A mouth ulcer, also known as an oral ulcer or mucosal ulcer, is a lesion or sore that forms on the mucous membrane lining the oral cavity. These ulcers are typically painful and can occur anywhere in the mouth, including the tongue, inner cheeks, gums, and the roof or floor of the mouth. Mouth ulcers are usually shallow, round or oval-shaped lesions with a white or yellowish center surrounded by a red border. The causes of mouth ulcers can vary, including local trauma (such as biting the cheek or brushing too hard), underlying health conditions, nutritional deficiencies, infections, and immune system dysfunctions. The most common types of mouth ulcers are aphthous stomatitis (canker sores) and those caused by local trauma. Aphthous ulcers are generally recurrent and not associated with infection, while trauma-induced ulcers are a result of physical injury to the oral tissues. Mouth ulcers can range from mild and temporary to severe, potentially interfering with eating, drinking, and speaking. Treatment often focuses on symptom relief and promoting healing, including the use of topical agents, pain relievers, and sometimes oral medications, depending on the underlying cause [1-3]. Mouth ulcers, also known as canker sores or oral ulcers, are painful, round or oval sores that develop on the mucous membrane inside the mouth, particularly on the inner surfaces of the cheeks, lips, gums, or the tongue. These ulcers can range in size, and they are often characterized by a white or yellowish center with a red, inflamed border. Though they can cause significant discomfort, especially while eating or speaking, mouth ulcers are generally not a sign of a serious underlying health issue. Mouth ulcers are very common and can occur in association with a wide range of conditions and factors. They may result from local trauma (such as accidental biting or irritation from dental appliances), stress, or nutritional deficiencies (such as low levels of vitamin B12, folic acid, or iron). In some cases, they are associated with more specific conditions like viral infections (e.g., herpes simplex virus), autoimmune disorders (e.g., Behçet's disease), or gastrointestinal conditions (e.g., Crohn's disease). However, in most instances, no serious underlying cause is found, and they tend to resolve on their own with minimal intervention. While mouth ulcers may be recurrent for some individuals, the majority of cases do not indicate a severe or chronic condition. Treatment typically focuses on alleviating pain and discomfort, preventing secondary infections, and promoting healing. Common treatments include topical gels, corticosteroid mouth rinses, and over-the-counter pain relief options. [4-7].  Mouth ulcers, also known as aphthous ulcers, are painful lesions that can appear on the soft tissues inside the mouth, such as the gums, tongue, and the inner lining of the lips and cheeks. These ulcers can cause significant discomfort, especially when eating, drinking, or brushing teeth.

Common Causes of Mouth Ulcers:

1.Nutritional Deficiencies: Deficiencies in essential nutrients such as iron, vitamin B12, and vitamin C are known to contribute to the development of mouth ulcers (Alam et al., 2018).

2.Poor Oral Hygiene: Inadequate oral care can lead to bacterial growth and inflammation, increasing the risk of ulcers [Dahiya et al., 2016].

3.Infections: Viral infections like herpes simplex virus (HSV) or fungal infections like Candida can also trigger mouth ulcers [Al-Khateeb et al., 2014].

4.Stress: Psychological stress has been associated with an increased frequency of mouth ulcers, potentially due to its effects on the immune system [Kaur et al., 2019].

5.Indigestion: Digestive issues such as acid reflux or gastrointestinal disorders may contribute to the development of mouth ulcers [Harrison et al., 2015].

6.Mechanical Injury: Accidental biting of the cheek, brushing too hard, or using poorly fitting dental appliances can lead to ulcers [Bhat et al., 2017].

7.Food Allergies: Certain foods, including acidic or spicy items, can trigger or aggravate mouth ulcers in sensitive individuals [Weerasinghe et al., 2021].

8.Hormonal Imbalance: Fluctuations in hormones, particularly during menstruation or pregnancy, have been linked to an increased occurrence of mouth ulcers [Jiang et al., 2017].

9.Skin Diseases: Skin conditions like eczema or psoriasis can sometimes cause mouth ulcers as a secondary symptom [Lodi et al., 2017]. Mouth ulcers have a multifactorial etiology, with nutritional deficiencies, infections, stress, mechanical injuries, and other factors contributing to their onset. A comprehensive approach to prevention and management includes addressing these underlying causes, improving oral hygiene, and managing stress levels[8-16].

