Why do my mouth ulcers keep coming back? 5 reasons you should know

Mouth ulcer: Why is it Painful?

A mouth ulcer is a break in the epithelial layer (topmost lining of our body parts).

Putting it in a simpler term, you may understand an ulcer as an open wound.

Ulcers can be painful due to the presence of pain receptors in the superficial skin.

Does everyone get mouth ulcers?

No. Not everyone will get mouth ulcers.

Having said that, the mouth ulcer is one of the most common conditions affecting the oral mucosa (lining inside the mouth) [1].

5 Conditions that cause Recurrent Mouth Ulcers

Ulcer(s) can develop due to many reasons, for example, injury, stress, nutritional deficiency, and so on.

This article will be focusing on mouth ulcers that keep coming back from time to time, in other words, it is called recurrent ulcers.

Here are some of the conditions or diseases that can cause recurrent mouth ulcers.

#1 Recurrent aphthous ulcerations

The layman term for this condition is called canker sore. If you have ulcers that keep coming back, canker sore is probably the most likely reason. This is because canker sore is the most common (among other conditions) to cause recurrent mouth ulcer.

There are a lot of reasons for canker sore to happen. This condition usually affects people at young age. The ulcer(s) usually heal within 1 to 2 weeks.

The dentist can identify the ulcer as canker sore through asking you about the condition and by its appearance. As it is quite obvious and straightforward, further test is usually not required. Once it is confirmed to be a canker sore, there is not much to worry about other than the pain. The medication to relieve the pain may be needed if it is not tolerable. Otherwise, the ulcer will eventually heal on its own.

#2 Recurrent intraoral herpes simplex infection

A patient who has this form of ulcer has a history of herpes infection in the early childhood. The herpes infection is caused by the herpes virus and it could remain in the body throughout the life (more precisely, it stays in the nerve). Sometimes, it gets active and starts harming the body again. This is called “reactivation” of infection.

When reactivation happens, it may cause bullae (swelling with colourless fluid), or ulcers (if the bullae ruptured) around the lips or inside the mouth.

Recurrent herpes simplex is different from a canker sore, because the recurrent herpes simplex is infectious, while canker sore is not. This means that the recurrent herpes simplex infection could go from one person to another through contact. Other than that, this disease rarely causes serious consequence or death in people with normal immune system. The treatment is to relieve the pain and treat the fever if there is any [2].

#3 Autoimmune oral disease

The word autoimmune means that our immune system mistakenly attacks our body cells. This disease is not so common as compared to the other ulcers mentioned above. This group includes erosive Lichen Planus, Pemphigus Vulgaris, Cicatricial Pemphigoid, and so on. Further tests like blood test or biopsy (tissue sample is taken and seen under the microscope) would be required for diagnosing this group of ulcers.

A very important fact about this condition is that this type of ulcer does not usually heal by itself like the canker sore. Some medications have to come into place to reduce the inflammation and heal the ulcer.

#4 Drug-induced mouth ulcers

Some medications may cause mouth ulcers. Yes, ulcers can be the undesirable side effect of some medications. Generally, this form of ulcer is bigger than that in the canker sore. Also, the topical steroid is not effective for this ulcer [3].

If the ulcer is caused by the medication, just stop taking the medication, right? Not so straightforward. You should leave the decision to stop or change the medication to your dentist and the physician in charge. Even the dentist who notices this ulcer has to discuss with physician who prescribed the medication.

Sometimes, continuing the medication is more important than stopping the medication just because of the mouth ulcer. The mouth ulcers can be managed by other methods, but stopping the medication may cause serious consequences.

#5 Ulcers secondary to systemic disease

Ulcers may form due to the underlying medical conditions. Some of the examples are uncontrolled diabetes, gastrointestinal (stomach and gut) disease, blood disorders such as leukemia and neutropenia. To manage this group of ulcers, the focus has to be addressed towards managing the underlying systemic disease.

Can a recurrent mouth ulcer be cancer?

Some mouth ulcers can happen because of mouth cancer. Therefore, it is very important to recognize it as soon as it is discovered.

Usually, a cancerous ulcer does not come and go. Most of the time, a cancerous ulcer presents as a persistent ulcer that does not heal for a long time.

The golden rule to follow is this: an ulcer that does not heal for more than 2 weeks should raise our concern. In this case, a cancerous ulcer should be considered especially when there is a positive history of smoking or betel chewing.

The above does not mean that a non-healing ulcer must be a cancer. Ulcer due to injury (traumatic ulcer) can last as long as the injury is there (eg. sharp point from the tooth, ill-fitting denture). A tuberculous (an infection) ulcer may exist until the tuberculous bacteria are eliminated.

Management of recurrent mouth ulcers

The dentist’s part

The dentists have to first find out the reason for the ulcer to appear. Usually, by knowing the history and doing a mouth check-up, the dentist could figure out the cause of ulcer (especially for canker sore). Only when necessary, a blood test is taken to see if there is any underlying nutritional deficiency or systemic disease.

A biopsy (tissue sample is taken and seen under the microscope) is only taken when the dentist wants to confirm what the ulcer is. This is particularly important when an ulcer is suspected to be dangerous, like the cancerous ulcer.

After figuring out the cause of the ulcer, what will the dentist do? The key for the dentist to manage recurrent ulcers is to address the underlying reasons that cause ulcers. For example, drug-caused mouth ulcers is due to the medication taken by the patient. Thus, the dentist may discuss with the physician if it is possible to stop and change the medication.

However, the diagnosis of a recurrent ulcer may not always be straightforward. Sometimes, there are just too many factors to be considered and it is not possible to confirm it in the first visit. In the meantime, the medication can be given to control the pain from the ulcer. The dentist may review you after some time to make sure that the ulcer is healing.

Your part

You should avoid things that are known to cause the ulcers. These triggers can be an injury from a sharp object, certain food, stress and etc. It may take some time to find out the trigger that is causing the recurrent mouth ulcers. Meanwhile, you can perform some self-care to reduce the pain and speed up the healing of ulcers. Visit here to know how to perform self-care for an ulcer.

Conclusion

Most mouth ulcers are not dangerous. People often learn to manage these recurring ulcers by performing self-care and avoiding triggers of their mouth ulcers. It is important to notice any changes in the size and the duration of the ulcer. If you are concerned, you should visit your dentist to find out more.

References

1. Little, J. W., Miller, C., & Rhodus, N. L. (2013). Dental Management of the Medically Compromised Patient, Eighth Edition. Elsevier Health Sciences. (Link)
2. Bhateja, S., Arora, G., & Mastud, S. K. (2017). Recurrent intraoral herpes (RIH) infection–A Case Report. Biomed J Sci Tech Res [Internet], 1(3), 3-5. (Link)
3. Jinbu, Y., & Demitsu, T. (2014). Oral ulcerations due to drug medications. Japanese Dental Science Review, 50(2), 40-46. (Link)
4. Scully, C., & Shotts, R. (2000). Mouth ulcers and other causes of orofacial soreness and pain. Bmj, 321(7254), 162-165. (Link)