Article Type : Research Article
Authors : Ahtesham AQ, Bakri MM and Alhazimi YA
Keywords : Ulcers; Recurrence; Citric acid; Lignocaine jelly
Oral ulcers are
painful sores that appear in the mouth and are characterized by defects in the
epithelium, underlying connective tissue, or both. Most of them are harmless
and resolve on their own, but they can be non-responsive and difficult to
manage sometimes owing to their diversity of causative factors and clinical
presentation. Although many treatment
options are in use for their treatment, this case report describes the use of3%
citric acid mixed with lignocaine Jelly for the treatment of recurrent oral
ulcers in a 70-year-old patient who was not responding to the conventional
treatment.
Oral ulcers are
considered as one of the most common problems that cause pain in the mouth [1].
The exact cause of mouth ulcers is still not known. But they may develop as a
result of stress or anxiety, traumatic injuries, hormonal changes during
pregnancy, puberty, and menopause. Deficiency diseases such as Crohn’s disease,
vitamin B12 or iron deficiency, or a weakened immune system may all be
considered as etiological factors for oral ulcers [2]. Any ulcerative lesion
that lasts for two weeks or longer, is considered chronic and any ulcer of
fewer than 14 days’ duration is considered Acute [3]. Recurrent ulcers usually
present with a history of similar episodes with intermittent healing [4]. Most
oral ulcers are usually harmless and resolve by themselves within a week or
two. Sometimes, however, they can be non-responsive to conventional therapies,
such as multi-vitamins and local analgesic jelly, or, in severe cases
antibiotics and Analgesics [5]. The use of Citric acid (3%) has been reported
to yield successful results in treating non-healing ulcers and a variety of
infected wounds located at various parts of the body other than in the oral
cavity [6]. Here we report a case of recurrent oral ulcers on the tongue which
was treated with a mixture of 3% citric acid with 2% lidocaine jelly. Follow up
of one year showed no recurrence.
A 70-year-old female patient reported to the Department of dentistry with a chief complaint of multiple recurrent ulcerations on the tongue for one year. The intraoral examination revealed that ulcers were present on lateral borders of the tongue bilaterally (Figure 1-3).
Figure 1: Oral ulcers on left side of tongue.
Figure 2: Oral ulcers on Right
side of tongue.
Figure 3: Histopathological examination.
Figure 4: After one year follow up.
History of present illness revealed that the
patient had visited many dentists in the past year but the ulcers subsided
temporarily and recurred again. The patient gave a history that she had applied
antiseptic and analgesic ointment Rexidine-M Forte Gel (lignocaine,
metronidazole, and chlorhexidine) many times in the past for relief of ulcers
along with chewable vitamin C tablets 3 times daily, but ulcers recurred after
medications were stopped. The medical history revealed patient was Diabetic and
hypertensive and on medication. Intra orally multiple mobile and non-restorable
teeth in maxilla and mandible were present. In the first appointment, occlusal
grinding of some posterior teeth which were sharp was done. But after a 1-week
patient reported no relief from ulcers. Now total extraction of teeth was
planned and the patient was convinced for a complete denture. After total
extraction also patient had no satisfactory relief from ulcers. An incisional
biopsy was done and the histopathological report revealed nonspecific
inflammatory changes, including ulceration of the mucosa, covered with acute
inflammatory exudate. However, these changes did not help to know the cause of
recurrence. Finally, Mixture of 3% Citric acid and with 2%lignocaine Jelly was
prepared from the Biochemistry Department of the local medical college. It was
applied three times daily on the affected areas for one week. The patient was
prescribed Multivitamin tablets and a dispersible tablet of DK-50 (Diclofenac
potassium) twice daily for one week for pain relief. After 1st weeks follow up
Pain killers were stopped but we continued the application of ointment. In 2nd
week follow up patient had no pain and ulcers had considerably reduced. In the
3rd week, follow-up ulcers were completely healed and application of citric
acid was stopped. Follow-up of one year showed no recurrence of ulcers (Figure
4).
Oral ulcerative lesions
can present themselves as solitary acute or multiple, chronic solitary or multiple,
and recurrent lesions. With various etiological factors like stress and
anxiety, traumatic injury, viral or bacterial infections, allergy, or cancer
chemotherapy [7]. Many treatment options available are the use of multivitamins
like vitamin B-12, vitamin -C, use of local ointments for pain relief like
lignocaine jelly, Antibiotics like Penicillin, and Metronidazole for infection
control, and pain killers. Although most ulcers respond well to such therapies
some ulcers do not. In this case, using a mixture of 3% citric acid and 2%
lignocaine jelly for the treatment of chronic recurrent oral ulcers showed
positive results, and no recurrence was observed even after one year of
follow-up. It is believed that the acidic nature of citric acid lowers pH and
makes the wound environment unsuitable for bacterial growth.it also keeps wound
surfaces moist and prevents wound desiccation, which impairs wound healing. All
of these actions increase the migration of epithelial cells from surrounding
skin, encouraging re-epithelialization and wound healing [8].
The results of the
present case report suggest that topical application of a mixture of 3% citric
acid and 2% lignocaine is a good treatment option for recurrent oral ulcers
which do not respond to the conventional treatment. However, it needs further studies involving a
larger cohort of patients with oral ulcers to determine the efficacy of the use
of citric acid in recurrent oral ulcers.
The authors declare that
no conflict of interest was involved in the study.