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Abstract: The patient in this case is a 35-year-old Ms. Li, who complained of incessant mouth ulcers in a fixed position for some time recently. A careful oral examination and medical history led to the diagnosis of oral ulcers, specifically traumatic oral ulcers. The oral ulcers were treated with medication, and Ms. Li was also advised to consult the orthodontics department for orthodontic treatment to remove the cause of the disease. The patient actively cooperated and the oral mucosal ulcers healed after treatment with good results.
Basic information】Female, 35 years old
Disease Type】Mouth ulcers
Hospital】Nei Mongol Autonomous Region Maternal and Child Health Hospital
Date of consultation】May 2022
【Treatment plan】Medication (multivitamin tablets, rehabilitation new liquid, oral ulcer powder)
Treatment Period】Outpatient treatment, follow-up after 1 week
【Treatment effect】The oral mucosal ulcer healed and the treatment effect was good
I. Initial consultation
Ms. Li’s self-report: Recently, her mouth kept getting mouth ulcers in a fixed position, repeatedly, and it was painful to talk and eat, which affected her appetite, sleep and work. During the conversation, we learned that Ms. Li is busy at work, often stays up late, eats less fruit and drinks less water, and has irregular meal times, and because of the painful mouth ulcers for a long time, she has some psychological worries, and recently her spirit is more nervous and she does not sleep very well.
Oral examination revealed that: an oval ulcer of about 1.2cm×0.8cm in size was seen in the mucosa of the left upper lip, reaching deep into the muscular layer, covered with white pseudomembrane on the surface, the surrounding mucosa was congested and red and swollen, with obvious tenderness, no obvious abnormalities in other oral mucosa, the teeth were not aligned, the oral hygiene was average, and no obvious abnormalities in the occlusal relationship. The diagnosis of oral ulcer (traumatic) was made on physical examination combined with medical history.
(face-to-face examination)
II. Treatment process
Ms. Li was suffering from painful mouth ulcers before she visited the clinic. Her current treatment plan is as follows: regular oral multivitamin tablets, gargling with rehabilitation solution after meals, and topical medication such as oral ulcer powder before eating to relieve pain during eating when the pain of mouth ulcers is heavy.
In terms of diet, regular eating time of three meals a day, with a light diet, it is recommended to consume green leafy vegetables, such as spinach and cabbage, and more fresh fruits, such as kiwi and apple. Avoid eating too hot food, such as spicy hotpot, hot pot, etc.
As the cause of Ms. Li’s mouth ulcers is: uneven teeth and repeated abrasion of oral mucosa caused by the tip of teeth, Ms. Li is suggested to consult the orthodontics department for orthodontic treatment at a later stage, without removing the cause, the mouth ulcers will recur.
III. Treatment effect
Before treatment, Ms. Li had painful meals and could not eat normally, but after medication, the pain during meals was obviously relieved; before treatment, she was emotionally tense and mentally stressed, but by adjusting her work and rest time and eating habits, her mental stress was obviously reduced, her tension was relaxed, and her sleep quality was improved; before treatment, she did not know that her uneven teeth would also bring about mouth ulcers, but after treatment, she was considering orthodontic treatment. In summary, through timely and effective treatment, Ms. Li’s oral mucosal ulcers healed after 1 week of follow-up, and the treatment effect was good.
IV. Notes
I am glad that Ms. Li’s oral mucosal ulcer healed after treatment, and the treatment effect is good. Ms. Li’s job requires her to sit in front of the computer often, and her work is stressful, so staying up late at night is common, and her meal time is irregular, which will affect her health and lower her body immunity, and also lead to changes in the hormone level in her body. Therefore, work is important, but also regular work and rest time, early to bed and early to rise, enhance physical exercise, more aerobic exercise. In terms of diet, regular three meal times a day, reasonable nutrition, avoid stimulating food, avoid overheated food, stay away from fried food, and take multivitamin tablets appropriately under the guidance of a doctor. For Ms. Li, the misalignment of teeth is the key stimulus for mouth ulcers, so she is suggested to undergo orthodontic treatment to align her teeth, remove the stimulus and say goodbye to mouth ulcers.
V. Personal insight
This case is a more representative case of traumatic oral ulcer. In today’s society, young people are busy with work, work pressure and mental pressure, so young people should also be concerned about their health, and bad habits such as staying up late and working overtime, smoking and drinking, and overeating can affect oral health. Therefore, for patients with mouth ulcers, first of all, they should pay attention to the adjustment of lifestyle, regular work and rest, and adjust their diet; for work pressure, they should choose appropriate adjustment methods to deal with it; in daily life, they should pay attention to oral cleaning and regularly check their oral conditions in oral clinics, and if mouth ulcers appear, they need to be treated in time to avoid aggravating the ulcers and affecting their daily life.