Recurrent oral ulcer (ROU), also known as recurrentaphthous ulcer (RAU) or recurrentaphthous stomatitis (RAS), is given the Greek word “aphthous” (burning) because of its pronounced burning pain. It is called “Aphthous” (burning pain). It is commonly referred to as “oral fire” or “mouth sore”. It is the most common oral mucosal disease, and its prevalence ranks first among oral mucosal diseases. Epidemiological surveys in various countries show that at least one out of every five people has had a mouth ulcer. It can occur in both men and women, at any age and of any race. The disease is characterized by recurrent ulcers in various parts of the oral mucosa, not accompanied by other disease signs, with periodic, recurrent, self-limiting characteristics, ulcers burning pain is obvious. It occurs in poorly keratinized areas of the lips, tongue, cheeks, and soft palate. It is not contagious. The ulcers occur once every few months in mild cases, but in severe cases, they occur continuously without any interval, affecting the patient’s quality of life by interfering with diet and speech. The etiology and pathogenesis are still unknown. The histopathological manifestation is non-specific inflammation. Most scholars believe that the development of oral ulcers is the result of a combination of factors. Immunity, genetics and environment may be the “triad of factors” in the development of oral ulcers, i.e., genetic background and appropriate environmental factors (including psychoneurological, psycho-behavioral state, life and work and social environment, etc.) can trigger abnormal immune response and develop the characteristic lesions of oral ulcers. With the active, alternating and overlapping of one or more factors there is a decrease in the immunity of the body, immune dysfunction, which also causes frequent attacks of recurrent oral ulcers. 1, immune: some patients show immune deficiency, some patients show autoimmune reaction, causing the destruction of tissue and the onset of disease. 2.Heredity: If one or both parents suffer from recurrent mouth ulcers, then their children are more prone to the disease than the general population. 3, Diseases or symptoms related, such as digestive system diseases gastric ulcer, duodenal ulcer, chronic or prolonged hepatitis, colitis, etc., in addition to anemia, paranoia, indigestion, diarrhea, fever. The role of bacteria on mouth ulcers has been proposed for many years, and the bacteria closely related to mouth ulcers are Streptococcus haematobium and Helicobacter pylori. Mouth ulcers can be triggered by an imbalance in the production and clearance rate of superoxide radicals in the body, an imbalance in the ratio of thromboxane B2 and 6-ketoprostane, and a decrease in overall levels. Microcirculatory disorders lead to slow blood flow, low blood flow, and dilated capillary venous end, resulting in local ischemia and hypoxia, thus causing mucosal membrane damage and ulcer formation. However, most patients are in good health and have no history of systemic diseases. 4. own mental affective problems: such as lack of sleep, excessive fatigue, mental tension, work stress, change of menstrual cycle, etc. Yin deficiency constitution becomes the patent of this symptom. 5. Vitamin or trace element deficiency: such as lack of trace elements zinc, iron, lack of folic acid, vitamin B12 and malnutrition, high copper, etc., can reduce immune function and increase the possibility of recurrent mouth ulcer development. 6. It has been reported that smoking cessation can also induce mouth ulcers. 7. Sodium 12-alkyl sulfate (SLS), a component of toothpaste, may irritate the mucosa and induce oral ulcers. Diagnosis The diagnosis is mainly based on the medical history and clinical manifestations, and there are no definite laboratory indicators that can be used as a basis for diagnosis. Recurrent oral ulcers are recurrent round or oval ulcers with “yellow, red, concave and painful” characteristics, i.e., yellow or grayish-white pseudomembrane on the surface of the lesion; a peripheral red band of congestion of about 1 mm; a central depression with a soft base; and significant burning pain. The cycle of attacks is about several days or months, and is self-limiting with no cure. Disease classification 1. Light: about 80%, ulcers are usually 3-5 and scattered. The ulcers are usually found in the non-keratinized or poorly keratinized mucosa of the lips, tongue, cheeks, and soft palate, while the keratinized mucosa of the attached gingiva and hard palate rarely develops. The ulcers begin to heal in about 5 days and heal completely without scarring in about 7 to 10 days. The interval varies from half a month to several months, with some patients experiencing intermittent and prolonged onset, either around the time of menstruation or after exertion. There are usually no obvious systemic signs and symptoms. 