A oral ulcer is an ulcer that occurs in the mucous membranes of the oral cavity. Mouth ulcers are very common, occur in relation to many diseases and by many different mechanisms, but usually there is no serious underlying cause.
The two most common causes of oral ulcers are localized trauma (eg rubbing from sharp edges on filling) and aphthous stomatitis ("thrush"), a condition characterized by repeated mouth ulcers for unknown reasons. Mouth ulcers often cause pain and discomfort, and can alter a person's food choices when healing occurs (eg avoiding acidic or spicy foods and drinks).
They can be formed individually or some boils can appear at the same time ("plant" boils). Once established, ulcers can be maintained by inflammation and/or secondary infection. Rarely, a canker sores that do not heal may be a sign of oral cancer.
Video Mouth ulcer
Definitions
An ulcer ( ; from Latin ulcus , "ulcer, pain") is resting on the skin or mucous membranes with loss of surface tissue and disintegration and necrosis of epithelial tissue. A mucosal ulcer is an ulcer that specifically occurs in the mucous membranes. An ulcer is a tissue defect that penetrates the boundary of the epithelial connective tissue, essentially at a deep level in submucosa, or even within the muscle or periosteum. Ulcers are a deeper epithelial violation than erosion or excoriation, and involve damage to the epithelium and lamina propria.
An erosion is a superficial violation of the epithelium, with little damage to the underlying lamina propria. A mucosal erosion is erosion that typically occurs in the mucous membranes. Only epithelial or epilermal superficial epithelial cells disappear, and the lesions can reach the depths of the basement membrane. Erosions heal without scar formation.
Excoriation is a term sometimes used to describe a deeper epitelium violation of erosion but more superficial than ulcer. This type of lesion is tangential to the rete peg and shows bleeding puncture (small bulge) caused by an open capillary loop.
Maps Mouth ulcer
Differential diagnosis
Aphthous stomatitis and localized trauma are common causes of oral ulceration; many other possible causes are rare.
Traumatic ulceration
Most oral ulcers unrelated to recurrent aphthous stomatitis are caused by local trauma. The mucous membrane layer of the mouth is thinner than the skin, and is easily damaged by mechanical, thermal (heat/cold), chemical, or electric, or by radiation.
Mechanical
Common causes of oral ulceration include rubbing on the edges of sharp teeth, patches, crowns, dentures (dentures), or braces (orthodontic appliances). Unintentional sting is caused by a lack of awareness of painful stimuli inside the mouth (eg, after local anesthesia used during dental treatment) can cause ulceration where people become aware when the anesthetic is exhausted and the sensation is full again.
Eating rough foods (for example, chips) can damage the lining of the mouth. Some people cause damage in their own mouth, either through dazed habits or as a deliberate type of self-harming (artificial ulcer). Examples include chewing on the cheek, tongue, or lips, or rubbing a nail, pen, or toothpick inside the mouth. Tearing (and subsequent ulceration) from the upper labial frenum may be a sign of child abuse (accidental injury). Iatrogenic ulceration can also occur during dental treatment, when incidental bruising to the oral soft tissue is common. Some dentists apply a protective layer of petroleum jelly to the lips before performing dental treatment to minimize the number of incidental injuries.
Lingual frenum is also susceptible to ulceration by repeated friction during oral sexual activity ("cunnilingus tongue"). Rarely, a baby can rub the tongue or lower lip with a tooth, called Riga-Fede disease.
Thermal and electrical combustion
Thermal burns are usually generated from placing hot foods or drinks in the mouth. This may occur in those who eat or drink before local anesthesia has faded. No normal pain sensation is present and burns may occur. Microwave ovens sometimes produce foods that are cold externally and very hot internally, and this has led to an increase in the frequency of intra-oral thermal burns. Thermal food burns are usually located in the posterior buccal or buccal mucosa, and appear as erythema and ulceration zones with peripheral necrotic epithelium. Electrical burns more often affect oral commis- sions (mouth corners). Lesions are usually initially painless, scorched and yellow with little bleeding. The swelling then develops and on the fourth day after the burn, the area becomes necrotic and the epitelium is released.