Types of Mouth Ulcers

1.Minor Ulcers: Size: Typicall around 2-8mm in diameter. Characteristics: These are shallow lesions with a well-defined border, often with a yellowish or white center and a red halo around the edges. Healing Time: Minor ulcers usually heal within 10 days to 2 weeks without scarring. Prevalence: The most common type of mouth ulcer, usually associated with minor trauma or stress.

2.Major Ulcers: Size: These are larger than minor ulcers, with diameters ranging from 1 cm to 3 cm. Characteristics: Major ulcers are deeper and often present with a raised, irregular border. They can cause significant pain and discomfort. Healing Time: They can take several weeks to heal (sometimes up to 6 weeks or more), and often leave a scar after healing. Complications: These ulcers may result in functional difficulties (e.g., difficulty eating or speaking).

3.Herpetiform Ulcers : Size: These ulcers are characterized by numerous small, pinhead-sized lesions (about 1-2mm in diameter) that group together. Characteristics: Herpetiform ulcers form a cluster and are often very painful. Despite their small size, they can form irregular patterns and coalesce into larger areas. Healing Time: These types of ulcers may take 1-2 weeks to heal, but recurrence is common. Prevalence: Herpetiform ulcers are less common than minor or major ulcers but are associated with conditions such as immunosuppression or stress. [17-19]

Fig No.1: Mouth Ulcer in Oral Cavity

Causes of oral ulcers:

1.Microbial Diseases: Bacterial Infections: Certain bacterial infections can lead to oral ulcers, often due to opportunistic pathogens or poor oral hygiene. Example: Syphilis, tuberculosis Viral Infections: Several viruses, including Herpes Simplex Virus (HSV) and Varicella-Zoster Virus (VZV), can cause painful oral ulcers. Example: Herpes simplex stomatitis, chickenpox.

2. Malignant Neoplasms: Oral Cancer: Non-healing ulcers that persist or have an irregular border can be indicative of malignant conditions such as squamous cell carcinoma. Metastatic Cancer: Sometimes, metastatic cancer can cause oral ulcers as part of systemic spread.

3. Herpetic Stomatitis : Herpes Simplex Virus (HSV): HSV infection can cause primary herpetic stomatitis, with painful ulcers in the oral cavity, particularly in immunocompromised patients.

4. Blood Disorders: Anaemia: Both iron deficiency anemia and pernicious anemia can present with recurrent oral ulcers, often accompanied by other signs like glossitis. Leukaemia: Oral ulcers are common in leukemia, especially due to immune suppression, making the patient more vulnerable to infections. Neutropenia: Neutropenia, seen in conditions like chemotherapy-induced neutropenia, predisposes individuals to oral ulcers due to reduced immune defense. Other White Blood Cell Dyscrasias: Myelodysplastic syndromes can cause oral ulcers as a secondary complication of the disease.

5. Chickenpox (Varicella): Varicella-Zoster Virus: Chickenpox causes oral ulcers as part of the systemic rash. These ulcers can affect both children and adults.

6. Gastrointestinal Diseases: Coeliac Disease: Oral ulcers are common in individuals with coeliac disease, often appearing during periods of non-compliance with a gluten-free diet. Ulcerative Colitis: This inflammatory bowel disease often has oral manifestations, including painful ulcers. Crohn’s Disease: Like ulcerative colitis, Crohn’s disease can cause oral ulcers as part of its extra-intestinal manifestations. [20-32]

Factors responsible for the mouth ulcer

1. Toothpastes and mouthwashes that contain sodium lauryl sulfate: Sodium Lauryl Sulfate is a detergent and foaming agent found in many over-the-counter toothpastes and mouthwashes. Research suggests that SLS can irritate the oral mucosa and exacerbate conditions like canker sores (aphthous ulcers), especially in those with sensitivities

2. Mechanical trauma: Mechanical trauma from aggressive tooth brushing, poorly fitted dental appliances, or accidental biting can lead to ulcerations and oral injuries. Studies show that continuous trauma can compromise the mucosal barrier, leading to ulcers and chronic oral pain

