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Mouth Ulcers (Aphthous Type)

What are aphthous mouth ulcers?

Aphthous mouth ulcers are painful sores that can occur anywhere inside the mouth. They are the most common type of mouth ulcer. At least 1 in 5 people can develop aphthous mouth ulcers at some stage in their life. Women are affected more often than men.

There are three types:

  1. Minor aphthous ulcers are the most common (8 in 10 cases). They are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are not usually very painful.
  2. Major aphthous ulcers occur in about 1 in 10 cases. They tend to be 10 mm or larger across. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, but will heal leaving a scar. They can be very painful and eating may become difficult.
  3. Herpetiform ulcers occur in about 1 in 10 cases. These are tiny pinhead-sized ulcers, about 1-2 mm across. Multiple ulcers occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. Despite the name, they have nothing to do with herpes or the herpes virus.

Aphthous ulcers usually first occur between the ages of 10 and 40. They then recur but there can be days, weeks, months, or years between each bout of ulcers. The ulcers tend to recur less often as you become older. In many cases, they eventually stop coming back. Some people feel a burning in part(s) of the mouth for a day or so before an ulcer appears.

What causes aphthous mouth ulcers?

The cause is not known. They are not infectious, and you cannot ‘catch’ aphthous mouth ulcers. In most cases, the ulcers develop for no apparent reason in people who are healthy.

In some cases the ulcers are related to other factors or diseases. These include:

  • Injury – such as badly fitting dentures, a graze from a harsh toothbrush, etc.
  • Changes in hormone levels. Some women find that mouth ulcers occur just before their period. In some women, the ulcers only develop after the menopause.
  • Some ex-smokers find they develop ulcers only after stopping smoking.
  • A lack of iron, or a lack of certain vitamins (such as vitamin B12 and folic acid) may be a factor in some cases.
  • Rarely, a food allergy may be the cause.
  • Mouth ulcers run in some families. So, a genetic factor may play a part in some cases.
  • Stress or anxiety is said to trigger aphthous mouth ulcers in some people.
  • Some medications can cause mouth ulcers. Examples of medicines that can cause aphthous ulcers are: nicorandil, anti-inflammatory drugs, and oral nicotine replacement therapy.
  • Mouth ulcers are more common in people with Crohn’s disease, coeliac disease, HIV infection, and Behçet’s disease. But the ulcers may not be aphthous-type.

Tell your doctor if you have any other symptoms in addition to the mouth ulcers. Other important symptoms would include skin or genital ulcers or rheumatological (joint) pains and inflammation. Rarely, severe mouth ulcers can occur after taking a medicine you are allergic to. Sometimes a blood test or other investigations are advised if other causes of mouth ulcers are suspected.

What are the treatments for aphthous ulcers?

Treatment aims to ease the pain when ulcers occur, and to help them to heal as quickly as possible. There is no treatment that prevents aphthous mouth ulcers from recurring.

No treatment may be needed

The pain is often mild, particularly with the common ‘minor’ type of aphthous ulcer. Each bout of ulcers will go without treatment.

General measures include:

  • Avoid spicy foods, acidic fruit drinks, and very salty foods (such as crisps) which can make the pain and stinging worse.
  • Use a straw to drink, to avoid the liquids touching ulcers in the front of the mouth. (Note: do not drink hot drinks with a straw, as you may burn your throat.)
  • Use a very soft toothbrush. See a dentist if you have badly fitting dentures.
  • If you suspect a medication is causing the ulcers, then a change may be possible. For example, if you are using oral nicotine replacement therapy (nicotine gum or lozenges), it may help to use a different type instead such as patches or nasal spray.

Some medicines may ease your symptoms from the mouth ulcers:

  • Chlorhexidine mouthwash (brand name Corsodyl® or Chlorohex®) may reduce the pain. It may also help ulcers to heal more quickly. It also helps to prevent ulcers from becoming infected. Unfortunately, it does not reduce the number of new ulcers. Chlorhexidine mouthwash is usually used twice a day. It may stain teeth brown if you use it regularly. However, the stain is not usually permanent, and can be reduced by avoiding drinks that contain tannin (such as tea, coffee, or red wine), and by brushing teeth before use. Rinse your mouth well after you brush your teeth as some ingredients in toothpaste can inactivate chlorhexidine.
  • Steroid lozenges (brand name Corlan® pellets or Betnesol® tablets) may also reduce the pain, and may help ulcers to heal more quickly. By using your tongue you can keep a lozenge in contact with an ulcer until the lozenge dissolves. A steroid lozenge works best the sooner it is started once an ulcer erupts. If used early, it may ‘nip it in the bud’, and prevent an ulcer from fully erupting. The usual dose is one lozenge, four times a day, until the ulcer goes. In children, use for no more than five days at a time.
  • A barrier paste or powder such as carmellose sodium (brand name Orabase® and Orahesive®) can be applied to the ulcer to protect it and reduce pain.
  • A painkilling oral rinse, gel, or mouth spray may help to ease pain. Examples include benzydamine spray (brand name Difflam®), or choline salicylate gel (brand name Bonjela®). Bonjela® should not be used in children under the age of 16 due to a potential risk of Reye’s syndrome if it is overused. This is the same reason why aspirin cannot be used in children too. Note: Bonjela teething gel® no longer contains choline salicylate and has been reformulated with lidocaine, a local anaesthetic (to cause temporary numbing).The effect of painkilling medicines is unfortunately short-lived.

You can buy all the treatments listed above from pharmacies without a prescription. Other treatments may be tried if the above do not help or where the pain and ulceration are severe. Examples include, a course of steroid tablets, strong steroid mouthwashes, colchicine, tetracycline or doxycycline mouthwashes, and some immunosuppressant drugs.

When should I see a doctor?

Aphthous mouth ulcers can be painful and are often a nuisance, but are not serious. Occasionally a mouth ulcer can become secondarily infected with bacteria. In this case you may notice increased pain or redness, or you may be feeling unwell with fever. Secondary bacterial infections are not common but may need antibiotic treatment. Remember, not all mouth ulcers are aphthous ulcers. Other types of ulcer can occur in the mouth and mouth ulcers can be a sign of an underlying illness or disease.

Important: cancer of the mouth can sometimes start as an unusual mouth ulcer that does not heal. You should see a doctor or dentist if you have a mouth ulcer that has lasted more than 2-3 weeks without sign of healing, or is different in any way. This is especially important if you are a smoker. Your GP or dentist may refer you urgently to the outpatient clinic to see an ear nose and throat (ENT) specialist or an oral (mouth) surgeon. A small sample (biopsy) of the ulcer may be taken in clinic and examined, to exclude cancer.

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