Proper oral hygiene prevents the formation of plaque, which in turn may lead to bacterial infections and ultimately, ulcers (below)

Food is meant to be chewed and savoured in the mouth before it is swallowed. This task becomes an unpleasant chore in 20 per cent of the population at any given time, as their mouths have painful ulcers.

Mouth ulcers appear around adolescence, are commoner in women and tend to recur throughout life. Ulcers run in families, with many members affected. They appear in clusters with symptom-free intervals. They are usually less than 10 mm in size and not more than three in number. Although they are superficial, the nerves are very close to the surface of the mucosa of the mouth and this makes ulcers extremely painful. They spontaneously disappear in two-three weeks without treatment and do not leave a scar.

Although many factors are presumed to precipitate ulcers, a single agent has not been identified as the cause. They appear to be precipitated by stress, debility, antibiotics and hormonal changes.

Viruses, particularly the herpes virus — Coxsackie, Cytomegalovirus and Hepatitis C virus have been implicated in causing recurrent ulcers. The herpes virus tends to produce multiple ulcers. This infection is commoner in children. Adults with herpetic ulcers may be diabetic, immuno-compromised, have cancer or HIV infection. These ulcers respond well to the antiviral medication, acyclovir.

Sometimes the herpes virus causes cold sores along the lip (not inside the mouth) as a cluster of painful, water-filled blisters. This occurs incidentally during some other febrile illness.

Fungal infection with candida (monilia) produces a red sore mouth and cheeks with white curd-like patches that are difficult to remove. If force is used, a raw red surface is seen. In children, this commonly occurs when feeding bottles are used, even if the nipple is apparently sterilised adequately. It is even more common with pacifiers. The 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 cause ulcers. This may be due to abrasive, poorly aligned dentures or broken irregular teeth with rough and jagged edges.

Poor oral hygiene with failure to brush morning and evening causes the build-up of hard, yellow disfiguring 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 halitosis (bad breath).

Food, particularly fast food (like chicken 65, cauliflower 65, etc.), is often coloured with red or yellow dyes. These may be contaminated, substandard and not food-grade. They can cause contact allergy, damage to the mucosa and ulcers.

Smoking or chewing tobacco, paan, supari and pan masala are toxic and can damage the lining of the mouth. Continuous long-term contact can cause loss of pigmentation (leukplakia), visible as white patches on the inside of the mouth. This condition can be pre-cancerous. It needs a diagnostic biopsy, expert evaluation and follow-up.

Illnesses like ulcerative colitis and SLE (Systemic Lupus Erythymatosis) 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 delicate and easily traumatised, producing ulcers.

If ulcers have formed —

• Sucking on an ice cube before eating will numb the pain.

• Local anaesthetic ointments may be used.

• Steroids (if prescribed) can be applied locally.

• A short course in antiviral medication (acyclovir) reduces the duration and severity of ulcers caused by herpes infection.

Any ulcer in the mouth which does not heal after two weeks of appropriate treatment needs a biopsy to rule out cancer.

To prevent ulcers —

• Brush your teeth twice a day.

• Take care of caries or broken teeth and ill-fitting dentures.

• Eat 60 ml (20 z) of curds a day first thing in the morning on an empty stomach. The lactobacillus in curds has an immunoprotective effect and reduces the incidence of aphthous (mouth) ulcers.

• Eat a well-balanced diet with vitamins, minerals, carotenoids and antioxidants. Eat at least three helpings of raw vegetables and fruits a day. Add fresh sprouts to salads.

• Avoid toxic chemicals and food with dyes.

• In case of children, do not use feeding bottles and pacifiers.

• Clorhexidine, povidone iodine and other antiseptic mouthwashes can be used to rinse out the mouth.

Despite everything, if signs of deficiency appear, take prescribed supplements of vitamins and minerals. All mouth ulcers decrease in frequency and intensity if stress is reduced. This can be done with regular exercise (40 minutes of walking daily) combined with meditation and yoga.

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