Idiopathic aphthous ulceration is common and affects upto 25% of the population. Recurrent painful round or ovoid mouth ulcers are seen with inflammatory halos. They are more common in females and non-smokers, usually appearing first in childhood and tend to reduce in number and frequency by age. Mouth ulcers, as they are called as in common usage, are largely annoying and recurrent disease, sometimes developing as a hint to the underlying condition.
Though not a fatal condition or medical emergency, mouth ulcer needs to be diagnosed and treated well because if not treated they can cause deficiencies and other complications due to lack of food intake. Sometimes, like in chemotherapy, mouth ulcers develop as the side effect of treatment which should be managed differently.
SIGNS AND SYMPTOMS
Typically seen on the buccal mucosa, the labial mucosa, the floor of the mouth or the tongue.
Severe pain or burning sensation develops one day before the actual development of ulcer.
Painful lesions with well-defined margins and shallow necrotic center.
Yellow-greyish membrane at the base of the lesion and surrounded by raised margins and erythematous haloes.
The pain is severe and gets aggravated on eating, swallowing and speaking. The pain usually persists for three to four days.
CAUSES
Idiopathic
Gastrointestinal diseases-Inflammatory bowel disease, coeliac disease
Infection- Viral: HSV, HIV, Coxsackie; Fungal: candidiasis; Bacterial: syphilis, Tuberculosis
Systemic disease- Reactive Arthritis, SLE,
Trauma- dentures
Neoplasia- Squamous cell carcinoma
Drugs- Chemotherapy:antimalarials
Skin disease- Pemphigus, Lichen planus
PATHOPHYSIOLOGY
The complex interactions of various etiological factors together can trigger ulcer formation. Etiological factors can be classified into predisposing factors and precipitating / triggering factors. The factors like HLA associations, immune dysregulation, nutritional deficiency, personality type A are the predisposing factors. Microtrauma, infections, stress could be the initiating or triggering factor for ulcer formation. Those individuals who are susceptible when exposed to the triggering factors for certain duration tend to develop ulcers. Based on the intensity and duration of the triggering factors, ulcer starts growing till the factors are removed. Pain suffered by the patients is directly proportional to the size of the ulcer and severity of the triggering factors. For example, the serum cortisol level: which is a biomarker of the stress was increased in the subjects with RAS and the increase was directly proportional to the ulcer size.
DIAGNOSIS
Physical examination – confirmatory in most of the cases
A fever also suggests the ulcers may be caused by a herpes simplex infection
Blood tests – to check for signs of infection and iron and folate deficiency
Skin biopsy – a small tag of tissue from the ulcer is taken and examined to rule out neoplasms.
TREATMENTS
There are no specific therapies. Patients are advised to avoid oral trauma and acidic foods and drinks which cause pain. Topical or systemic corticosteroids may lessen the duration and severity of the attacks. Chlorhexidine gluconate or tetracycline mouthwash, dapsone, colchicine, thalidomide and azathioprine have all been used with variable effect.
PROGNOSIS
Most ulcers clear up without treatment and do not leave scars, although they usually return.
COMPLICATIONS
Untreated, mouth ulcers can occasionally lead to complications including: Bacterial infection; Inflammation of the mouth (cellulitis) and Tooth abscess. In chronic cases, food intake is affected both in quantity & quality which can lead to deficiency diseases.
DISEASE AND AYURVEDA
Mukhavrana
NIDANA
Causative factors for the vitiation of Pitta, especially
Food which is not habitual or suitable to body
Alcohol intake
Haemorrhoids
Intestinal parasites
Suppression of natural urges
PURVARUPA
Not mentioned
SAMPRAPTI
Due to the causative factors, Pitta dosha vitiates along with rasa-raktadhatus. When these dosha-dooshyas get lodged inside themouth, skin and mucosa are affected and rashes appear.
LAKSHANA
Pain & burning sensation inside mouth
Painful, reddish, round or oval shaped ulcers with well-defined margins that develop inside the mouth
Divisions
Not mentioned
Prognosis
Saadhya in most of the cases
Chikithsa
Ayurveda treatment for mukhavrana includes avoiding the causative factors. Treatment depends upon the disease or condition that is causing the disease. For example, if arsas is causing recurrent mouth ulcers, treatment for arsas should be done and the lesions will be less. Mild fasting is advised if indigestion is present in adults. It cannot be done in small babies & weak people. Management of aggravated Pitta and bringing back the normalcy of Rasa-raktadhatus are the treatment methods.
Samana
Internal medicines with tiktarasa and rookshaguna
Fasting in cases of indigestion & obesity
Kabalagraha & gandoosha with vranahara kwaatha
Sodhana
No sodhana is done in children unless fatal & emergency condition.
