INTRODUCTION:

Mouth ulcer refers to any damage to the lining of the mouth, such as cuts, dentures, dryness, viruses, and immune-related issues. Recurrent aphthous ulcer (RAU) is the most common type of ulcerative disease, affecting approximately 25% of young adults and an even larger number of children.¹ Oral ulceration (OU) is the most common oral mucosal disease globally²

In the language of dentistry, mouth ulcers are painful mucosal lesions that usually affect the tongue, lip, cheek, or gums. Between 5 and 20% of people in general have mouth ulcers. Mouth ulcer pain and discomfort can make it difficult to speak, eat, drink, brush, breathe, and even speak, which lowers the patient's quality of life and productivity at work even though the lesion is benign and self-healing³ Oral ulceration is defined by a chronic flaw or breakdown in the integrity of the oral epithelium, along with varying degrees of connective tissue loss beneath it, giving the condition a crater-like appearance.⁴ India's ancient science is called Ayurveda. All that Ayurveda defines as health is completely essential. Ayurveda focuses on both curative and preventive measures. Pittaj Mukhapak recurs frequently. Another name for Mukhpak is Sarvasara roga. Mouth ulcers, burning pain, difficulty swallowing food, redness, anxiety, and enlarged lymph nodes associated with fever are the symptoms of stomatitis. Mukhavran has a single or multiple nature. Mouth ulcers have a spherical, whitish-yellow patch with red corners surrounding it. The Charaka lists Mukhapaka as one of the 40 varieties of Nanatmaja pitta rogas. rogas.⁵ Different types of artificial and partially artificial drugs are recommended for treating mouth sores, such as antibiotics and antiseptics, local anesthetics, local pain relievers, steroidal and non-steroidal anti-inflammatory medications. Topical steroids such as triamcenolon and prednisolon are commonly used treatments, but their continuous application can lead to serious side effects like adrenal insufficiency, immuno-suppression, osteoporosis, hyperglycemia, and gastrointestinal disturbance. Additionally, commercially available formulations with synthetic and semi-synthetic active agents may cause local irritation, staining of teeth, and a burning sensation due to their high alcohol concentration and presence of organic compounds.⁶ Since ancient times, humans have utilized herbal remedies in various forms such as powders, decoctions, churnas, and bhasmas as an alternative approach to treatment.⁷

Types of Mouth Ulcers:

Based on how they present and develop, oral ulcers can be categorized as either acute or chronic. Acute ulcers are distinguished by their sudden onset and brief duration, while chronic ulcers are linked to a gradual onset and subtle progression.⁸ Broadly classified based on the duration of their presence.

Acute ulcers:

It including aphthous, herpetic, traumatic, and chancres ulcers, heal on their own and typically last three weeks or less.

Chronic ulcers: that linger for weeks or months include major phaethous ulcers, odontogenic infections, malignant ulcers, gummas, ulcers caused by debilitating systemic diseases, and some traumatic ulcers (with a persistent traumatic element)⁹

Based on the quantity and dimensions of the lesions:

Mouth ulcers types are minor, large, and herpetiform.^10,11

Figure 1: Types of mouth ulcers

Minor ulcers: Minor ulcer Small ulcers usually heal in 10 days to 2 weeks and have a diameter of 2 to 8 mm.

Major ulcers: Major ulcers Larger, deeper ulcers frequently have an uneven or elevated border. They could leave a scar in the mouth and heal slowly.¹²

Herpetiform ulcers: Herpetiform ulcers are a collection of several tiny, pinhead-sized lesions that are grouped together.¹³

Ulcerative Conditions: Ulcerative Conditions: Although mouth ulcers are relatively common, they are mostly caused by trauma from things like badly fitting dentures, broken teeth, or fillings. Patients who have an ulcer that lasts longer than three weeks should have a biopsy or other investigation done to rule out cancer or other serious conditions like persistent infections.¹¹

Etiology of Mouth Ulcer:

