Oral health

There is a wide range of conditions that can affect the mouth and compromise oral health. Several of the more common conditions are discussed below, together with advice about management and medication.

MOUTH ULCERS

Mouth ulcers are very common, with most people having experienced a mouth ulcer at some stage of their life. More than 20% of the population suffer from recurrent ulcers at one time or another. This often starts in childhood /adolescence, with most people fortunately growing out of this painful condition by their late twenties. It tends to be familial, with a number of family members being affected.

Mouth ulcers occur either singly or in a group and can cause a lot of pain and discomfort. These painful sore/s develop on the inner cheeks of the mouth or on the gums. They usually clear within 7 – 10 days, but some type of analgesic medication is usually required to relieve the painful symptoms. Mouth ulcers can also be single or recurrent.

Single mouth ulcers are usually due to trauma from a toothbrush or sharp tooth/filling, or from accidental biting of the cheek. These usually clear spontaneously once the source of trauma is removed; a visit to the dentist may be required.

Recurrent ulcers come and go, recurring as frequently as every few weeks. They are not contagious, as they are not caused by an infection. There are a number of possible causes of recurrent mouth ulcers, including low iron, Vitamin C or B12 deficiency, hormonal changes (especially around menses), stress, and sensitivity to various food flavourants and preservatives.

• Minor ulcers are the most common type and are typically round ”punched-out” ulcers;
• Major ulcers are larger and more painful and can last up to 5-10 weeks;
• Herpetiform ulcers occur en masse, with up to 100 very small but very painful ulcers at a time..

Treatment of mouth ulcers includes advice about self-care measures:

• Avoid spicy, salty and acidic food
• Rinse frequently with warm salty water to keep the mouth clean
• Diluted chlorhexidine mouthwash used once daily helps to quicken healing e.g. Orosept^®, Corsodyl^®.

Medication may also be required:

• Topical analgesics give symptomatic relief, e.g. Andolex^® gel and spray
• Aloclairä Gel creates a protective film over the ulcer, shielding the nerve endings and thus relieving pain
• Certain topical corticosteroids e.g. Triamcinalone (Kenalog in Orobase^®) may be beneficial in cases of recurrent ulcers, with the base (Orobase^®) having a mechanical protective effect.

Be aware that a mouth ulcer can be the first sign of a more serious condition. Refer anyone with an ulcer that:

• Is painless
• Is deep/>1cm diameter/uneven discoloration
• Occurs in pregnancy
• Lasts more than 3 weeks with no signs of healing

ORAL THRUSH

Oral thrush is due to an overgrowth of Candida albicans, which is naturally present in the mouth.

A number of factors increase the chance of getting thrush:

• Wearing dentures;
• Lowered immunity due to diabetes, steroid medication, HIV infection;
• Decrease/alteration in normal bacteria in the mouth, e.g. after a course of antibiotics;
• Reduction in amount of saliva caused by certain drugs, or after chemotherapy/radiotherapy to the head and neck.

Signs and symptoms include:

• White spots/patches on the tongue and inside the cheeks;
• Red, raw-looking areas inside the mouth;
• The corners of the mouth may be red and sore – “angular stomatitis”

Treatment includes patient education and the use of topical antifungal agents.

• Denture wearers: keep the mouth as clean as possible, rinse after meals, remove dentures at night and clean thoroughly, avoid smoking.
• Diabetics: good glucose control decreases the risk of thrush.
• Steroid inhalers: use a spacer device, and rinse the mouth well and gargle after using the inhaler, to remove any steroid residue.
• Dry mouth from medication: sip water frequently to keep the mouth moist.
• Local antifungal treatment with miconazole (e.g.Daktarin^® oral gel) or nystatin (e.g. Mycostatin^® suspension) is usually successful in getting rid of oral thrush. Treatment must be continued until after all signs and symptoms of infection have disappeared – this can take up to a month. In severe or resistant cases, systemic treatment with fluconazole or ketoconazole may be required.

HALITOSIS (BAD BREATH)

This is an embarrassing but common problem – 90% of cases are due to poor dental hygiene, including plaque deposits and gum disease.

Other causes are:

• Strongly flavoured foods (e.g. garlic, onions), alcohol and coffee
• Smoking, which also increases the risk of gum disease
• Dry mouth (Xerostomia) – decreased saliva results in a build-up of bacteria in the mouth
• Certain medications
• Infections in the throat (pharyngitis), nose (sinusitis) or lungs (bronchitis);
• Diabetes
• Gastritis and reflux.

The mainstay of treatment is improved oral and dental hygiene: regular brushing – at least twice a day – and flossing is the most effective treatment. A visit to the dentist is recommended. In addition suggest:

• Scraping or brushing the tongue after brushing the teeth
• Daily rinsing with an anti-bacterial/anti-odour mouthwash, e.g. Listerine^® Cool Mint; alcohol dries out the mouth, which can exacerbate a bad breath problem.  An alcohol free mouth wash e.g. Dentyl pH should be considered
• Avoiding spicy/strongly flavoured foods, decreasing alcohol, stopping smoking
• Treatment of any underlying medical problems, e.g. infections, diabetes.

BLEEDING GUMS

Bleeding gums usually signal gum disease. Gingivitis (inflammation of the gums) is the most common cause. If not treated, gingivitis can progress to periodontal disease. This can cause damage to the gums and even loss of teeth if left untreated. Pregnancy is another, quite common cause of bleeding gums. The hormonal changes that accompany pregnancy result in softening of the connective tissue in the gums and increased blood supply, with the result that gums bleed more easily.

Other possible causes include:

• Smoking
• Poor diet
• Stress
• Uncontrolled diabetes
• Certain medications.

Treatment

• Good oral hygiene: twice daily brushing and flossing, regular visits to the dentist/oral hygienist to remove plaque build-up
• Regular use of a mouthwash, especially one containing chlorhexidine, which helps treat gum infections (e.g. Corsodyl^®, Orosept^®)
• Reduce the amount of sugar in the diet – cut down on fizzy drinks, sweets and chocolates
• Avoid snacking between meals – plaque builds up on dirty teeth
• Stop smoking – smoking not only increases the production of plaque, which results in gum disease, it also decreases oxygen in the blood, so gums heal more slowly.

CANCER OF THE MOUTH

Always be aware of the possibility of cancer of the lip, tongue, gums and floor of mouth.

Signs and symptoms to be aware of include

• Non-healing sores or ulcers in the mouth
• Lumps or tissue changes in the mouth or on the tongue that persist longer than a month
• Persistent white or red patches in the mouth, which may indicate a pre-cancerous condition.

Risk factors are:

• Male sex – twice as common in men as women
• Age – more common in people over 40 years old
• Smoking cigarettes or a pipe, using oral snuff, chewing tobacco
• Excess alcohol consumption
• Poorly-fitting dentures, jagged/crooked teeth (constant irritation).

References on Request

Dr Rowena Caudwell MBChB