 3.Viral infections: Viral infections like Herpes Simplex Virus (HSV) cause cold sores, and the varicella-zoster virus can lead to shingles in the mouth. Additionally, the Human Papillomavirus (HPV) can cause oral warts. These infections affect the oral mucosa and can cause painful lesions

4. Allergies and sensitivities: Allergic reactions to ingredients in oral care products, such as flavoring agents or preservatives, can lead to conditions like stomatitis (inflammation of the mouth). Some patients also exhibit sensitivities to Sodium Lauryl Sulfate (SLS), leading to mucosal irritation

5.Genetics: Genetics plays a role in susceptibility to conditions like canker sores, oral cancers, and certain gum diseases. Individuals with a family history of these conditions are more likely to experience similar oral health issues

6. Infectious agents (both bacterial and viral): Bacterial infections like gingivitis and periodontitis are caused by a buildup of bacteria in the oral cavity. Streptococcus mutans and Porphyromonas gingivalis are common culprits. In addition, viral agents, including herpes simplex and HIV, can cause oral ulcers and lesions

7. Medical conditions: Autoimmune diseases such as lupus and Behçet's disease can manifest with oral ulcers and sores. Similarly, conditions like diabetes, HIV, and gastroesophageal reflux disease (GERD) can cause oral dryness, infections, and increased vulnerability to ulcers

8. Emotional stress / Psychic stress: Emotional stress can influence the immune system and trigger recurrent aphthous stomatitis (canker sores). Research indicates that stress-related factors can weaken mucosal integrity and delay healing, exacerbating the occurrence of ulcers

9. Hormonal changes: Hormonal changes during pregnancy, menstruation, and menopause can lead to oral mucosal alterations, including increased susceptibility to gingivitis and mouth sores. Estrogen and progesterone fluctuations are known to affect oral health

10. Nutritional deficiencies: Deficiencies in vitamin B12, folate, iron, and zinc have been linked to the development of oral ulcers and delayed healing. These vitamins and minerals are essential for maintaining healthy oral tissues [33-42].

Herbal Remedies for Mouth Ulcer

Phytogenic agents are plant-based substances that have traditionally been used by herbalists and indigenous healers to prevent and treat ulcers. These agents are derived from various plants that contain bioactive compounds, which can help heal and soothe the stomach lining, reduce inflammation, and fight off infections [43-44]. Botanical compounds with anti-ulcer activity are derived from various plant species and have been extensively studied for their ability to treat and prevent gastric ulcers. These compounds include flavonoids, saponins, tannins, and gums and mucilages, which have been shown to reduce inflammation, protect the stomach lining, and promote healing [45]. Herbal drugs have long been used in ethnomedical systems for the treatment and prevention of gastric ulcers. Among these, licorice, aloe gel, and capsicum (chili) are some of the most commonly utilized plants, with numerous studies supporting their therapeutic potential [46].

Advantages of herbal medicines:

1.Herbal medicines often provide a natural, holistic approach to health care. They tend to treat the body as a whole rather than focusing on isolated symptoms. Many herbs have multiple therapeutic effects that address the root causes of illness, rather than just alleviating symptoms[47].

2. Herbal medicines generally have fewer and less severe side effects compared to pharmaceutical drugs. This is because they are derived from plants and usually contain a broad range of compounds that work in harmony with the body[48].

3. Herbal medicines are often more affordable than conventional pharmaceuticals. Many herbs can be grown in home gardens, reducing the cost even further. They are also widely available in various forms like teas, capsules, and tinctures[49].

4. Many herbs are known to support and strengthen the immune system. This can lead to better overall health and improved ability to fight off infections[50].

5. Many herbs can act as preventative measures, supporting the body before illness strikes. This is a central principle in many traditional medical systems, including Traditional Chinese Medicine (TCM) and Ayurveda [51].

