Recurrent stomatitis (RAU for short), characterized by repeated episodes of restricted ulcerative damage to the oral mucosa, has the highest prevalence among oral mucosal diseases and is most prevalent in young adults, with the highest prevalence in the 25-34 age group for both sexes, according to the data. It is more prevalent in women than men, 9.53% in men and 20.82% in women. The current treatment can reduce the symptoms and promote the healing of ulcers but cannot prevent recurrence, which belongs to the category of “mouth sores” in Chinese medicine.
Etiology and pathogenesis
1. Heart and spleen heat accumulation type
According to the General Record of Shengji, “Those who have sores on their mouths and tongues are caused by heat in the heart and spleen. The heart is fire, and the spleen is earth. The heart fire accumulates heat, which is transmitted to the spleen and earth, and the two organs both accumulate heat and poison, which are not allowed to pass through and attack the upper jiao, thus causing sores and swelling between the mouth and tongue. The Nei Jing also says: “All painful and itchy sores belong to the heart.” “The tongue is the seedling of the heart.” The spleen opens the mouth, and the spleen pulse holds the tongue. Heat accumulation in the heart and spleen is the most common pathogenesis of mouth sores. The characteristics of mouth sores are
(1) They usually occur on the tip of the tongue and lips.
(2) The ulcers of mouth sores are congested and painful, especially when irritated.
(3) The duration of the disease is short and the onset of the disease is rapid.
④Symptoms such as dry mouth, palpitation, insomnia, and dry stools.
2.Yin deficiency and fire type
Shou Shi Bao Yuan? Mouth and Tongue”: “Mouth sores that do not heal for years, this deficiency fire also.” This is because of a deficiency of yin in the body, or after an epidemic due to dampness and heat, or after overwork, the true yin is lost and the false fire is burned in the mouth and the muscle membrane is injured and ulcerated. The characteristics of mouth sores are
(1) The mouth sores are recurring, with one after another.
(2) The ulcers of mouth sores are light red in color, with a light red surface and few pseudomembranes.
③Tongue light red without moss
④Symptoms such as night sweating, lumbar fatigue, little sleep and dreaminess.
3. Spleen qi weakness type
Danxi Xinfa: “Mouth sores that do not heal after taking cold medicine are due to the deficiency of the middle jiao earth and the inability to eat, and the phase fire rushes up without control, so use Rizhong Tang. Ginseng, white atractylodes, licorice to supplement the deficiency of the earth, dry ginger to disperse the fire of the standard, and even add sapodilla, or hold the official gui is also good.” The characteristics of his mouth sores are
(1) Recurrent attacks of mouth sores, triggered by excessive fatigue.
The ulcers are light red or light white with no obvious redness around them.
③Tongue is light in texture, and there are teeth marks on the edge of the tongue.
④No symptoms of fire and heat such as dry mouth, bad breath, dry stool and yellow urine.
⑤ If there are symptoms of spleen deficiency, such as tiredness, weakness, poor appetite and loose stools, the type of evidence can be clarified.
4.Dampness and turbidity congestion type
In the Medical Digest, “dampness and cold in the spleen and stomach, bile and fire on the inflammation, resulting in mouth sores”, clear yang does not rise, turbidity clouding the clear channel, the spleen loses its health, evil turbidity accumulates and is trapped in the middle of the state for a long time, depressing the steam and overwhelming the clear orifices. The characteristics are
(1) The base of the mouth sore ulcer is gray with a pseudomembrane, thicker, and the surrounding mucosa is light red or light white in color.
The mouth is dry and does not want to drink much, the tongue stretches and salivates a lot, the mouth is sticky and unpleasant, or the mouth has a light or sweet taste, sometimes the breath has a rag taste, accompanied by physical sleepiness, laziness, poor appetite, and even nausea, the tongue coating is white and greasy, and the pulse is slow.
