Chapter 13- Ulcers

Ulcer is a descriptive term and means ‘a hole in your skin’.

There are actually 40 different types of mouth ulcer and the ‘history’ starts to give the clinician a clue as to what type they are. The history as you say in the medical profession is the ‘story’ in the patients words how long you’ve had something, what makes it better, what makes it worse etc followed by the answer to various questions your health professional might ask you.

An ulcer is as if you got a pair of eyebrow tweezers and pulled a good deep chunk off the top layer of your skin. There are various conditions where the very thin superficial layer thins, sloughs off, atrophys or appears to be eroded but an ulcer goes down deeper through the top layer of epithelium [skin with no tough keratin and very few layers such as you find in your mouth] and down to the layer below which is called the lamina propria. The lamina propria has little nerve endings in it, that and superficial infection is why ulcers can be so sore and as we all know are made even sorer by eating things such as spicy foods and citrus.

Causes of ulcers.

Systemic [whole body] diseases which cause ulcers of various sizes and characteristics. These range from; – immunological diseases, various infectious diseases [such as syphilis, chicken pox, HIV and herpes], some disorders in your gastrointestinal tract [stomach and intestines][such as Crohns disease, Coeliac disease and Ulcerative colitis], some skin diseases and some blood disorders [anaemia, leukaemia].

Oral cancer can also present as an ulcer [see chapter on oral cancer].

Drugs a patient may be on can cause ulcers.

All of the above are very rare the vast majority of ulcers are caused by either local damage or are apthous ulcers.

Local Damage/ Traumatic Ulcers are causes by things such as;-

Trauma from a broken tooth rubbing a hole, a brace that is rubbing on your cheek, ill-fitting dentures, accidentally biting yourself etc.

Burns from food especially things like melted cheese on pizza, hot coffee, hot toffee, chips straight out of the fryer, soup that’s just been heated in a microwave. Be careful with microwaves as they heat unevenly which is why you should stir everything after heating and never give a baby a bottle of milk that has been warmed in the microwave without stirring and temperature testing first. Much better to use a bottle warmer.

Aspirin also causes burns if held on the site of a sore tooth. Painkillers act on your brain, not on the spot. People tend to use other painkillers now a days but aspirin burns were common in the past. Aspirin is acetylsalicylic acid and so will cause a chemical burn.

With all of the above, remove the cause and it will go away. If it doesn’t within about 3 weeks, go and see your dentist/ GP.

Apthous Ulcers.

These are the sort of ulcers we all get. Nowadays they are technically called Recurrent apthous stomatitis or RAS for short.

Very common affects about 20% of the population in the UK.

It’s not thought that they are infectious.

Usually starts in childhood or adolescence.

It’s never really been decided exactly what causes them but we do know that in about 1/3^rd of cases it seems to run in families and we do know that they are stress linked typically occurring when changing schools, sitting exams, family break up, domestic problems, moving house etc.

Sometimes it will be deficiencies such as iron, vit B12 and folic acid.

Sodium laurel sulphate is a foaming detergent used in tooth paste which can cause ulcers in some people so it’s worth switching to another brand to see if that helps.

With women it’s sometimes linked to your cycle.

Food allergies are sometimes the culprit, a common one is cinnamon found hidden in a lot of processed foods and ready meals.

They come in 3 main types; – Minor [little ones], Major [big ones] and Herpetiform [lots of little pin head sized ones and nothing to do with Herpes infection, the term is descriptive].

There is no real cure. They usually heal spontaneously in about 7-10 days though the big ones can take up to 6 weeks. If you get the odd one that’s manageable but if you get them a lot and they make your life a misery go and see your dentist, there are various anti-inflammatory and steroid preparations that can help.

Smokers who stop will sometimes get ulcers or get worse ulcers if they already have them. This will settle down. Please don’t start again.

General Management;-

Good oral hygiene.

Plenty of fruit and veg, 5 a day, preferably 7 if not more.

Change toothpaste to one without sodium laurel sulphate.

Cut out cinnamon.

Keep your iron levels up.

A mouthwash with Chlorhexidine [Corsodyl] or Triclosan once a day might help.

Get enough sleep.

Reduce the stress in your life [what idiot said that? But it has been said to me on more than one occasion by people who should know better].

NB- This is very serious.

If you have an ulcer which doesn’t go away within a normal length of time and you have removed all the normal causes please go and see your dentist it could be cancer.

If you have lots of episodes of mouth ulcers and you have them on your genitals and possibly eye problems as well, especially if you are of Eastern Mediterranean, Arabic, Jewish, Chinese, Japanese or Korean descent go to your doctor or your dentist. This could be a condition called Bechet’s  Syndrome [should have a cedilla under the ‘c’ he was Turkish] which is very rare but can be life threatening.

Any ulcers out of the ordinary should be investigated as they could possibly be linked to other serious conditions. Go and see your GP or your dentist, they not necessarily trained to be experts in everything, what they are trained to be is SUSPICIOUS.