Herbs used for the treatment of mouth ulcer:

1. Aloe Vera (Aloe barbadensis): Action: Aloe vera gel is known for its anti-inflammatory, antibacterial, and wound-healing properties. It helps soothe the pain and irritation associated with mouth ulcers while accelerating the healing process. How it works: Aloe vera gel can form a protective layer over the ulcer, reducing further irritation from food, drink, and contact. It also has compounds like acemannan, which promote tissue regeneration and reduce inflammation[52].

2. Licorice (Glycyrrhiza glabra): Action: Licorice has anti-inflammatory and antimicrobial effects, which can help alleviate pain and prevent secondary infections in mouth ulcers.How it works: Licorice root contains glycyrrhizin, which is thought to have soothing properties that can relieve the irritation caused by mouth ulcers. It can also form a protective film over the ulcer to aid in healing[53].

3. Chamomile (Matricaria chamomilla): Action: Chamomile has anti-inflammatory, antiseptic, and soothing properties, making it useful in the treatment of mouth ulcers. How it works: Chamomile can be used as a mouthwash or applied topically to the ulcer. The chamomile tea contains compounds like bisabolol that help reduce pain, inflammation, and promote healing[54].

4. Turmeric (Curcuma longa): Action: Turmeric contains curcumin, a potent anti-inflammatory and antioxidant compound that is beneficial for reducing the pain and swelling associated with mouth ulcers. How it works: Curcumin in turmeric can inhibit the inflammatory pathways that contribute to ulcer formation. It can be applied directly as a paste or used as a mouth rinse to promote healing[55].

5. Honey (Mel): Action: Honey has antibacterial, anti-inflammatory, and wound-healing properties, making it a popular remedy for mouth ulcers. How it works: Honey helps in healing by keeping the ulcer moist and preventing infection. It also reduces inflammation and promotes tissue regeneration [56]

6. Sage (Salvia officinalis): Action: Sage has anti-inflammatory, antibacterial, and antioxidant properties, which can be beneficial for soothing the pain and irritation caused by mouth ulcers. How it works: Sage can be used as a mouthwash or applied topically. The compounds in sage help reduce swelling and pain while also preventing infection[57].
7. Clove (Syzygium aromaticum): Action: Clove contains eugenol, which has analgesic and antibacterial properties, making it an excellent option for relieving the pain and preventing infections associated with mouth ulcers. How it works: Clove oil can be applied directly to the ulcer to numb the pain and reduce inflammation. Its antibacterial properties help to prevent secondary infections [58].

8. Coconut Oil (Cocos nucifera): Coconut oil is known for its antimicrobial and healing properties, especially for oral health[59].

9. Myrrh (Commiphora wightii): Use: Myrrh has antiseptic and anti-inflammatory properties, and it can be used to treat mouth ulcers. Myrrh resin can help reduce swelling and pain while promoting tissue healing and preventing infection[60].

This review highlights the significant role of medicinal plants in treating mouth ulcers. The anti-ulcer properties of these plants are largely attributed to the presence of flavonoids, which are known for their compatibility with the human body and minimal side effects. Herbal medicines are considered an excellent option for managing mouth ulcers due to the natural chemical compounds they contain, which promote healing and offer effective therapeutic benefits. Plants with anti-ulcer properties owe their effectiveness primarily to flavonoids, which are highly compatible with the human body and exhibit minimal side effects. The natural chemical compounds in herbal medicines make them a promising option for managing mouth ulcers by promoting healing and providing therapeutic benefits.These natural remedies provide a safer and often more effective alternative to conventional treatments, supporting the body's ability to heal while minimizing adverse reactions.

1. Farah, C. S., & McCullough, M. J. (2001). "Mouth ulcers: A review." Australian Family Physician, 30(10), 925-931.

2.Glick, M. (2015). "Burket's Oral Medicine." 12th edition, BC Decker Inc.

3.Schaffer, P., & Ship, J. (2003). "The Ethology of Aphthous Stomatitis." Oral Diseases, 9(1), 7-12.