5.Blood stasis and stagnation type
This type is rare. The fire and heat in the mouth sores are so strong that they cause the blood to flow poorly, or the fire and heat torment and deplete the fluids, causing the blood to thicken. For example, in the Revision of the Treatise on Common Typhoid, it is said that “evil heat burns brightly, and the blood becomes clotted due to the fumigation of the fire.” The characteristics of mouth sores are: the ulcers are not healed for a long time, the ulcers are basically fixed, or the recurrence is still around the original ulcers after healing, the pain is more severe, there are petechiae on the tongue, or petechiae on the lips.
Key points for identification
1.Discerning deficiency and reality
Surgical Authentic” said: “The mouth broken, there are deficiency fire, real fire, the color of the light color red. Deficiency fire, light color and spots, and even trapped in the turtle pattern, pulse deficiency is not thirsty, this is because the thought of too much trouble, more awake less sleep, deficiency fire moving and hair.” The “Golden Guide to Medicine? The “Heart of Surgery” says: “Mouth sores with real fire are bright red, full of rotten spots, and even the cheeks and tongue are swollen, and the pulse is dry.” The “Shou Shi Bao Yuan? Mouth and Tongue: “Mouth sores, which do not heal for years, are deficiency fire.” Although the ancients have discussed, clinically it can be distinguished from the following three aspects.
(1) Asking about the course of the disease Where the acute onset of the disease, no previous history of mouth sores, the short course of the disease is the actual evidence. Where there are recurrent episodes of mouth sores and the duration of the disease is long, the chronic onset of the disease is a mixed evidence of deficiency and reality or deficiency evidence.
(2) Ask about triggering factors Where there are clear triggering factors such as drug allergy-induced mouth sores, oral trauma-induced mouth sores are real evidence.
(3) Look at the shape of the ulcer. Where the ulcer is congested, there is fibrinous exudation on the surface of the ulcer and pain is obvious, this is a real evidence. Where the ulcer is light in color and the pain is mild, it is a deficiency. Where acute superficial ulcers are solid evidence, chronic superficial ulcers are deficiency evidence or mixed evidence of deficiency and reality. Where acute deep ulcers such as necrotizing ulcerative gingivostomatitis, noma, are generally real evidence. Where chronic deep ulcers such as chronic mucosal traumatic ulcers, mucosal trophic ulcers, generally for deficiency or mixed evidence of deficiency and reality.
2.Identify the internal organs
From the point of view of the internal organs, mouth sores are closely related to the heart, spleen, stomach, liver and kidneys.
The nature of the lesion and the internal organs involved can be distinguished by the local shape of the mouth sore, the surrounding redness and swelling, the color of the pseudomembrane and the pain.
(1) Identification of internal organs from localized areas. In the book of “Rules for the Treatment of Evidence? The eighth book of “Miscellaneous Diseases” has “wind-heat transmitted to the spleen, lip swelling and cracking or callus lips”. The mouth is the external orifice of the spleen, and the redness and swelling of the lip ulcers are related to the spleen; “The Secret of Wai Tai” Volume 22 says: “The tongue is the master of the heart, and the hidden heat should be the tongue sore and cracked lips uncovered red.” The ulcers on the tip of the tongue are related to the heart; the branch of the foot fruct Yin liver meridian goes down to the cheek and surrounds the mouth and lips, so the ulcers on the edge of the tongue and the mucous membrane of the cheek are related to the liver; the foot yangming stomach meridian enters the upper teeth and comes out to hold the mouth and surround the lips, so the gum ulcers are related to the stomach.
② Special symptoms to identify the internal organs
Dry mouth or sweet mouth: belongs to spleen heat. Medical Zhengzhuan, Volume 5: “Spleen heat makes the mouth dry.”
Bitter mouth: liver heat. Su Wen? Fistula”: “If the liver is hot, the mouth is bitter when the bile is drained.
Mouth acidity: liver heat. The pathological relationship between liver heat and sourness of the mouth is proposed in the Danxi Xinfa.
Mucous in the mouth and lack of taste in food: related to the spleen. Ling Shu? Spleen Qi is connected to the mouth. If the spleen is in harmony with the mouth, the mouth can know the five grains.
