Introduction

Mouth ulcers are inflammatory, white-reddish spots that develop on the mucous membrane lining the mouth; two to four are frequently present at the same time. Many mouth ulcers heal without treatment, but some may require medical attention.¹

It is calculated that around 25% of populations around the world are affected by mouth ulcers. There are multiple factors that contribute to the condition.² But what is the link between the mouth ulcers and smoking? Could the smoking habit be the hidden cause of these painful ulcers? Could quitting smoking help in management?

That's what we will focus on in the article, along with discussing the common symptoms, diagnosis, and the available treatment.

Types of mouth ulcers

A mouth ulcer is a painful sore that develops inside your mouth.³

Mouth ulcers can develop on your:³

• Gums
• Tongue
• Palate: roof of the mouth
• Cheeks inside
• Inner lips

Different types of mouth ulcers 

Mouth sores and lesions come in a variety of forms, such as:³

• Canker sores (aphthous ulcers) are the commonest type. The exact cause is not known, but some factors like minor injuries ( such as biting your cheek), acidic foods, and stress may contribute. They often appear white or yellow with reddish borders
• Oral lichen planus can lead to itchy rashes and white, lace-like sores in the mouth. It is an immune response condition that is mainly assigned to females at birth over 50 years old
• Leukoplakia: This is a condition that causes white or gray patches in the mouth and is caused by an overgrowth of cells. It is very often due to chronic irritation, such as from smoking or using chewing tobacco, though it may also appear for no known reason. The patches are usually not malignant
• Erythroplakia is another condition linked to smoking or chewing tobacco, presenting as red patches, often found behind the lower front teeth or under the tongue. Unlike leukoplakia, erythroplakia patches can be precancerous or cancerous
• Oral thrush is a fungal infection caused by an overgrowth of yeast called candida albicans. It often occurs after taking antibiotics or when the immune system is weakened. This condition results in red and creamy white sores in the mouth
• Mouth cancer can manifest as red or white sores or ulcers that do not heal. If a mouth ulcer lasts longer than three weeks, it is recommended to seek medical attention

Causes of mouth ulcers

There are various causes of mouth ulcers; most single mouth ulcers happen due to things you can try to avoid, like:⁴

• Cheek biting
• ill-fitting braces, uneven fillings, sharp teeth, or dentures
• Cuts or burns from eating or drinking, like hard foods or hot beverages
• Food allergies or intolerances
• Gum damage from brushing too hard or using irritating toothpaste

Sometimes, they can be caused by factors beyond your control, such as:⁴

• Hormonal changes, like during pregnancy
• Genetics: some families are more liable to mouth ulcers
• Vitamin deficiencies, including iron, zinc, folic acid, vitamin B, or vitamin D
• Certain medications, like some NSAIDs, beta blockers, or nicorandil
• Quitting smoking: Some people may experience mouth ulcers when they quit smoking¹⁰

If you have multiple mouth ulcers, it may indicate:⁴

• Hand, foot, and mouth disease, which also causes a rash on hands and feet
• Oral lichen planus, which creates a white, lacy pattern inside the cheeks
• Crohn's disease and coeliac disease, which affect the digestive system
• A weakened immune system due to conditions like HIV or lupus

Symptoms of mouth ulcers

There are a group of symptoms the patient may experience. Mouth sores usually have these features:³

• Red edges
• A centre that is yellow, grey or white

You might have just one ulcer, or you could have several. Other signs may include:³

• Swelling around the sores
• More pain when brushing your teeth
• Increased discomfort when eating spicy, salty, or sour foods

How does smoking affect oral health?