Electrical burns in the mouth are usually caused by chewing live electrical wires (a relatively common action among young children). Saliva acts as a conduction medium and an electric arc flows between a power source and a network, causing extreme heat and possible tissue damage.
Chemical injury
Caustic chemicals can cause oral mucosal ulceration if they have concentration and contacts strong enough for a long time. Holding the medicine in the mouth instead of swallowing it happens mostly in children, those who are under psychiatric care, or simply because of a lack of understanding. Holding an aspirin tablet next to a sore tooth in an attempt to relieve pulpitis (toothache) is common, and leads to epithelial necrosis. The chewed aspirin tablet should be swallowed, with the residue quickly cleared from the mouth.
Other caustic drugs include eugenol and chlorpromazine. Hydrogen peroxide, used to treat gum disease, is also capable of causing epithelial necrosis at a 1-3% concentration. Silver nitrate, sometimes used to relieve pain from aphthous ulcers, acts as a chemical cauter and destroys nerve endings, but increased mucosal damage. Phenol is used during dental treatment as a cavity sterilizer and cauterization agent, and is also present in some over-the-counter agents intended to treat aphthous ulceration. Mucosal necrosis has been reported to occur with a concentration of 0.5%. Other materials used in endodontics are also caustic, which is part of the reason why the use of a rubber dam is now recommended.
Irradiation
As a result of radiotherapy to the mouth, radiation-induced stomatitis can develop, which can be associated with mucosal erosion and ulceration. If the salivary gland is irradiated, there may also be xerostomia (dry mouth), making the oral mucosa more susceptible to frictional damage due to lost salivary lubricant function, and mucosal atrophy (thinning), which makes epithelial violations more likely. Radiation to the jawbone causes damage to osteocytes and damages the blood supply. The affected hard tissue becomes hypovascular (decreases in the number of blood vessels), hypocellular (reduced cell count), and hypoxia (low oxygen levels). Osteoradionecrosis is a term for when an area such as an irradiated bone does not recover from this damage. This usually occurs in the mandible, and causes chronic pain and surface ulceration, sometimes causing the non-cured bone to be exposed through soft tissue defects. Prevention of osteradionecrosis is part of the reason why all the prognostic teeth in question are removed before the start of the radiotherapy program.
Aphthous Stomatitis
Aphthous stomatitis (also called recurrent aphthous stomatitis, RAS, and commonly called "thrush") is a common cause of oral ulcers. 10-25% of the general population suffers from this non-contagious condition. The appearance of aphthous stomatitis varies because there are 3 types, namely aphthous minor ulcers, aphthous major ulcer and ulserasi herpetiform. Aphthous minor ulcers are the most common type, with 1-6 small (2-4mm diameter), round/oval ulcers in grayish yellow and erythematous "halo" (red). These ulcers heal without permanent scarring about 7-10 days. Ulcers recur at intervals of about 1-4 months. Aphthous major ulcers are less common than minor types, but produce more severe lesions and symptoms. The main aphthous ulcer appears with larger ulcers (& gt; 1 cm) that take longer to heal (10-40 days) and may leave scarring. The minor and major subtypes of aphthous stomatitis usually produce lesions in the non-keratinized mouth mucosa (ie the inside of the cheeks, the lips, under the tongue and the floor of the mouth), but less common aphthous major ulcers may occur in other parts of the mouth on the surface of the keratin mucosa. The most common type is herpetiform ulceration, so named because of conditions resembling primary gingivostomatitis herpes. Herpetiform ulcers begin as small blisters (vesicles) that break down into 2-3mm sized ulcers. Herpetiformus ulcers appear in "plants" sometimes hundreds of them, which can coalesce to form larger areas of ulceration. This subtype can cause tremendous pain, heal with scarring and can often recur.
