propylthiouracil]] (e.g. used for [[hyperthyroidism]]). Some recreational drugs can cause ulceration, e.g. [[cocaine]].<ref>{{cite journal |vauthors=Fazzi M, Vescovi P, Savi A, Manfredi M, Peracchia M | title = [The effects of drugs on the oral cavity] | journal = Minerva Stomatologica | volume = 48 | issue = 10 | pages = 485–92 | date = October 1999 | pmid = 10726452 }}</ref>
==== Malignancy ====
[[File:PLoS oral cancer.png|right|thumb|Advanced [[oral cancer]] ([[TNM staging system|T4 N2 M0]], stage 4). Note rolled margins of central ulcer and surrounding areas of [[premalignant]] change. The patient died two months after subsequent partial [[glossectomy]] (removal of part of the tongue)]]
{{main|Oral cancer}}
Rarely, a persistent, non-healing mouth ulcer may be a [[cancer]]ous lesion. Malignancies in the mouth are usually [[carcinoma]]s, but [[lymphoma]]s, [[sarcoma]]s and others may also be possible. Either the tumor arises in the mouth, or it may grow to involve the mouth, e.g. from the [[maxillary sinus]], [[salivary gland]]s, [[nasal cavity]] or peri-oral skin. The most common type of oral cancer is [[squamous cell carcinoma]]. The main risk factors are long-term [[smoking]] and [[alcohol (drug)|alcohol]] consumption (particularly when combined) and [[betel]] use.
Common sites of oral cancer are the lower lip, the floor of the mouth, and the sides, underside of the tongue and mandibular alveolar ridge, but it is possible to have a tumor anywhere in the mouth. Appearances vary greatly, but a typical malignant ulcer would be a persistent, expanding lesion that is totally red ([[erythroplasia]]) or speckled red and white (erythroleukoplakia). Malignant lesions also typically feel [[induration|indurated]] (hardened) and attached to adjacent structures, with "rolled" margins or a punched out appearance and bleeds easily on gentle manipulation.<ref name="Contemp OMFS textbook">{{cite book|author1=James R. Hupp|author2=Myron R. Tucker|author3=Edward Ellis|title=Contemporary oral and maxillofacial surgery|url=https://archive.org/details/contemporaryoral00hupp|url-access=limited|year=2008|publisher=Mosby Elsevier|location=St. Louis, Mo.|isbn=978-0-323-04903-0|edition=5th|page=[https://archive.org/details/contemporaryoral00hupp/page/n445 433]}}</ref> If someone has an unexplained mouth ulcer persisting for more than 3 weeks this may indicate a need for a referral from the GDP or GP to hospital to exclude oral cancer.<ref>{{Cite web|url=https://www.nice.org.uk/bnf-bnfc-uk-only|title=BNF and BNFc are only available in the UK|website=NICE|access-date=2018-12-11}}</ref>
==== Vesiculobullous diseases ====
{{main|Vesiculobullous disease}}
Some of the viral infections mentioned above are also classified as [[vesiculobullous disease]]s. Other example vesiculobullous diseases include [[pemphigus vulgaris]], [[mucous membrane pemphigoid]], [[bullous pemphigoid]], [[dermatitis herpetiformis]], [[linear IgA disease]], and [[epidermolysis bullosa]].<ref name=Regezi2011>{{cite book|vauthors=Regezi JA, Sciubba JJ, Jordan RK |title=Oral pathology : clinical pathologic correlations|year=2011|publisher=Elsevier/Saunders|location=St. Louis, Mo.|isbn=978-1455702626|edition=6th}}</ref>{{rp|1,22}}
====Allergy====
{{main|Stomatitis#Allergic contact stomatitis}}
Rarely, allergic reactions of the mouth and lips may manifest as erosions; however, such reactions usually do not produce frank ulceration. An example of one common [[allergen]] is [[Balsam of Peru]]. If individuals allergic to this substance have oral exposure they may experience [[stomatitis]] and [[cheilitis]] (inflammation, rash, or painful erosion of the lips, [[oropharyngeal]] [[mucosa]], or angles of their mouth).<ref name="dermnetnz1">{{cite web|url=http://dermnetnz.org/dermatitis/balsam-of-peru-allergy.html |title=Balsam of Peru contact allergy |publisher=Dermnetnz.org |date=December 28, 2013 |access-date=March 5, 2014}}</ref><ref name="google2">{{cite book|url=https://books.google.com/books?id=mrreTHuo54wC&q=balsam+of+peru+allergy&pg=PA352 |title=Biocompatibility of Dental Materials |author1=Gottfried Schmalz |author2=Dorthe Arenholt Bindslev |publisher= Springer|date= 2008|access-date=March 5, 2014|isbn=9783540777823 }}</ref><ref name="google5">{{cite book|url=https://books.google.com/books?id=kDWlWR5UbqQC&q=%22balsam+of+peru%22+allergy&pg=PT530 |title=Clinical Dermatology |author=Thomas P. Habif |publisher=Elsevier Health Sciences |date=2009 |access-date=March 6, 2014|isbn=978-0323080378 }}</ref><ref>{{cite book|url=https://books.google.com/books?id=fmwYAgAAQBAJ&q=%22balsam+of+peru%22+allergy&pg=PT264 |title=Conn's Current Therapy 2014: Expert Consult |author1=Edward T. Bope |author2=Rick D. Kellerman |publisher=Elsevier Health Sciences |date= 2013 |access-date=March 6, 2014|isbn=9780323225724 }}</ref>  Balsam of Peru is used in foods and drinks for flavoring, in perfumes and toiletries for fragrance, and in medicine and pharmaceutical items for healing properties.<ref name="dermnetnz1"/><ref name="google2"/><ref name="google5"/>
