Causes of smoking Rule out:

1. Increase in Ibuprofen 1. Anaemia Medical History:

2. Crohn’s Disease
• Blood in the stools
• Tummy upset
• Frequent Diarrhoea
3. Smoking cessation
Management:
1. Steroid ointment
2. Benzydamine mouthwash
3. Refer to GP - blood test to
rule out anaemia
4. Diet advice - no spicy food
2. Crohn’s disease
3. Behcet’s disease
4. Medication updose
1. Are you currently fit and healthy?
• Do you have anaemia? (Some components in the blood are low)
• Do you get excessive bleeding from minor cuts and bruises?
• Any tummy problems? Loose stools with blood?
• Liver problems?
2. Are you under GP or specialist care?
3. Any medication over the counter or prescribed? Have your recently
changed the dose of any medication? Are you taking any oral
contraceptives?
4. Any allergies?
5. Do you still have your period? Are the period heavy?
6. Any surgery or hospitalisation over the past 10 years?
7. Any family history of these ulcers?

Social History:
1. Do you smoke?
I’m so sorry to hear that you’re having ulcers in your mouth. I can 2. Do you take alcohol?
understand it’s very distressing. Rest assured we will treat it in our best 3. Is your diet balanced? Are you vegetarian by any chance?
possible way. 4. Are you stressed? Any major changes in your life?
History: Explanation:
1. Where are the ulcers present? Are they present anywhere else on Based on all the information that you’ve given me, it seems like you’re
the body? Any similar ulcers on eyes, skins, joints or reproductive suffering from aphthous ulcer.
parts?
2. How many? These are just tiny ulcers that may appear at some point in life,
3. Since when? Is it the first time? How often? occurring in over 60% of the population.
4. What is the size and shape? Any increase in the size? It has multifactorial causation. It could be because of:
5. How long do they take to heal? Do they heal with scarring? • lack of vitamins, e.g. iron, B12 and C in the diet
6. Are they preceded by blisters? • Bowel disease, e.g. Crohn’s disease, ulcerative colitis
7. Do you have pain, tingling, numbness, bleeding from the ulcers? • Coeliac disease (gluten intolerance)
8. How is this affecting your daily life? Eating or brushing? • Behcet’s disease
9. Did you get any recent treatment in which you get a filling that • Hormonal changes (menorrhagia during menopause)
might have a rough edge or sharp tooth that might be impinging on • Stress
your cheek? Any trauma to the ulcer region? • Certain foods
10. Any allergy to new toothpaste or food? • Smoking cessation
I’ll be referring you to your GP for
• some blood investigations to rule out anaemia and you will be given
vitamins if the blood factors are low in your blood.
• investigate the tummy upset and loose stools
• prescribing stronger painkillers as increasing the dosage of
painkillers might lead to ulcers

Also, you mentioned that you recently quit smoking. That’s very good,
I’d like to congratulate. Keep up the good work. But what happened is
when you quit smoking, the nicotine level in your blood drops suddenly
and your body is reacting to the sudden drop of nicotine, causing
ulcers. Don’t worry, it is just a temporary side effect of quitting smoking,
it will go away with time.

To relief your pain, I’ll be prescribing

• Benzydamine mouthwash for you. You can use 15ml half an hour
before your meal for 7 days to numb the area.
• Orabase gel which you can apply to the area of the ulcers. It will not
speed up the healing of the ulcers but it will protect the ulcers against
further injury
• Chlorhexidine mouthwash which you can use 10ml twice per day for
7-14 days, don’t use more than 2 weeks as it can cause
discolouration of your teeth. It’s just an antibacterial mouthwash
which kill are the germs in your mouth and prevents infection of the
ulcers.
• Advice for healthy diet, 5 portions of vegetables and fruits, avoid
carbonated drink, acidic juices, spicy food and dry hard food
• Recall after 2 weeks to make sure the ulcers go away. If the ulcers
don’t go away, I’ll like to refer you to a specialist for further
investigations.

Your ulcers don’t look sinister to me, because cancerous ulcers don’t
come and go or heal by its own. Also, you don’t have risk factors like
alcohol drinking or smoking which can lead to cancer. But we will
monitor you to make sure it doesn’t go in that direction.