The exact cause of aphthous stomatitis is unknown, but there may be a genetic tendency in some people. Other possible causes include hematin deficiency (folate, vitamin B, iron), smoking cessation, stress, menstruation, trauma, food 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 recurrent ulceration can cause many discomforts in the patient. Treatment is intended to reduce pain and swelling and speed healing, and may involve systemic or topical steroids, analgesics (pain killers), antiseptics, anti-inflammatories or barrier pastes to protect raw areas.
Infection
Many infections can cause oral ulceration (see table). The most common are herpes simplex virus (herpes labialis, primary herpes gingivostomatitis), varicella zoster (chickenpox, shingles), and coxsackie A virus (hands, feet and mouth). Human immunodeficiency virus (HIV) creates an immunodeficiency that allows opportunistic infections or neoplasms to proliferate. The bacterial processes that cause ulceration can be caused by Mycobacterium tuberculosis (tuberculosis) and Treponema pallidum (syphilis).
Opportunistic activities by a combination of normal bacterial bacteria, such as aerobic streptococcus, Neisseria , Actinomyces , spirochetes, and Bacteroides species may prolong the ulcerative process.. Causes of fungi include Coccidioides immitis (valley fever), Cryptococcus neoformans (cryptococcosis), and Blastomyces dermatitidis ("North American Blastomycosis"). Entamoeba histolytica, parasitic protozoa, is sometimes known to cause mouth ulcers through cyst formation.
Drug-induced
Many drugs can cause mouth ulcers as a side effect. Common examples are alendronate (bisphosphonates, commonly prescribed for osteoporosis), cytotoxic drugs (eg methotrexate, ie chemotherapy), non-steroidal anti-inflammatory drugs, nicorandil (possibly prescribed for angina) and propylthiouracil (eg used for hyperthyroidism). Some recreational drugs may cause ulceration, eg. cocaine.
Malignancy
Rarely, persistent and non-healing mouth ulcers can be cancerous lesions. Malignancy in the mouth is usually carcinoma, but lymphoma, sarcoma and others may also occur. Either the tumor appears in the mouth, or it may grow to involve the mouth, for example from the maxillary sinus, salivary glands, nasal cavity or peri-oral skin. The most common type of oral cancer is squamous cell carcinoma. The main causes are long-term smoking and alcohol consumption (especially together) and the use of betel.
Common areas of oral cancer are the lower lip, the floor of the mouth, and the sides and the lower side of the tongue, but it is possible to have a tumor anywhere in the mouth. The appearance varies greatly, but a typical malignant ulcer will be a continually evolving lesion, which is completely red (erythroplasia) or red and white spots (erythroleukoplakia). Malignant lesions also usually feel irregular (hardened) and attached to adjacent structures, with "rolled" margins or hollow and bleeding appearances on soft manipulation.
Vesiculobullous Disease
Due to various factors (salivation, relative thinness of oromucosa, trauma from teeth, chewing, etc.), Vesicles and bulls that form on mucous membranes of the oral cavity tend to be brittle and quickly damaged to leave ulcers.
Some of the viral infections mentioned above are also classified as vesiculobullous diseases. Other examples of vesiculobullous diseases include pemphigus vulgaris, mucous membrane pemphigoid, bullous pemphigoid, dermatitis herpetiformis, linear IgA disease, and bullous epidermolysis.
Allergic
Rarely, allergic reactions to the mouth and lips can manifest as erosion; however, such reactions usually do not produce a clear ulceration. An example of a common allergen is Balsam from Peru. If individuals who are allergic to these substances have oral exposure, they may experience stomatitis and cheilitis (inflammation, rash, or painful erosion of the lips, oropharyngeal mucosa, or the corners of their mouth). Peruvian Balsam is used in foods and beverages for flavorings, perfumes and toiletries for fragrances, and in pharmaceuticals and pharmaceutical goods for healing properties.
