Mouth Sores (Pathology of GI System)

Mouth Sores Mouth sores vary in appearance and size. Some may be raised, usually filled with fluid (in which case it is called as a vesicle or bulla); others may be ulcers. An ulcer is a hole that forms in the lining of the mouth when the top forms in the lining of the mouth, when the top layer of cells breaks down and the underlying tissue shows through. An ulcer appears white because of the dead cells and food debris inside the hole. Sores can affect any part of the mouth, inside and outside. Canker sores/aphthous ulcers and cold sores are perhaps the most well know, but there are many other types and causes of mouth sores. Any sore that lasts for 10 days or more must be examined by a dentist or doctor to ensure that it is not cancerous or precancerous.


Canker Sores (aphthous ulcers) Aphthous ulcers are small, painful sores inside the mouth

• Aphthous ulcers are very common. The cause is unknown, but stress seem to play a role - for example, a BMS student may get aphthous ulcers during final exam week.
  
• Aphthous ulcer appears as a round white spot with a red border. The ulcer almost always forms on soft, loose tissue on the inside of the lip or cheek; on the tongue, the floor of the mouth, or soft palate; or in the throat.
• Small aphthous ulcers (less than 1/2 inch in diameter) often appear in clusters of two or three; generally, they disappear by themselves within 10 days and do not leave scars.
  
• Larger ulcers are less common, they are irregularly shaped, can take many weeks to heal, and frequently leave scars.
• People with AIDS often have large ulcers that persist for weeks.
• Many people who get aphthous ulcers get them repeatedly - often several times a year.

Symptoms and Diagnosis

• The main symptoms of aphthous ulcers is pain - far more than would be expected from something so small.
• The pain, which lasts 4 to 7 days, worsens if the tongue or food rubs the sore or if hot or spicy foods are eaten.
  
• Severe ulcers can cause fever, swollen lymph nodes in the neck, and a generally run-down feeling.
• A doctor or dentist identifies aphthous ulcers by its appearance and the pain it causes.

Symptoms and Diagnosis

• Treatment consists of relieving the pain until the sore heals by itself.
• An anesthetic such as dyclonine or lidocaine may be used as a mouth rinse.
• However, because these mouth rinses numb the mouth and throat and thus may make swallowing difficult, children using them should be watched to ensure that they do not choke on their food.
  
• Lidocaine in a thicker preparation (viscous lidocaine) can also be swabbed directly on the aphthous ulcers.
  
• A protective coating gel of carboxymethylcellulose, often combine with a corticosteroid (such as triamcinolone or betamethasone), may be applied to protect the ulcers and temporarily relieve pain.
• Finally, for the most severe cases, a corticosteroid may be prescribed as a dexamthasone mouth rinse or, rarely, as predisone tablets taken by mouth.
• However, before prescribing as corticosteroid, a doctor ensures that the person does not also have oral herpes simplex infection, which can be further spread by corticosteroid given in gel form , so the side effects may be a concern.

Oral Herpes Simplex/Cold Sores

Infection of the mouth with herpes simplex virus causes recurring sore (often called cold sores), in which small fluid-filled sore develop on the skin, lips, or mouth in single or multiple clusters.

• The 1st eruption of sores due to infection with oral herpes simplex virus is called primary herpes. It is usually contracted in childhood. Primary herpes may be mild or severe, but it often affects large areas of the mouth and always the gums.
  
• Any subsequent eruption of the sores is called secondary herpes. Secondary herpes is a reactivation of the virus rather than a new infection.
  
• There are at least two forms of herpes simplex virus. In the past, herpes simplex virus type I only caused sores above the waist, and type 2 only below the waist (genital herpes). Click here to more detail on types of herpes simplex virus.
  
• Now however, either type can cause sores anywhere on the body because of sexual behavior etc. Herpes simplex 2 tends to be more severe than type I.
• Typically, a previously uninfected child acquires the virus from contact with an adult who has a cold sore. In rare cases, a person first acquires herpes simplex virus in adulthood, also after contact with someone with a cold sore.
• A person is capable of spreading the infection (contagious) from the time the tingling sensation that proceeds the development of a sore (the prodorome) is experienced to the time at which the sore has completely crusted over. It is unknown whether herpes can be spread by sharing a glass or touching something that an infected person has touched.

Symptoms

• When primary herpes is acquired in childhood, the infection causes gum inflammation and extensive mouth soreness. Fever, swollen lymph nodes in the neck, and general discomfort may develop.
• A child may be cranky and cry continually. However, many cases are mild and go unrecognized. Parents often mistake the problem for teething or another illness. In more severe cases, small blisters form in the child's mouth. These blisters may not be noticed because they rupture within a day or two, leaving many ulcers. The ulcers may occur anywhere in the mouth but always include the gums. Though the child get better in a week to 10 days, the herpes simplex virus never leaves the body.
• When a primary herpes is acquired in adulthood, symptoms are usually more severe and include multiple rapidly developing painful sores on the gums an other parts of the mouth.
• Unlike primary herpes, which causes widespread mouth soreness, the flare-ups of secondary herpes usually produce a single raw, weeping open sore on the outer lip that later crusts over before healing within 2 or 3 weeks. The sore is sometimes called a cold sore or fever blister. Less commonly, a cluster of blisters (vesicles) forms on the roof of the mouth. These small blisters run together and quickly break down into a sore. There is no crusting stage.
• Flare-ups are commonly triggered by sunburn on the lips, certain foods, anxiety, a cold (hence the name 'cold sore'), fever, or anything that lowers the body's resistance to infection. Certain dental procedures can cause a flare-up as well; if a cold sore already exists, dental visits should be postponed until the sore heals.
• Although merely a painful annoyance for most people, flare-ups of oral herpes simplex infection can be life-threatening for a person with an impaired immune system. Impairment of the immune system can be caused by diseases (such as AIDS), chemotherapy, radiation therapy, or a bone marrow transplant. In such people, large, persistent sores in the mouth can interfere with eating; spreading of the virus to the brain can be fatal.

Treatment

• Treatment for primary herpes aims to relieve the pain so that the person can sleep, eat, and drink comfortably. Pain may keep a child from eating and drinking, which, combined with a fever, can quickly lead to dehydration. Thus, a child should drink as much fluids as possible. An adult or older child can use a prescribed anesthetic mouth rinse such as lidocaine to reduce pain. A mouth rinse containing baking soda may also be soothing.
• Treatment for secondary herpes works best when started before the sore erupts - as soon as the person has the sensation (the prodorome) that an attack is starting. Taking vitamin C (1,000 to 2,000 milligrams per day) during the prodrome may make the attack less severe. A doctor may prescribe penciclovir cream or amlexanox paste, which is applied during the prodorome to shorten the duration and severity of the outbreak. The virus itself cannot be permanently eliminated.
• Protecting the lips from direct sunlight by wearing a wide-brimmed hat or by using lip balm containing sunscreen can reduce the possibility of of a flare-up. Also, a person should avoid activities and food that are know to cause flare-ups. Anyone who suffers frequent, severe flare-ups may try taking lysine (available at food stores) indefinitely.
  
• Levaisole, available by prescription, is another drug that seems to reduce recurrences.
• For people with severe herpes simplex and for people with and impaired immune system, acylovir or penciclovir capsules may be prescribed to prevent or limit the severity of the infection. Corticosteroids are not used for herpes simplex because they may allow the infection to spread.