It is unclear what exactly causes aphathous stomatitis. Anxiety, hormonal imbalances, mechanical trauma, deficiencies in specific microelements and vitamin B12, elevated oxidative stress, food allergies, microbial factors, systemic diseases like ulcerative colitis, celiac disease, AIDS, and Crohn's disease, are just a few of the causes of aphathous ulcers. (Table-2).^15,16,17

Table 1: Clinical features of ulcer¹⁴

	Minor Ras	Major Ras	Herpetiform Ras
Gender Predilection	Equal	Equal	Female
Morphology	Round or oval lesions Gray-white psuedomembrane. Erythematous halo	Round or oval lesions Gray-white psuedomembrane. Erythematous halo	Small, deep ulcers that commonly converge. Irregular contour
Distribution	Lips, cheeks, tongue, floor of Mouth	Lips, soft palate, pharynx	Lips, cheeks, tongue, floor of mouth, gingiva
Number of ulcers	1–5	1–10	10–100
Size of ulcers	<10mm	>10mm	2–3mm
Prognosis	Lesions resolve in 4–14 days. No scarring	Lesions persist >6 weeks. High risk of scarring	Lesions resolve in <30 days. Scarring uncommon

Table 2: Etiology of Mouth Ulcer

Etiology of Mouth Ulcer	Description
1. Stress	Physiological instability and high stress levels increase the likelihood of ulcer development.
2. Hormonal Changes	The fluctuations in hormones, especially during the menstrual cycle, can result in oral problems like canker sores and bleeding of the gums.
3. Drugs (Medication-Induced)	Some medications, especially NSAIDs like diclofenac, can cause mouth ulcers as a side effect.
4. Allergies and Sensitivities	Aphthous ulcers could result from food allergies.
5. Genetic Predisposition	Family history contributes to about 40% of ulcer cases, particularly serious ulceration.
6. Mechanical Injury	Ulcers can develop due to local trauma, such as dental procedures, sharp teeth, or brushing injuries.
7. Mechanical Trauma	Basically, the Two factors that can lead to recurrent aphthous stomatitis (RAS) are oral mucosal trauma and inadequate saliva.
8. Nutritional Deficiency	RAS development is connected to deficiencies in iron, folic acid, and vitamin B12.^15,18
9. Viral Infections	Herpes Simplex Virus 1 (HSV-1) Primary (HSV-1) The most cause ulcer affected worldwide widespread small superficial ulcers.^19,20 Epstein-Barr Virus (EBV): EBV is associated with conditions such as oral hairy leukoplakia and is capable of inducing white spot mouth sores, particularly in individuals with infectious symptom mononucleosis or weakened immune systems.²¹
10. Fungal Infections	Candida albicans is the frequently occurring fungal species infection that is usually present in the mouth as part of the natural flora, but can become a pathogen in certain circumstancessuch as immune suppression or extended antibiotic treatment. It is the primary reason for fungal infections in the mouth
11. Bacterial Infections	Bacterial infection: ANUG, which stands for Acute Necrotizing Ulcerative Gingivitis, is a bacterial infection that results caused the painful ulcerations of the gums along the gingiva edges. evere ulcerative periodontal disease impacts the gums, associated with factors such as diabetes and smoking. Patients feel pain from small injuries or dental procedures. More frequently seen in women who have gone through menopause, it can appear similar to other conditions. Severe acute necrotizing ulcerative gingivitis results in painful sores, which can lead to complications. Cancrum oris, like ANUG, impacts undernourished people, especially kids in Central Africa as a result of poverty and political turbulence.²²
12. Immune System Dysregulation	Numerous researchers theorize that canker sores are caused by various disease mechanisms, all of which are influenced by the system that protects the body from disease.