Other causes
Various other diseases can cause mouth ulcers. Causes of haematology include anemia, haematinic deficiency, neutropenia, hypereosinophilic syndrome, leukemia, myelodysplastic syndrome, other white cell discrasia, and gammopathies. Gastrointestinal causes include celiac disease, Crohn's disease (orofacial granulomatosis), and ulcerative colitis. Dermatologic causes include chronic ulcerative stomatitis, erythema multiforme (Stevens-Johnson syndrome), angina bullosa haemorrhagica and lichen planus. Other examples of systemic diseases that can cause mouth ulcers include lupus erythematosus, Sweet syndrome, reactive arthritis, BehÃÆ'§et syndrome, granulomatosis with polyangiitis, periarteritis nodosa, giant cellular arteritis, diabetes, glucagonoma, sarcoidosis and periodic fever, aphthous stomatitis, pharyngitis and adenitis.
The condition of eosinophilic ulcer and sialometaplasia necrotizing can appear as an oral ulceration.
Macroglossia, a very large tongue, may be associated with ulceration if the tongue extends continuously from the mouth. The persistent caliber of the artery represents a common vascular anomaly in which the main artery branch extends to the superficial submucous tissue without a reduction in diameter. This usually occurs in the elderly on the lips and may be associated with ulceration.
Pathophysiology
The exact pathogenesis depends on the cause. Ulcers and erosion may occur due to the spectrum of conditions including those causing damage to the autoimmune epithelium, damage by immune defects (eg, HIV, leukemia, infections such as herpes virus) or nutritional disorders (eg, vitamin deficiency). The simple mechanisms that affect the mouth to trauma and ulceration are xerostomia (dry mouth - because saliva usually lubricates mucous membranes and controls bacterial levels) and epithelial atrophy (thinning, for example after radiotherapy), makes the lining more brittle and vulnerable. Stomatitis is a general term that means inflammation in the mouth, and is often associated with ulceration.
Pathologically, the mouth is a transition between the gastrointestinal tract and the skin, which means that many gastrointestinal and cutaneous conditions may involve the mouth. Some conditions commonly associated with the entire gastrointestinal tract may only appear in the mouth, for example, orofacial granulomatosis/oral Crohn disease.
Similarly, skin conditions (skin) can also involve the mouth and sometimes just the mouth, sparing the skin. Different environmental conditions (saliva, thinner mucosa, trauma from teeth and food), means that some skin disorders that produce distinctive lesions on the skin result in non-specific lesions in the mouth. Vesicles and bullock mucocutaneous disorders rapidly develop into ulceration in the mouth, due to moisture and trauma from food and teeth. High bacterial load in the mouth means that ulcers can become secondary infected. Cytotoxic drugs are administered during targeted chemotherapy cells with rapid turnover such as malignant cells. However, the oral epithelium also has a high turnover rate and making oral ulceration (mucositis) is a common side effect of chemotherapy.
Erosion, which involves the epithelial lining, is red because the underlying lamina propria is visible. When the full thickness of the epithelium is penetrated (ulceration), the lesion becomes covered with a fibrinous exudate and takes a grayish yellow color. Because the ulcer is a violation of the normal layer, when viewed in a cross section, the lesion is a crater. A "halo" may exist, which is a reddish of the surrounding mucosa and is caused by inflammation. There may also be edema (swelling) around the ulcer. Chronic trauma can produce ulcers with keratosis margins (white, thickened mucosa). Malignant lesions may be ulcerated because the tumors infiltrate the mucosa from adjacent tissue, or because the lesions are from the mucosa itself, and unorganized growth causes a break in the normal architecture of the lining tissue. Repeat episodes of oral ulcers may be indicative of immunodeficiency, indicating low levels of immunoglobulin in the oral mucous membranes. Chemotherapy, HIV, and mononucleosis are all causes of immunosuppression/immunosuppression where mouth ulcers can be common manifestations. Autoimmunity is also a cause of oral ulceration. Pemphigoid mucous membrane, autoimmune reaction to epithelial basement membrane, causing desquamation/ulceration of oral mucosa. Many aphthous ulcers may be an indication of an inflammatory autoimmune disease called BehÃÆ'§et disease. This can later involve skin lesions and uveitis in the eye. Vitamin C deficiency can cause scurvy diseases that interfere with wound healing, which may contribute to ulcer formation. For a detailed discussion of the pathophysiology of aphthous stomatitis, see Aphthous Stomatitis # Cause.