3. Identify the nature
Mouth sores are an oral mucosal disease characterized by ulcers of the oral mucosa. Identifying the benignity and malignancy of the ulcer is of great significance to the diagnosis and prognosis of the ulcer. Benign ulcers are generally small and shallow, with a variable location and can heal on their own. Cancerous ulcers are generally chronic deep ulcers of the oral mucosa. Early cancerous ulcers have the following characteristics: typical cancerous ulcers are cauliflower-shaped and can also have
(1) Cleft groove ulcers. Most of them occur on the back of the tongue, with deep cleavage grooves, mild infiltration around, and normal surface color.
(2) Disc-shaped ulcers. Mostly seen on the ventral part of the tongue, floor of the mouth, soft palate, tongue and palate arch, round and oval on the basis of the original erythema, with slightly raised edges and a dark red fine velvety or generally granulomatous trauma at the base, without pseudomembranes, with a soft rubber-like texture on finger palpation.
(3) Crater-like ulcers. Mostly seen in the buccal mucosa and dorsum of the tongue, the ulcer is small and deep, with mildly raised margins and infiltration at the base and margins. The above ulcers are usually usually more than 3 weeks old and are ineffective to any treatment. The diagnosis can be made by pathological biopsy combined with the characteristics of the ulcer margin or the presence of early cancer cell infiltration at the base.
Treatment tips
1. To drain the fire from the actual evidence, do not forget to draw the fire from the bottom
The actual evidence of mouth sores is usually caused by heat in the heart and spleen, damp heat in the spleen and stomach, or fire heat in the liver. The main rule of treatment is to clear the heart and relieve heat from the spleen. Fire is a Yang evil, and too much of it consumes fluid and burns intestinal fluids, resulting in constipation and other symptoms. The clinical use of raw rhubarb to clear heat from the internal organs, so that the stagnant material can not stay in the gastrointestinal tract for a long time. If the elderly and frail people can use Guaouhu Ren, fire marijuana and other laxative products.
2, the actual evidence of diarrhea, do not forget to generate fluid
Danxi Xinfa” “throat sores and pain, mostly due to deficiency fire parade uncontrolled guest in the throat also”. The “Jing Yue Quan Shu” cloud “throat ringworm disease, Yin deficiency labor loss of people have this disease, this real fire deficit deficiency fire disease. The ancients have long discussed the use of medicine for mouth sores in the case of real fire, while not forgetting the products that produce fluid. For example, Zhang Jinyue suggested that “mouth sores and bitterness, where internal heat in the three jiao, such as evidence, it is appropriate to Ganlu drink”, which is characterized by the clearing of the heart and fire, accompanied by nourishing yin and generating fluid products, clinically it is common to see a focus on bitter and cold diarrhea of fire products, although the symptoms can be controlled in the short term, but the ulcer is slow to heal, after adjuvant with the product of generating fluid, the symptoms can be greatly improved. As the saying goes, “strengthen the main water to control the sun”.
3, damp and turbid congestion, treatment when aromatic turbidity to strengthen the spleen
This is a common clinical condition, characterized by a lack of invigoration of the spleen and yang, the dampness of the spleen and earth is not moistened by yang, the clear yang does not rise, and the turbidity overshadows the clear path. Treatment should be based on aromatizing dampness and strengthening the spleen to raise Yang. In particular, Professor Gan Zu Wang of our department suggested that aromatizing dampness and strengthening the spleen and benefiting qi is one of the main rules for treating recurrent mouth sores. At the same time, it is believed that there is no harm in using less tonic medicine and more aromatic medicine for this type. [5] Commonly used drugs include: prunus ginseng, atractylodes, poria, patchouli, pelargonium, asclepias, bupleurum, henbane, licorice, etc. Clinically, it can be used if the patient has no obvious congestion and swelling of the ulcer, more pseudomembranes on the surface of the ulcer, and a light tongue with a white and greasy coating.
4.See “Invigorating Blood” for long-standing diseases.