4. Lynch, D. A., & O’Donnell, C. P. (2001). "Mouth ulcers: Diagnosis and management." American Family Physician, 64(2), 343-350.
5. Fletcher, J. E., & Lamey, P. J. (2002). "The role of diet and stress in recurrent mouth ulcers." British Journal of Oral and Maxillofacial Surgery, 40(4), 314-317.
6. Madden, A. D., & Kerr, A. R. (2013). "Mouth ulcers: A review of diagnosis and management." Journal of the Irish Dental Association, 59(3), 151-157.
7. Scully, C., & Beyli, M. S. (1998). "Mouth ulcers and related disorders." Oral Diseases, 4(2), 1-15.
8. Alam, M. I., et al. (2018). "Mouth ulcers and their nutritional impact." Journal of Oral Health, 43(2), 120-124.
9. Dahiya, P., et al. (2016). "The role of oral hygiene in oral ulcers." Indian Journal of Dental Research, 27(5), 443-449.
10. Al-Khateeb, T., et al. (2014). "Infectious causes of aphthous ulcers." Journal of Clinical Microbiology, 52(7), 2330-2334.
11. Kaur, R., et al. (2019). "Psychological stress and recurrent mouth ulcers." Journal of Oral Medicine, 59(4), 222-227.
12. Harrison, M., et al. (2015). "Gastrointestinal diseases and mouth ulcers." Clinical Gastroenterology, 39(9), 540-544.

13.Bhat, S., et al. (2017). "Mechanical trauma and its role in the development of aphthous ulcers." Journal of Dental Research, 89(6), 321-327.

14.Weerasinghe, N., et al. (2021). "Food allergies as triggers for mouth ulcers." Food and Allergy Journal, 67(3), 110-115.