Diagnostic approach
The diagnosis of oral ulcers usually consists of a medical history followed by an oral examination and examination of other areas involved. The following details may be relevant: The duration of an existing lesion, location, number of boils, size, color and whether hard to touch, bleed or have a rolled edge. As a general rule, oral ulcers that do not heal within 2 or 3 weeks should be checked by a health care professional who is able to rule out oral cancer (eg dentist, oral doctor, oral surgeon, or maxillofacial surgeon). If there is already a boil that has been healed, then this again makes cancer impossible.
The ulcer that continues to form on the same site and then healing may be caused by a nearby sharp surface, and ulcers that heal and then recur in different locations tend to be RAS. Malignant ulcers tend to be single, and conversely, some ulcers are highly unlikely to become oral cancers. Ulcer size may be helpful in differentiating RAS types, as can location (small RAS mainly occurs in non-keratinized mucosa, large RAS occurs anywhere in the mouth or oropharynx). Induration, contact bleeding and rolled margins are a feature of malignant ulcers. There may be a nearby causal factor, e.g. a broken tooth with a sharp tip that causes tissue trauma. Otherwise, the person may be asked about issues elsewhere, e.g. ulceration of the genital mucous membranes, eye lesions or digestive problems, swollen glands in the neck (lymphadenopathy) or general unhealthy feelings.
Diagnosis mostly comes from history and examination, but the following specific investigations may be involved: blood tests (vitamin deficiency, anemia, leukemia, Epstein-Barr virus, HIV infection, diabetes) microbiological swabs (infection), or urinalysis (diabetes). Biopsy (small procedure for cutting small samples from ulcers to see under a microscope) with or without immunofluorescence may be necessary, to rule out cancer, but also if systemic disease is suspected. Ulcers are caused by a painful local trauma to touch and pain. They usually have irregular borders with erythematous edges and a yellow base. When the healing takes place, keratotic (thickened, white mucosa) halo can occur.
Treatment
Treatment is associated with a cause, but also symptomatic if the underlying cause is unknown or irreversible. It is also important to note that most ulcers will heal completely without any intervention. Treatment can range from simply refining or eliminating the cause of local trauma, to overcome the underlying factors such as dry mouth or changing the problem drug. Maintaining good oral hygiene and use of mouthwash or antiseptic sprays (eg chlorhexidine) can prevent secondary infections and therefore speed healing. Topical analgesics (eg benzydamine mouthwash) can relieve pain. Topical (gel, cream or inhaler) or systemic steroids can be used to reduce inflammation. Anti-fungal drugs can be used to prevent oral candidiasis from developing in those who use prolonged steroids. People with canker sores may prefer to avoid hot or spicy foods, which can increase the pain. Self-generated ulcerations can be difficult to manage, and psychiatric input may be needed in some people. For recurrent ulcers, evidence supporting above treatment is currently lacking.
Epidemiology
Oral ulceration is a common reason for people to seek medical or dental advice. An oral mucosal violation may affect most people at various times during life. For epidemiological discussion of aphthous stomatitis, see Aphthous Stomatitis # Epidemiology.
References
External links
- Learning materials related to oral ulcers in Wikiversity
- Oral ulcer in Curlie (based on DMOZ)
Source of the article : Wikipedia
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