2. Heavy: Also known as recurrent necrotizing mucosal glandular periarthritis or periglandular stomatitis. This type accounts for about 8% of cases. It occurs in adolescence. The ulcer is deep and large, resembling a “crater”, and can reach deep into the submucosal glands and periglandular tissue, with a diameter of 1 cm or greater, with red and slightly elevated surrounding tissue, a slightly hard base, and a gray-yellow pseudomembrane or gray-white necrotic tissue on the surface. It lasts for a long time, up to 1-2 months or longer. It is usually 1-2 ulcers, but 1 or several small ulcers may appear again during the healing process. The pain is severe, and scarring may remain after healing, which may result in tissue defects such as the tip of the tongue and palatal lobe. Systemic symptoms such as headache, fever, and local lymph node enlargement may be present. The ulcer may recur in the previously healed area. 3. Herpes-like ulcers: also known as stomatitis-type mouth sores, accounting for about 10% of the ulcers, the diameter of the ulcers is small, about 2mm, and the number of ulcers is large, up to a dozen or dozens, scattered distribution, like a “star in the sky”, adjacent ulcers can be fused into pieces, the mucosa is congested and red, the pain is the heaviest, and saliva secretion increases. It may be accompanied by headache, low-grade fever and other general discomfort, local lymph node pain and other symptoms. The onset pattern is the same as that of mild recurrent oral ulcer, which does not leave a scar after healing. Disease differentiation 1. Celiac disease: In the clinical manifestations of celiac disease and superficial ulcers are different. Oral ulcers can be caused by systemic or local factors, a variety of ulcers, although there are intra-epithelial or subepithelial, superficial or deep, acute or chronic, benign and malignant, but all have depression; shape is regular, round or oval; boundary is well-defined, and the surrounding normal mucosa “warp and woof”. In contrast, the clinical manifestation of oral erosion is congestion and erosion flush with the normal mucosal surface, and no depression, covered with exudative pseudomembrane, with various shapes and irregularities, and the boundary between the surrounding normal mucosa is unclear. Second, the course and healing of the two are different. Ulcers generally have a shorter course, and once healed, they are “crisp and clean”, and shallow and benign ulcers heal without scarring, with the exception of deep and muscular ulcers and malignant oral ulcers. Cicatricial ulcers generally have a longer duration, are recurrent, and have a “delayed” healing process, but cicatricial ulcers generally do not leave a scar. Finally, the two appear differently under the microscope. Ulcers show an interruption in epithelial continuity, while erosions are more superficial without an interruption in epithelial continuity. When ulcers and vesicles are less typical, differentiation can be difficult, but with careful observation, they can generally be distinguished. It is worth suggesting that the two lesions are interconvertible or both exist simultaneously. Herpes simplex: It occurs in infants and young children and is characterized by clusters of small blisters in the early stages, which fuse into larger vesicles or irregular ulcers after breaking. Recurrence is clearly related to the trigger, and recurrence is often preceded by prodromal symptoms such as sore throat and malaise, and is mostly accompanied by significant general discomfort during the onset. Severe recurrent oral ulcers should be differentiated from cancerous ulcers, tuberculous ulcers, traumatic ulcers and necrotizing salivary gland metaplasia. Treatment There is still no specific method to cure the disease. The principles of treatment are to eliminate the causes, enhance physical fitness and treat symptomatically to reduce the number of recurrences, prolong the gap period, reduce pain and promote healing. Treatment advocates a combination of systemic and local, Chinese and Western medicine, and physical and psychological. A. The ulcer recurs only a few times a year, each recurrence lasts only a few days, and the pain is tolerable. Look for relevant triggers and control them. Help the patient to summarize safe and effective treatment modalities and continue to use them. B. The ulcers recur monthly, each lasting 3-10 d, and the pain interferes with eating and daily mouth cleaning. Discuss the possible triggers with the patient and control them. Apply corticosteroids during the prodromal phase of the ulcer (tingling, swelling, etc.) to terminate its development. Either a compounded chlorhexidine rinse, a dexamethasone rinse containing 0.05 mg/5 ml (3 times daily), or a topical high potency corticosteroid such as an oral ointment containing 0.05% clobetasol propionate or fluorescein acetate (3 times daily) may be used. Provide proper oral