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Abstract: The patient in this case is 36-year-old Mr. Li, who came to our hospital because of pain in the oral cavity for 2 months after eating. Mr. Li described himself: 2 months ago, he had multiple ulcers in his mouth that had not healed since then, and the pain was severe. He was diagnosed with oral aphthous ulcer after completing relevant examinations to assess his condition. He was given medication for 2 weeks. After 2 weeks of follow-up, the ulcer disappeared and the symptoms were reduced, and the treatment effect was good.
Basic information】Male, 36 years old
Type of disease】Oral aphthous ulcer
Hospital】The Second Affiliated Hospital of Nanchang University
Date of consultation】September 2021
Treatment plan】Medication (trimethoprim injection, lidocaine carbonate injection, thalidomide tablets, zinc glycyrrhiza capsules, transfer factor capsules, multivitamin tablets, sipay gingival solution, recombinant bovine basic fibroblast growth factor gel)
[Treatment period] 2 weeks of outpatient treatment, follow-up after 2 weeks
Treatment effect】The ulcer disappears, the symptoms are reduced, and the treatment effect is good
I. Initial consultation
In September 2021, 36-year-old Mr. Li came to our department because of pain in his mouth when eating for 2 months. He had a history of smoking for 15 years, about half a pack per day, and no family history of severe recurrent oral ulcers, but he had a history of recurrent oral ulcers for more than 9 years, with one or more ulcers on the lips, tongue, cheeks and palate, which usually healed in 7-14 days with an interval of about half a month. 2 months ago, the lower lip ulcer had not healed, and the pain was severe. The effect of self-administered anti-inflammatory drugs was not obvious, so he came to our hospital for consultation.
On examination: multiple ulcers were seen on the lower lip and cheeks, with a diameter of about 0.2cm-1.5cm, a grayish-yellow pseudomembrane on the surface, red and slightly elevated surrounding tissues, a slightly hard base, and obvious pain. No residual crowns, roots or sharp tooth tips were found in the oral cavity, and enlarged lymph nodes were felt. Laboratory tests were given, and no abnormalities were found in the five immunological tests and trace element assay. Based on Mr. Li’s clinical manifestations, laboratory tests and relevant auxiliary examinations, he was diagnosed with oral aphthous ulcer.
II. Treatment history
Mr. Li was explained his condition, treatment plan and related costs, and Mr. Li gave his informed consent and requested treatment, using conventional treatment and therapeutic drugs to relieve pain and terminate the lesion. The treatment plan is as follows: use trimethoprim injection + lidocaine carbonate injection for local closure, and also give thalidomide tablets, zinc glycyrrhiza capsules, transfer factor capsules, and multivitamin tablets. Topical sipay gingival solution with gargling was also used, while recombinant bovine basic fibroblast growth factor gel was applied to the ulcer surface.
During the treatment period, Mr. Li was advised to avoid spicy and stimulating foods, quit smoking and alcohol, enhance nutrition, eat more fresh vegetables and fruits, and follow up promptly if he felt uncomfortable or had any adverse reactions.
(Interview)
III. Treatment effect
After local and systemic medication, Mr. Li’s ulcer interval was prolonged and the attack period was shortened, and his condition was relieved. After giving Mr. Li local anti-inflammation and pain relief and preventing secondary infection, Mr. Li’s pain symptoms disappeared, the ulcer surface gradually became smaller and the redness and swelling subsided. After 2 weeks of drug treatment, Mr. Li’s ulcer had disappeared, and the oral mucosa had recovered flatness and redness, and the treatment effect was remarkable.
IV. Notes
We are glad that Mr. Li’s pain was relieved and the ulcer disappeared after treatment. It should be noted that if the patient has misaligned teeth or bad restorations, it is easy to repeatedly rub and damage the oral mucosa, and then mucosal ulcers will appear frequently. Therefore, Mr. Li also needs to correct bad habits such as lip biting, cheek biting, tongue biting, etc., extract the remaining teeth or replace bad restorations, and if there is poor intraoral hygiene and more tartar, regular supragingival scaling is recommended. In case of recurrent oral aphthous ulcers, Chinese herbal medicine can be used to regulate them under the guidance of a doctor.
Since long-term sleep deprivation and overwork are common triggers for recurrent oral aphthous ulcers, you should ensure sufficient sleep and avoid overwork in daily life. Keep your mood relaxed, optimistic and cheerful, and avoid being troubled by bad emotions such as irritability, depression and depression for a long time. Maintain adequate nutrition supply, eat a light diet, and consume more vegetables and fruits to ensure adequate supply of vitamins and trace elements. Avoid the intake of stimulating food, quit smoking and alcohol, avoid betel nut, brush your teeth in the morning and evening, and rinse your mouth after meals to maintain oral hygiene.
V. Personal insight
The etiology of oral aphthous ulcers is complex and caused by a combination of multiple factors, so although there are many treatment methods, the efficacy is not ideal. Clinically, after local treatment combined with systemic treatment can only prolong the interval, shorten the attack period and relieve the disease, but it is difficult to completely cure oral aphthous ulcer. Therefore, daily prevention should be the main focus to reduce recurrence. Due to the existence of obvious individual differences, it is recommended to find out the recurrence pattern of oneself, find recurrence triggers and reduce the stimulation of triggering factors.
In this case, Mr. Li’s recurrent oral aphthous ulcers are due to smoking, so Mr. Li should drink less alcohol, not smoke and develop good living habits on a daily basis to reduce recurrence. At the same time, adjust the rhythm of life and work, do not stay up late and get enough sleep; adjust the mood and maintain an optimistic state of mind; exercise moderately to enhance the immunity of the body; eat a balanced diet, take a variety of vitamins and trace elements, and eat less spicy and other stimulating foods.