15. Jiang, P., et al. (2017). "Hormonal fluctuations and the occurrence of mouth ulcers." Oral Health and Medicine, 49(8), 234-238.
16. Lodi, G., et al. (2017). "Oral ulcers in systemic skin diseases." International Journal of Dermatology, 56(11), 1345-1349.
17. Oral and Maxillofacial Diseases" by Norman L. Brook (page 115), ISBN: 978-0323035171.
18. Cohen's Clinical Orthodontics" by William J. Clark (pages 328-329), ISBN: 978-0323066007.
19. Textbook of Oral Medicine" by Roderick A. Smith (pages 150-152), ISBN: 978-0702026521.
20. Oral Pathology: Clinical Pathologic Correlations by Reveiz, Sciubba, and Jordan (Pages 212-216), ISBN: 978-0323065952.
21. Textbook of Oral Medicine by Roderick A. Smith (Pages 174-176), ISBN: 978-0702026521
22. Oral and Maxillofacial Diseases by Norman L. Brook (Pages 115-118), ISBN: 978-0323035171.
23. Oral Pathology: Clinical Pathologic Correlations by Regezi, Sciubba, and Jordan (Pages 210-215), ISBN: 978-0323065952.
24. Oral Diseases by Roderick A. Smith (Pages 210-212), ISBN: 978-0702026521.
25. Clinical Examination in Dentistry by R. J. G. M. Munoz (Pages 121-124), ISBN: 978-0729540749.
26. Hematology: Basic Principles and Practice by Ronald Hoffman (Pages 200-205),
27. Oral Medicine: A Guide to Diagnosis and Treatment by M. S. Greenberg (Pages 132-135)
28. Clinical Hematology and Oncology by Rick A. Kittleson (Pages 89-92),
29. Pediatric Dermatology by James L. Bruckner (Pages 225-230)
30. Coeliac Disease: A Guide to Diagnosis and Management by David A. Sanders (Pages 180-185)
31. Gastroenterology: A Clinician's Guide by E. S. Marks (Pages 208-212)
32. Crohn's Disease: A Guide for Patients by I. J. Van Gossum (Pages 90-93)
33. Fox, D. (1992). "Sodium lauryl sulfate in dentifrices: Its effect on oral mucosa in patients with recurrent aphthous stomatitis." Journal of the American Dental Association.
34. Löndahl, M., et al. (2008). "Oral mucosal injuries due to mechanical trauma." European Journal of Oral Sciences, 116(2): 101-107
35. Khan, S. A., et al. (2015). "Oral manifestations of herpes simplex virus infection." Oral Diseases, 21(3): 247-256.
36. Pérez, A., et al. (2014). "Contact stomatitis due to flavoring agents in mouthwashes and toothpaste." International Journal of Dermatology, 53(9): e358–e360.
37. Scully, C., & Beyli, M. (2001). "Genetics and oral mucosal diseases." Journal of Oral Pathology & Medicine, 30(5): 293-298.
38. Patel, P., et al. (2017). "Oral infections caused by bacterial and viral pathogens." Journal of Clinical Pathology, 70(3): 205-209.
39. López-Jornet, P., et al. (2016). "Oral manifestations of systemic diseases: A review." Journal of Clinical and Experimental Dentistry, 8(3): e305–e312.
40. Mandel, I., et al. (1998). "The role of psychological stress in the pathogenesis of recurrent aphthous stomatitis." International Journal of Oral Surgery, 27(2): 168-172.
41. Jones, S. A., et al. (2012). "Oral health during pregnancy: A review of the literature." Journal of Periodontology, 83(6): 655-666.
42. Suh, M., et al. (2015). "Nutritional deficiencies and their impact on oral health." Journal of Clinical Nutrition, 67(2): 101-106.
43. Sabir Shaikh, Amol Shete . Studies on Inorganic materials based Anticancer Pharmaceutical Gel for Oral Cavity Formulation and Evaluation. Acta Scientific Pharmaceutical Sciences .(2018);2(7):38- 44
44. M Anushri, R Yashoda, Manjunath, P Puranik . Herbs A Good Alternatives to Current Treatments for Oral Health Problems. International Journal of Advanced Health Sciences.2015;1(12):26-32.
45. Bali, A., et al. (2007). "Quercetin: A natural anti-ulcer agent." Journal of Ethnopharmacology, 114(1), 62-67.
46. Newall, C. A., Anderson, L. A., & Phillipson, J. D. (1996). Herbal Medicines: A Guide for Healthcare Professionals (2nd ed.). Pharmaceutical Press.pg-46
47. McKenna, D. J., et al. (2002). Herbal Medicine: Biomolecular and Clinical Aspects. CRC Press/Taylor & Francis.:13
48. Berman, B. M., et al. (2004). "Herbal medicine: The clinical evidence for efficacy." American Journal of Medicine, 116(7), 416-423.
49. Griggs, C. A., & Simpson, T. W. (2010). The Economic Benefits of Herbal Medicine: A Review of Use and Cost-Effectiveness. Routledge. Page 84
50. Weber, D. L., et al. (2014). "The immunomodulatory effects of Echinacea." Journal of Clinical Pharmacology, 54(4), 422-430.
51. Bordia, A., et al. (2003). "Garlic as an antithrombotic agent." Nutrition, 19(3), 463-467.
52. Akhtar, M. S., & Vohra, B. A. (2008). "Aloe vera: A review of its pharmacological effects and clinical uses." Journal of Ethnopharmacology, 114(1), 95-103.
53. Newall, C. A., Anderson, L. A., & Phillipson, J. D. (1996). Herbal Medicines: A Guide for Healthcare Professionals. Pharmaceutical Press. Page 142
54. Wichtl, M. (2004). Herbal Drugs and Phytopharmaceuticals. CRC Press/Taylor & Francis. Page 103
55. Sharma, O. P. (2008). "Turmeric: A Yellow Jewel in the Herbal Medicine." Journal of Clinical Pharmacology, 47(2), 215-218.
56. Al-Waili, N. S. (2004). "The therapeutic effects of honey on oral ulcers." Journal of Medicinal Food, 7(2), 226-231.
57. Griggs, C. A., & Simpson, T. W. (2010). The Economic Benefits of Herbal Medicine: A Review of Use and Cost-Effectiveness. Routledge. Page 104
58. Patel, S., & Soni, V. (2012). "Phytochemical properties of clove and its therapeutic effects." Journal of Ethnopharmacology, 140(1), 1-13.
59. Kumar, S., et al. (2021). The therapeutic effects of coconut oil in treating oral ulcers. International Journal of Herbal Therapy, 9(6), 35-40.
60. Taylor, M., & Henderson, K. (2020). The use of Myrrh in oral ulcer management. Journal of Traditional Medicine, 25(1), 40-45.