The Telegraph
Monday , December 17 , 2012
Since 1st March, 1999
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A mouthful of pain

At any given time, 20 per cent of the population is suffering from one or more mouth ulcers (aphthous ulcers). These can develop inside the cheeks, tongue, on the roof of the mouth or the inside of the lips. They may be one or many, small or large. Usually such ulcers are less than 10mm in size and three in number. There may be also be enlarged painful lymph nodes below the jaw.

The mucosa in the mouth is abundantly supplied with nerves so mouth ulcers are extremely painful. Contact of hot or spicy food increases the pain so those suffering from mouth ulcers are often unable to eat.

Unfortunately, no clear single cause for the ulcers has been identified. Children can develop mouth ulcers due to a viral infection, teething, fungus or an injury. In some adults, ulcers may start after a swollen area in the mouth is inadvertently bitten. Usually, around adolescence, ulcers start to “just appear” several times a year, spontaneously and mysteriously. Women are more likely to suffer from such ulcers. Stress, illness, antibiotic use and general debility may also precipitate mouth ulcers.

The viruses implicated in mouth ulcers are Herpes, Coxsackie, Cytomegalovirus and Hepatitis C . The Herpes virus tends to produce multiple ulcers. Adults with herpetic ulcers may be diabetic, immunocompromised, or have cancer. These ulcers respond well to antiviral medication.

Fungal infection with candida (monilia) produces a red sore mouth and cheeks with white curd-like patches. If the patches are scrubbed clean, a raw red surface is seen. Children who use feeding bottles usually suffer from such an infection, even if the nipple is apparently sterilised adequately. Those who use pacifiers are even more prone to it. Such a child finds it difficult to swallow and may lose interest in feeding. In adults, monilial infection can occur with uncontrolled diabetes, prolonged antibiotic use, cancer and its treatment. It is one of the markers for HIV infection.

Constant trauma to the mucosa of the mouth can also cause ulcers. This may be due to abrasive, poorly aligned dentures or broken irregular teeth with rough and jagged edges.

Failure to brush the teeth morning and evening causes build up of hard yellow plaque on the inside of the teeth near the gums. Once this has occurred, vigorous brushing no longer removes the tartar. Bacteria are able to gain a foothold in the crevices resulting in recurrent mouth ulcers with accompanying bad breath.

Food, particularly fast food, is often coloured with red or yellow dyes. These are often contaminated, substandard and non-food grade. They can cause contact allergy, damage to the mucosa as well as ulcers.

Smoking as well as chewing tobacco, paan, gutka, supari and Pan Parag (all of them are toxic) can damage the lining of the mouth. Continuous use can cause loss of pigmentation (leukplakia), visible as white patches on the inside of the mouth. This condition can be precancerous. It needs a diagnostic biopsy, expert evaluation and follow up.

Illnesses like ulcerative colitis and SLE (Systemic lupus erythematosus, a long-term autoimmune disorder) affect the immune system of the body and can produce chronic mouth ulcers.

Deficiency of iron, zinc and the B group of vitamins can cause a red sore mouth with a smooth tongue and fissured lips. The mucosa becomes thin and delicate. It is easily traumatised producing ulcers.

The response to treatment is difficult to assess as ulcers spontaneously disappear in 2-3 weeks even if untreated and do not scar.

Ulcer treatment

Sucking on an ice cube before eating numbs the pain.
Local anaesthetic ointments dull the pain.
Mix equal quantities of antacid and benedryl syrup and swirl it in the mouth several times a day.
Steroids (if prescribed) can be applied locally (They will aggravate ulcers due to infections).
Ulcers due to the herpes virus respond to a short course of antiviral medication.
Any ulcer in the mouth which does not heal after two weeks of treatment needs a biopsy to rule out cancer.

Dr Gita Mathai is a paediatrician with a family practice at Vellore. Questions on health issues may be emailed to her at