The Effects of Smoking on Oral Mucosa^5,6

• Increased risk of oral diseases: Chronic oral conditions may occur in more than 60% of smokers compared with nonsmokers; the most common chronic oral diseases include stomatitis, cheilitis, and several forms of leukoplakia
• Precancerous condition: With a possibility of malignant transformation, leukoplakia can be considered a premalignant condition. It commonly relates to smokers. The most involved sites are those that usually come in direct contact with tobacco smoke: cheeks, lips, and tongue
• Oral tissue changes: Tobacco smoking leads to thickening of oral mucosa, which then assumes a bluish-red or brownish hue. Over time, there may be an increase in keratinization, or thickening of the outer layer of skin cells. This may offer some protection for a time but also carries the risk of developing into cancer
• Destruction of oral cells: tobacco smoke can be responsible for quicker cell death and desquamation in the oral mucosa. It encourages the growth of fibrotic tissue—that is, thickened scar-like tissue - which weakens the barrier function of the mucosa, making it further vulnerable to infection
• Development of hyperkeratosis: Smokers often develop thickening of the mucosal surface, or hyperkeratosis, which sometimes provides protection against minor injuries but could become precancerous
• Increased oral cancer risk: Chronic smoking exposes the person to a high chance of oral cancers, more so where the smoke usually hits areas such as the tongue, bottom of the mouth, and oropharynx
• Immune response: It inhibits the effectiveness of the general immune response of an individual within the oral cavity; hence, the infection can lead to oral candidiasis
• Reversibility with cessation:  Some lesions, such as the type of leukoplakia, show regression or improvement after smoking cessation. If continued, these may lead to malignant changes

Overall, smoking causes severe injury to the oral mucosa with both immediate and long-term health risks of precancerous lesions and oral cancer.

Diagnosis of mouth ulcers

The diagnosis is based on  the following approaches:³

History taking

Your healthcare provider will take a thorough medical history to identify potential risk factors and symptoms related to the mouth ulcers.

Visual inspection

A medical professional can identify a mouth ulcer by visual inspection. Your doctor could request blood testing if you have a serious outbreak or if you have a particular medical issue.

Management of mouth ulcers

After diagnosing the condition, the aim of the management is based on relieving the symptoms and providing protective strategies.

Treatment options⁴

• Pain killer: you can use over-the-counter medicines that can help in easing pain
• Some medicines: chlorhexidine mouthwash, steroid lozenges, soothing protective pastes, a painkilling oral rinse, gel, or mouth spray

Prevention Strategies

Quitting smoking⁷

It is a cornerstone in dealing with recurrent mouth ulcers. You will notice good changes happen when you stop smoking; your health in general can start to improve practically right away.

Many people attempt to stop smoking on their own, but with the correct support, quitting smoking is quite simple.

There are several resources available to assist you as you begin on your quitting journey. You may wish to think about the side effects and the price of such aids. If you've tried to quit in the past, consider the strategies that worked for you and any changes you might want to make.

The important thing is to keep trying; experiment with different methods until you discover what suits you best.

Good oral hygiene practices

You should brush your teeth as well as you usually do when not experiencing a mouth sore, even though the movement of your mouth tends to cause the pain. Using a gentle brush can help to avoid gum injuries, which may be a risk for new mouth sores.⁸

Cleaning between your teeth can be done in various ways, including using dental floss or an interdental brush. Consult your dentist to help you decide what is best for you.⁸

Also, check the contents of an oral hygiene product: For example, mouthwash containing alcohol can further irritate the pain. Some people also develop sensitive reactions to toothpaste that contains sodium lauryl sulphate.⁸

Regular dental check-ups

Regularly visiting your dentist is essential to follow-up on your oral health.⁹

Summary

Mouth ulcers are painful ulcers that develop on the mucous lining of the mouth, capable of affecting primary areas like the gums, tongue, palate, inner lips, and cheeks. Their types are many: canker sores, leukoplakia, and oral thrush, amongst others, that may result from factors like minor injuries to infections to other underlying body health conditions.

It has to be pointed out that tobacco smoking seriously deteriorates oral health due to a number of conditions like leukoplakia and a heightened risk of oral cancer. More importantly, tobacco smoking turns the mucosa of the oral cavity into thicker tissue, possibly precancerous, and weakens the response of the immune system, which makes the mouth more vulnerable to a candida infection that is more commonly known as oral candidiasis.

Diagnosis usually involves clinical examination, and diagnostic tests may be conducted. Management is mainly symptomatic, with the practice of good oral hygiene, non-irritant oral products, and consultation with a dentist regularly. Stopping smoking is recommended for preventing the recurrence of ulcers and maintaining oral health in general. There are resources and techniques to quit: nicotine replacement therapy.

FAQs

Does smoking cigarettes cause mouth ulcers?

Yes, tobacco smoking causes damage to the mucosa that lines the oral cavity.

Can giving up smoking cause mouth ulcers?

Yes, quitting smoking could cause mouth ulcers.