Symptoms in the Pharmacy :Gastrointestinal Tract Problems(1)

Mouth ulcers

Mouth ulcers are extremely common, affecting as many as one in five
of the population and they are a recurrent problem in some people.
They are classified as aphthous (minor or major) or herpetiform
ulcers.

Most cases (more than three quarters) are minor aphthous
ulcers, which are self-limiting. Ulcers may be due to a variety of causes
including infection, trauma and drug allergy. However, occasionally
mouth ulcers appear as a symptom of serious disease such as carcinoma.
The pharmacist should be aware of the signs and characteristics
that indicate more serious conditions.

What you need to know

• Age
• Child, adult
• Nature of the ulcers
• Size, appearance, location, number
• Duration
• Previous history
• Other symptoms
• Medication
• Significance of questions and answers

Age
Patients may describe a history of recurrent ulceration, which began in
childhood and has continued ever since. Minor aphthous ulcers are
more common in women and occur most often between the ages of 10
and 40.

Nature of the ulcers
Minor aphthous ulcers usually occur in crops of one to five. The
lesions may be up to 5mm in diameter and appear as a white or
yellowish centre with an inflamed red outer edge. Common sites are
the tongue margin and inside the lips and cheeks. The ulcers tend to
last from 5 to 14 days.

Other types of recurrent mouth ulcer include major aphthous and
herpetiform. Major aphthous ulcers are uncommon, severe variants of
the minor ones. The ulcers, which may be as large as 30mm in
diameter, can occur in crops of up to ten. Sites involved are the lips,
cheeks, tongue, pharynx and palate. They are more common in sufferers
of ulcerative colitis.

Herpetiform ulcers are more numerous, smaller and, in addition to
the sites involved with aphthous ulcers, may affect the floor of the
mouth and the gums. Systemic conditions such as Behc¸et’s syndrome and erythema
multiforme may produce mouth ulcers, but other symptoms would
generally be present (see below).

                            
Duration
Minor aphthous ulcers usually heal in less than 1 week; major
aphthous ulcers take longer (10–30 days). Where herpetiform ulcers
occur, fresh crops of ulcers tend to appear before the original crop
has healed, which may lead patients to think that the ulceration is
continuous.

Oral cancer
Any mouth ulcer that has persisted for longer than 3 weeks
requires immediate referral to the dentist or doctor because an ulcer
of such long duration may indicate serious pathology such as carcinoma. 

Most oral cancers are squamous cell carcinomas, of which
one in three affects the lip and one in four affects the tongue. The
development of a cancer may be preceded by a premalignant lesion,
including erythroplasia (red) and leucoplakia (white), or a speckled
leucoplakia. Squamous cell carcinoma may present as a single ulcer
with a raised and indurated (firm or hardened) border. 

Common locations include the lateral border of the tongue, lips, floor of the
mouth and gingiva. The key point to raise suspicion would be a lesion
that had lasted for several weeks or longer. Oral cancer is more
common in smokers than non-smokers.

Previous history
There is often a family history of mouth ulcers (estimated to be present
in one in three cases). Minor aphthous ulcers often recur, with the
same characteristic features of size, numbers, appearance and duration
before healing. The appearance of these ulcers may follow
trauma to the inside of the mouth or tongue, such as biting the inside
of the cheek while chewing food. Episodes of ulceration generally
recur after 1–4 months.

Ill-fitting dentures may produce ulceration and, if this is a suspected
cause, the patient should be referred back to the dentist so that the
dentures can be refitted. However, trauma is not always a feature of
the history, and the cause of minor aphthous ulcers remains unclear
despite extensive investigation.

In women, minor aphthous ulcers often precede the start of the
menstrual period. The occurrence of ulcers may cease after pregnancy,
suggesting hormonal involvement. Stress and emotional factors at
work or home may precipitate a recurrence or a delay in healing but
do not seem to be causative.

Deficiency of iron, folate, zinc or vitamin B12 may be a contributory
factor in aphthous ulcers and may also lead to glossitis (a condition
where the tongue becomes sore, red and smooth) and angular stomatitis
(where the corners of the mouth become sore, cracked and red).
Food allergy is occasionally the causative factor and it is worth
enquiring whether the appearance of ulcers is associated with particular
foods.

Other symptoms
The severe pain associated with major aphthous or herpetiform ulcers
may mean that the patient finds it difficult to eat and, as a consequence,
weight loss may occur. Weight loss would therefore be an
indication for referral.

In most cases of recurrent mouth ulcers the disease eventually burns
itself out over a period of several years. Occasionally, as in Behc¸et’s
syndrome, there is progression with involvement of sites other than
the mouth. Most commonly the vulva, vagina and the eyes are
affected, with genital ulceration and iritis .

Behc¸et’s syndrome can be confused with erythema multiforme,
although in the latter there is usually a distinctive rash present on
the skin. Erythema multiforme is sometimes precipitated by an infection
or drugs (e.g. sulphonamides or barbiturates).

Mouth ulcers may be associated with inflammatory bowel disorders
or with coeliac disease. Therefore, if persistent or recurrent diarrhoea
is present, referral is essential. Patients reporting any of these symptoms
should be referred to their doctor.

Rarely, ulcers may be associated with disorders of the blood
including anaemia, abnormally low white cell count or leukaemia.
It would be expected that in these situations there would be other
signs of illness present and the sufferer would present directly to the
doctor.