==== Other causes ====
A wide range of other diseases may cause mouth ulcers. [[hematologic disorder|Hematological]] causes include [[anemia]], [[hematinic]] deficiencies, [[neutropenia]], [[hypereosinophilic syndrome]], [[leukemia]], [[myelodysplastic syndrome]]s, other white cell [[dyscrasia]]s, and [[gammopathy|gammopathies]]. [[Gastrointestinal disorder|Gastrointestinal]] causes include [[celiac disease]], [[Crohn's disease]] ([[orofacial granulomatosis]]), and [[ulcerative colitis]].  [[Cutaneous condition|Dermatological]] causes include [[chronic ulcerative stomatitis]], [[erythema multiforme]] (Stevens-Johnson syndrome), [[angina bullosa haemorrhagica]] and [[lichen planus]]. Other examples of systemic disease capable of causing mouth ulcers include [[lupus erythematosus]], [[Sweet syndrome]], [[reactive arthritis]], [[Behçet syndrome]], [[granulomatosis with polyangiitis]], [[periarteritis nodosa]], [[giant cell arteritis]],<!-- oral ulcers in giant cell arteritis? Pls confirm --> [[diabetes]], [[glucagonoma]], [[sarcoidosis]] and [[periodic fever, aphthous stomatitis, pharyngitis and adenitis]].<ref name="OMF medicine textbook" />
The conditions [[Eosinophilic ulcer of the oral mucosa|eosinophilic ulcer]] and [[necrotizing sialometaplasia]] may present as oral ulceration.
[[Macroglossia]], an abnormally large tongue, can be associated with ulceration if the tongue protrudes constantly from the mouth.<ref name="OMF path textbook" /> <!-- p.9 --> [[Caliber persistent artery]] describes a common vascular anomaly where a main arterial branch extends into superficial submucosal tissues without a reduction of diameter. This commonly occurs in elderly people on the lip and may be associated with ulceration.<ref name="OMF path textbook" /> <!-- p.15 -->
== Treatment ==
Treatment is cause-related, but also [[symptomatic treatment|symptomatic]] if the underlying cause is unknown or not correctable. It is also important to note that most ulcers will heal completely without any intervention. Treatment can range from:
* Smoothing or removing a local cause of trauma
* Addressing dry mouth
* Substituting a problem medication or switching to [[Sodium dodecyl sulfate#Mouth Ulceration|SLS-free toothpaste]]
* Maintaining good [[oral hygiene]] and use of an [[antiseptic]] mouthwash or spray (e.g. [[chlorhexidine]]), which can prevent secondary infection and therefore hasten healing
* A topical analgesic (e.g. [[benzydamine]] mouthwash) to reduce pain
* Topical (gels, creams or inhalers) or systemic steroids may be used to reduce inflammation
* An [[antifungal medication|antifungal]] drug may be used to prevent [[oral candidiasis]] developing in those who use prolonged steroids<ref name="OMF medicine textbook" />
* People with mouth ulcers may prefer to avoid hot or spicy foods, which can increase the pain<ref name=MedlinePlus />
* Self-inflicted ulceration can be difficult to manage, and psychiatric input may be required in some people<ref name="Tyldesley OM textbook" />{{rp|53}}
* For recurrent ulcers, [[vitamin B12]] has been shown to be effective<ref>{{Cite journal |doi = 10.3122/jabfm.2009.01.080113|pmid = 19124628|title = Effectiveness of Vitamin B12 in Treating Recurrent Aphthous Stomatitis: A Randomized, Double-Blind, Placebo-Controlled Trial|journal = The Journal of the American Board of Family Medicine|volume = 22|issue = 1|pages = 9–16|year = 2009|last1 = Volkov|first1 = I.|last2 = Rudoy|first2 = I.|last3 = Freud|first3 = T.|last4 = Sardal|first4 = G.|last5 = Naimer|first5 = S.|last6 = Peleg|first6 = R.|last7 = Press|first7 = Y.|doi-access = free}}</ref>
== Epidemiology ==
Oral ulceration is a common reason for people to seek medical or dental advice.<ref name="Tyldesley OM textbook" />{{rp|52}} A breach of the oral mucosa probably affects most people at various times during life. For a discussion of the epidemiology of aphthous stomatitis, see [[Aphthous stomatitis#Epidemiology|the epidemiology of aphthous stomatitis]].
== See also ==
* [[Sodium dodecyl sulfate]]
== References ==
{{reflist}}
== External links ==
{{Medical resources
| DiseasesDB      = 22751
| ICD11           = {{ICD11|DA01.15}}
| ICD10           = {{ICD10|K|12}}<!-- unsure if correct... -->
| ICD9            = {{ICD9|528.9}}
| ICDO            =
| OMIM            =
| MedlinePlus     = 001448
| eMedicineSubj   =
| eMedicineTopic  =
| MeshID          = D019226
| SNOMED CT       = 26284000
}}
* {{wikiversity inline|Oral ulceration}}
{{Oral pathology}}
{{DEFAULTSORT:Mouth Ulcer}}
[[Category:Herpes simplex virus–associated diseases]]
[[Category:Oral mucosal pathology]]