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Abstract: Oral mucosal ulcer belongs to a kind of ulcer. In this case, the patient is a 23-year-old female who reported recurrent oral mucosal ulcers in the past two years, but did not use medication to treat the ulcers.
Basic information】Female, 23 years old
Disease Type】Ulcer (oral mucosal ulcer)
Hospital】The First Hospital of Jilin University
Date of consultation】June 2021
Treatment plan】Medication (bovine basic fibroblast growth factor gel, compound chlorhexidine liquid, vitamin B complex tablets)
Treatment period】1 day of outpatient treatment, 1 week of outpatient medication, 1 month of outpatient follow-up
Treatment effect】The oral mucosal ulcers disappeared.
I. Initial consultation
The patient is a young woman who complained of recurrent oral mucosal ulcers in the past two years since she graduated from school and joined the workforce, and in severe cases, multiple ulcers occurred at the same time, affecting her normal diet. In the last two months, the oral mucosal ulcer suddenly worsened and did not heal, and it was already affecting the daily speech and was very painful. Based on the patient’s complaints and his symptoms and signs, he was diagnosed with oral mucosal ulcer.
II. Treatment history
After communicating with the patient and learning that she had no history of drug allergy and no remaining underlying diseases, she explained her condition to the patient and emphasized to her the need for treatment with drugs, to which the patient readily agreed. Considering the patient’s recurrent mouth ulcers and more severe pain, the following medications were prescribed, including recombinant bovine basic fibroblast growth factor gel, to promote recovery of the ulcer surface. A compound chlorhexidine solution was given to reduce inflammation and prevent secondary infection of the ulcer surface, as well as vitamin B complex tablets to improve the body’s ability to heal itself. Patients were also instructed to avoid spicy, acidic or overly hot foods while the ulcerated surface in the mouth is still healing, so as not to aggravate the ulcer or affect the treatment effect.
III. Treatment effect
The patient was given topical medication to promote the healing of the ulcer surface, and combined with compound chlorhexidine liquid and vitamins to shorten the ulcer attack period, and the pain symptoms gradually reduced until they disappeared, the diameter of the ulcer surface became smaller, and the pseudomembrane and redness disappeared. When the patient came to the outpatient clinic for follow-up 1 week later, the original ulcer at the back of the tongue had completely healed and returned to normal mucosal form, and the treatment effect was good.
IV. Precautions
After the ulcer healed, the patient could speak normally and was very happy, thanking me one after another. In addition, I told the patient to eat less spicy food to avoid stimulating the oral mucosa and causing the recurrence of ulcers, and to pay attention to the eating habits to avoid eating too quickly and biting the tongue or the mucosa in the mouth, and to eat more fruits rich in vitamins, such as citrus and blueberries, etc. In addition, although the patient is young, he still needs to pay attention to regulating his work and rest to avoid staying up late and working long hours. This also has a positive effect on avoiding ulcer recurrence.
V. Personal insight
Oral mucosal ulcer is a common disease that often does not attract attention, but if, like the patient in this article, the ulcer is recurrent or even does not heal for a long time, it is necessary to consult a doctor in a timely manner and take medication in the early stage, which can be recovered quickly, and in the later stage, it is necessary for the patient to improve living habits, avoid excessive stress, and exercise appropriately, rinse and brush teeth reasonably to reduce the recurrence rate of oral mucosal ulcer to The recurrence rate of oral mucosal ulcers should be minimized.