hygiene instructions to patients. For more recalcitrant cases, short-term systemic application of adrenocorticosteroids, no more than 50 mg/d (preferably morning), may be used for 5 d orally. C. Painful ulcers with recurrent attacks. Topical potent adrenocortical steroid hormones such as betamethasone, beclomethasone, clobetasol propionate, fluticasone propionate. Systemic adrenocorticosteroids, azathioprine or other immunosuppressive agents such as aminophenone, hexoketocine and reactive stop. Submucosal injections of corticosteroids, such as betamethasone, dexamethasone, and tretinoin, are also feasible to shorten the duration of systemic administration. Oral hygiene instruction is provided for patients with poor oral hygiene. (I) Local treatment: The main purpose is to reduce inflammation, relieve pain and promote ulcer healing. 1. Rinse: 0.25% aureomycin solution, 1:5000 chlorhexidine solution, 1:5000 potassium permanganate solution, 1:5000 furacilin solution, etc. 2. Tablets: Dumefene tablets, lysozyme tablets, chlorhexidine tablets. 3. Dispersions: bing boran, tin type dispersion, qing dai dispersion, nourishing yin and generating muscle dispersion, etc. are the main medicines for treating oral ulcers in Chinese medicine. In addition, compound betamethasone sprinkle also has anti-inflammatory, pain relief, promote ulcer healing effect. 4. Medicine film: its matrix contains antibiotics and cortisone and other drugs. It is applied to the ulcer to reduce pain, protect the ulcer surface and promote healing. 5. Pain relievers: 0.5-1% procaine solution, 0.5-1% dacronin solution, 0.5-1% dicaine solution, applied to the ulcer surface for 2 consecutive times, used for temporary pain relief before eating. 6. Cautery method: It is suitable for those with small number of ulcers, small area and long intermittent period. The method is to first use 2% dicaine surface anesthesia, isolate the wet, dry the ulcer surface, with an area smaller than the ulcer surface of a small cotton ball dipped in 10% silver nitrate solution or 50% tincture of triazolium acetate or iodophenol solution, placed on the ulcer surface to the extent that the surface whitening. These drugs can make the ulcer surface protein precipitation and the formation of film to protect the ulcer surface, to promote healing. 7. Local closure: Applicable to heavy recurrent aphthous ulcers. Inject 2.5% prednisolone acetate suspension 0.5~1ml with 1% procaine solution 1ml into the lower part of the ulcer, 1~2 times a week, 2~4 times in total. It has the effect of accelerating ulcer healing. 8. Laser treatment: irradiation with helium-neon laser can make the mucosal regeneration process active, inflammatory response decreases, and promote healing. (B) Systemic treatment 1. Immunosuppressant: If it can be determined by the examination of autoimmune diseases, the use of immunosuppressant has obvious efficacy. Commonly used drugs for prednisone (prednisone). To prevent the spread of infection, antibiotics should be added. For severe Behçet’s syndrome, hydrocortisone or dexamethasone and tetracycline are given. They should be prohibited or used with caution in patients with gastric ulcer, diabetes mellitus, and active tuberculosis. 2. Immunomodulators and enhancers (1) Transfer factors, pidomod, levamisole are used for those who need to enhance the effect of cellular immunity. (2) Vitamin drugs can maintain normal metabolic function and promote healing of lesions. Vitamin C 0.1-0.2g 3 times a day and vitamin B complex 1 tablet 3 times a day are given during ulcer attack. (3) Those with reduced serum zinc levels of trace elements have improved after zinc supplementation and can be treated with 1% zinc sulfate syrup or zinc sulfate tablets. Chinese medicine treatment: can be divided into local treatment and systemic treatment: local treatment: can be used to nourish Yin and produce muscle, watermelon cream, ice borax, etc. Systemic treatment: The treatment is based on the identification of evidence, and recurrent mouth ulcers are roughly divided into real fire type and deficiency fire type. The real fire type mouth ulcers can be treated with clearing stomach san, guiding redness san, etc. The deficiency fire type mouth ulcers should be treated with Liu Wei Di Huang Wan and Qiao Ju Di Huang Wan. Chinese herbal medicines can be chosen from clearing heat and detoxifying capsules, stomatitis clearing punch, etc. Prevention of mouth ulcers is largely related to personal physical quality, try to avoid triggering factors, can reduce the incidence. 1. Pay attention to oral hygiene, avoid damage to the oral mucosa, avoid spicy and irritating food and local stimulation. 2. Maintain a relaxed mood, optimism and cheerfulness. 3. Ensure sufficient sleep time and avoid excessive fatigue. 4. Pay attention to regularity of life and balanced nutrition, and develop certain bowel habits to prevent constipation.