Mouth ulcers, bad breath and the small things

Small oral problems account for a substantial number of pharmacy purchases and a small number of them matter considerably more than the rest.

Mouth ulcers

Extremely common and usually trivial.

Recurrent aphthous ulcers are round or oval, with a grey or yellow base and a red halo, painful and healing within one to two weeks without scarring.

Triggers reported include trauma from biting or a sharp tooth, stress, hormonal change, certain foods, and toothpaste containing sodium lauryl sulfate — where switching to an SLS-free toothpaste helps some people.

Management is symptomatic: analgesic gels, protective pastes, chlorhexidine or benzydamine rinses, and avoiding acidic and spicy foods while they heal.

None of these speed healing substantially, which is worth knowing before buying several.

When ulcers are not ordinary

The important exceptions.

Any ulcer lasting more than three weeks requires assessment, because this is the classic presentation of oral cancer and delay affects outcome substantially.

Persistent white or red patches, particularly if they cannot be wiped off.

A lump anywhere in the mouth, or in the neck.

An ulcer with hardened edges or a raised margin.

Unexplained loose teeth, numbness or difficulty swallowing.

And severe or very frequent ulcers, which may indicate coeliac disease, inflammatory bowel disease, iron, B12 or folate deficiency, or Behçet's disease — all of which are worth testing for rather than treating symptomatically for years.

Bad breath

Where the cause is usually local.

The large majority originates in the mouth: bacterial coating on the tongue, gum disease, food trapping, dry mouth and poor denture hygiene.

Which means the effective response is oral rather than cosmetic.

Tongue cleaning, which is the single most effective measure and which most people do not do.

Interdental cleaning, which removes the trapped debris that mouthwash cannot reach.

Treating gum disease.

Maintaining saliva flow — hydration, sugar-free gum, and reviewing medications that cause dryness.

Cleaning dentures properly and leaving them out overnight.

And treating any dental infection, which produces a distinctive smell.

When bad breath points elsewhere

A minority of cases.

Sinus and tonsil problems, including tonsil stones.

Reflux.

Certain medications.

Poorly controlled diabetes, which produces a characteristic sweet odour.

Liver and kidney failure, which produce their own.

And rarely, respiratory infection or malignancy.

Persistent bad breath despite good oral hygiene warrants assessment rather than a stronger mouthwash.

Dry mouth

Which underlies several problems at once.

Saliva buffers acid, provides minerals for repair and clears debris, so reduced flow substantially increases decay risk as well as causing discomfort and bad breath.

Causes: many common medications including antidepressants, antihistamines, some antihypertensives, diuretics and opioids; Sjögren's syndrome; radiotherapy to the head and neck; dehydration; and mouth breathing.

Management: saliva substitutes, sugar-free gum to stimulate flow, frequent sips of water, high-fluoride toothpaste, avoiding alcohol-containing mouthwashes, and reviewing medications with a prescriber.

Anyone on several medications with a dry mouth is at genuinely elevated risk of decay and frequently unaware of it.

Sensitivity

Common and manageable.

Usually caused by exposed dentine at the gum margin, from gum recession, abrasion from overzealous brushing, or acid erosion.

Desensitising toothpaste used consistently over weeks — rubbed onto the sensitive area and not rinsed off — is the standard first measure.

Reducing acidic food and drink, and not brushing immediately after them.

Using a soft brush and less pressure.

And assessment if it is severe, localised to one tooth, or associated with pain that lingers, since this may indicate a crack, decay or pulp involvement.

Cold sores and oral thrush

Two common conditions with specific treatments.

Cold sores are herpes simplex, recur at the same site, and respond best to antiviral cream applied at the first tingle rather than once blistered.

Anyone with an active cold sore should not kiss a newborn, since neonatal herpes is serious.

Oral thrush appears as white patches that can be wiped off leaving a red base, and is associated with inhaled steroids without rinsing, dentures, dry mouth, antibiotics, diabetes and immunosuppression.

It responds to antifungal treatment, and recurrent episodes warrant looking for the underlying cause.

The cheap measures that prevent most of it

Consistent across the list.

Brush twice daily with fluoride toothpaste, spit and do not rinse.

Clean between the teeth daily.

Clean the tongue.

Maintain saliva flow.

Do not smoke, which is the largest risk factor for oral cancer alongside alcohol.

Rinse the mouth after inhaled steroids.

And attend dental examinations, which include a soft tissue check that is the main route to early detection of oral cancer.

General information only, not medical or dental advice. Any mouth ulcer lasting more than three weeks should be assessed by a dentist or clinician.