For those who have obvious clinical signs of blood stasis, treatment can be used to activate blood circulation and remove blood stasis, but for a few mouth sores that are recurrent and do not heal, it is necessary to use blood-activating products while clearing heat or supporting the righteousness. For example, the “Puji Formula” says that “blood is always in the body of a person, and any disease that does not heal after many days of treatment must be treated by regulating blood”. In recent years, studies have concluded that local ischemia and hypoxia caused by microcirculatory disorders can lead to mucosal damage, coupled with increased capillary permeability and leakage of immunologically active substances, resulting in an enhanced autoimmune response and inducing mouth sores. Clinical signs of stasis should be carefully identified, such as angered blood vessels at the base of the tongue, petechiae on the tongue, long-term ulcers in an adjacent area, and long-term recurrence of ulcers that do not heal. Or on the basis of the prescription, refer to the products that activate blood circulation and remove blood stasis.
5. Pay attention to external treatment, blowing medicine needs to be identified
Recurrent mouth sores were often treated with tin-like powder and pearl yellow powder applied externally to the ulcers. Recently, watermelon cream spray and swelling and pain capsule powder have been applied externally to the ulcer for treatment. Traditional Chinese medicine laryngology attaches great importance to the external treatment method, the reasonable use of blowing medicine, can quickly relieve pain, accelerate the ulcer healing. Take the prescription for nourishing Yin and generating muscle as an example, its drugs are composed of Xiong Huang, gypsum, Qing Dai, peppermint, Huang Bai, ice chips, licorice, etc., processed according to the pharmaceutical order of mineral drugs first, then plant drugs, and finally incorporated into the aromatic drugs. If the local mucous membrane is red in color, the evil heat is more prevalent, and the dosage of Xiong Huang, Peppermint, Huang Bai and Gypsum can be increased. If the ulcer is accompanied by more yellow-white pseudomembrane, it is more dampness, and the dosage of Qing Dai can be increased or add calcined Ren Zhong Bai, sweeping cream to dispel rot and create new. If the ulcer is about to heal, the dosage of licorice and pu huang can be increased to produce muscle and close the mouth. If the ulcer occurs at the tip of the tongue, Chuan Lian can be added to clear the fire. If the ulcer occurs at the edge of the tongue, gentian herb can be added to clear the heat from the liver. If the ulcer is on the gum, the dosage of Phellodendron can be increased. Mouth sore ulcers have aura symptoms: such as a dry feeling in the mouth, a hairy feeling in one part of the oral mucosa, localized red thorny spots, and a foreign body feeling when speaking, which can become ulcer spots overnight if not treated in time. As long as the timely external application of yin nourishing muscle medicine in the ulcer, it can be controlled and does not develop.
6, pay attention to dietary conditioning, soothe the emotions
The diet of recurrent mouth sores has a great deal to do with the occurrence and degree of attack of mouth sores. First of all, we should prevent spicy and stimulating products, such as over-eating Sichuan cuisine, garlic, ginger and pepper. The second is to prevent the over-eating of hot and dry products, such as wine, mutton and dog meat. Third, to prevent stimulating fire products, such as fried foods, peanuts, etc. Four avoid mechanical friction, such as fish, shrimp, crab and other rough food damage to the mucosa. Can eat more fruits such as pears, water chestnuts, celery, chrysanthemum brain and other products. In addition, those who work under too much pressure, have an irregular life and are depressed need to avoid overworking or staying up all night to hurt the mind and fire, and keep their mood relaxed to prevent depression and fire, and adjust their sleep to avoid insomnia and heart fire, which are beneficial to the recovery of mouth sores.
In short, recurrent mouth sores are rarely seen in clinical practice, but more often in the case of deficiency, and secondly, in the case of mixed deficiency and reality, which should be carefully identified in clinical practice. Most of the ulcers occur at the counterparts of carious teeth and dentures due to long-term abrasion. It is often cured by removing caries and other causes. Most scholars believe that recurrent mouth sores are related to the low immune function of human beings, so do not forget to support the treatment in the process of treatment to improve the immune function of human beings. It is easy to reduce the symptoms of the disease, but difficult to control recurrence, so persistent treatment is needed. It is important to take medication intermittently to consolidate treatment after healing.