Therapies done in adults for sodhana include:
Vamana
Virechana
Snehavasti
Kashayavasti
Commonly used medicines
Thriphalachoornam
Gandharvahastadi kashayam
Amruthotharam kashayam
Vilwadi lehyam
Hinguvachadi choornam
Dadimashtakachoornam
Gairikam
Brands available
AVS Kottakal
AVP Coimbatore
SNA Oushadhasala
Home remedies
Following are used in traditional ways as home remedies for recurrent mouth ulcers:
Honey
Coconut oil
Aloe vera juice
Tulsi (Holy basil) leaves
Apple cider vinegar
Salt water gargling
Garlic
Turmeric
Orange juice
Lemon juice
Diet
- To be avoided
Heavy meals and difficult to digest foods – cause indigestion.
junk foods- cause disturbance in digestion and reduces the bioavailability of the medicine
carbonated drinks – makes the stomach more acidic and disturbed digestion
refrigerated and frozen foods – causes weak and sluggish digestion by weakening agni (digestive fire)
curd – causes vidaaha and thereby many other diseases
- To be added
Drink only boiled water
Light meals and easily digestible foods
Green gram, soups, buttermilk boiled with turmeric, ginger and curry leaves
Freshly cooked and warm food processed with cumin seeds, ginger, black pepper, ajwain etc
Behaviour:
Better to avoid extreme hot climate
Better to avoid exposure to excessive sunlight wind rain or dust.
Avoid lifting heavy weights and other vigorous physical activities.
Maintain a regular food and sleep schedule.
Avoid sitting continuously for a long time and avoid squatting.
Avoid holding or forcing natural urges like cough, sneezing, urine, faeces etc.
Yoga
Following a daily exercise routine will help the person to improve digestion & health. Balanced normal digestion lessens the chance of development of moth ulcers.
Stretching exercises and specific yoga asanas like pavanamuktasana, vajrasana, bhujangasana etc are recommended.
Regular exercise helps improve bioavailability of the medicine and food ingested and leads to positive health.
Yoga can maintain harmony within and with surroundings.
Pavanamuktasana
Vajrasana
Bhujangasana
All the exercises and physical exertions must be decided and done under the supervision of a medical expert only.
RESEARCH ARTICLES
https://doi.org/10.1111/j.1346-8138.1995.tb03947.x
The prognosis of Recurrent Oral Ulcers (ROU) by performing prospective evaluations of 67 patients who had only a history of ROU and were registered at the Behçet’s Disease Specialty Clinic at Severance Hospital of Yonsei University, Seoul, Korea was studied. Thirty-five patients (52.2%) developed overt manifestations of BD at an average of 7.7 years after the onset of ROU. The frequency of recurrence was 9.8 times per year in progressive cases. From these results, it appears that highly recurrent ROU is a warning signal for BD. Careful examinations of patients, including their minor symptoms, additional laboratory tests, and regular follow-ups by physicians are required for proper diagnosis.
DOI: 10.1111/j.1468-3083.2007.02564.x
The efficacy and safety of the topical application of Hyaluronic acid (HA) gel on recurrent oral ulcers was studied. Thirty-three outpatients with recurrent oral ulcers were included in the study.The patients used topical 0.2% HA gel twice daily for 2 weeks. A subjective reduction in the number of ulcers and a decrease in the ulcer healing period was observed in 72.7% of the patients. 75.8% experienced improvement in visual analogue scale for pain. Objective inspection of the ulcers showed a reduction of numbers in 57.6% of the patients, and 78.8% of the ulcers showed a decrease in area. Among the inflammatory signs, swelling and local heat were significantly improved after treatment. The study concluded that topical application of 0.2% HA gel seems to be an effective and safe therapy in patients with recurrent oral ulcers.
These statements have not been evaluated by the Food and Drug Administration, United States. This product is not intended to diagnose, treat, cure or prevent any disease. Please consult your GP before the intake.
Writer:
Dr. Rajesh Nair, the co-founder and chief consultant of Ayurvedaforall.Com, is a graduate of prestigious Vaidyaratnam Ayurveda College (affiliated with the University of Calicut), Kerala, India. Additionally, he holds a Postgraduate Diploma in Yoga Therapy from Annamalai University.
Dr. Nair offers consultation at two busy clinics in and around Haripad, Alleppey, Kerala, the southern state famous worldwide for authentic ayurvedic treatment and physicians. While offering consultation on all aspects of ayurvedic treatments Dr. Nair has a special interest in Panchkarma, Yoga, and Massage.
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