Table 3: Recommended management of oral ulceration

Condition Path	Decision Point	Next Step	Outcome
Oral ulceration with pre-existing systemic disease or drug therapy	Is the ulceration an oral manifestation or drug reaction?	Yes	Investigate predisposing disease or the refer to a specialist
		No	Symptomatic treatment or biopsy
Previously healthy individual	Does the ulcer arise de novo (primary ulcer)?	Yes	Treat underlying cause or biopsy if persistent
Vesicles or bullae present	Is the ulcer febrile with constitutional upset?	Yes	Probable viral, symptomatic treatment
		No (afebrile)	Investigate for dermatosis or refer for specialist investigation
Recurrent ulcers	Typical aphthous stomatitis	Treat	Resolution or refer if refractory/change in disease pattern
	Not aphthous stomatitis	Refer to specialist	Investigation or treatment
Persistent ulcers	Local cause present	Remove cause	Resolution or biopsy if no resolution
	No local cause	Biopsy	Further investigation or refer

Table 4: Stages of mouth ulcer heals

Stages	Description
1. Hemostasis	Initial response to blood vessel injury; exposure of subendothelial ECM activates platelets, initiating the hemostatic cascade.
2. Inflammation	Peaks intensity reaches with in 24–48 hours after injury, persisting for several days; inflammation recruits immune cells and enhances vascular permeability.
3. Proliferation	Characterized by the replacement of fibrin clot with granulation tissue, driven by regenerative growth factors.
4. Maturation	Final phase, where granulation tissue remodels into a denser ECM, restoring homeostasis over time.

Medical Treatment:

A common inflammatory lesion in the oral mucosa, chronic recurrent oral aphthous ulcers affect 2–10% of Caucasians. As part of treatment, hard, acidic, and salty foods as well as specific toothpastes and drinks must be avoided. In Germany, corticosteroids, topical antiseptics, and local anesthetics are approved forms of treatment. Although their effectiveness is debatable, systemic medications like colchicine or prednisolone may be taken into consideration for severe cases.²⁷ The use of herbal remedies for mouth ulcers, highlighting their cultural significance in India and their benefits over synthetic drugs because they have fewer adverse effects. According to this definition, mouth ulcers are common disorders that affect the oral mucosal membrane and are indicated by open sores. Herbal gels and flavonoid-rich herbs that are commonly used medicinally.²⁸ The herbal plant's Polyconstitutients are abundant in anti-oxidant properties. Because of their antioxidant properties, a large number of research studies have been launched on medicinal plants. The antioxidant activities of phenolic compounds are attributed to them treat stomach, oral ulcer.²⁹

Conventional Treatments:

Topical Medications for Mouth Ulcers: Topical corticosteroids are the anti-inflammatory medications most frequently used to treat inflammations of the oral cavity.³⁰ Multiple approaches can be used to treat recurrent phathous stomatitis: topical anesthetic preparations such as lidocaine with diphenhydramine, dyclonine hydrochloride, and benzocaine, as well as systemic and topical corticosteroids. Laser therapy is another option. Cuticle atrophy and oral candidiasis are two possible adverse effects of topical corticosteroids.^31,32

Oral Rinses: Oral rinses, sprays, and gels containing benzodamine are commercially available. Because of the short contact time of these formulations with the affected area, it is necessary to extend the duration of treatment, requiring frequent application (4-6 times daily). Additionally, the buccal cavity's constant salivary flow and tongue movement.³³

Pain Relief: A chemical derivative of first-generation tetracyclines is doxycycline, an antibiotic. Because it binds to the 30S ribosomal subunit of both gram-positive and gram-negative bacteria, it has a broad-spectrum bacteriostatic action that prevents bacterial protein synthesis.^34,35 NSAIDs such as indomethacin and aspirin are frequently prescribed to treat arthritis, offer cardiovascular protection, and reduce inflammation. The gastric disturbances like ulcers and erosions are the complications that result from this usage. Gastric complications are experienced by one quarter of NSAID users. The development of these complications appears to occur because of their effect on COX (cyclo-oxygenase) inhibition and prostaglandin (PG) deficiency in the body. PGs are essential in the protection of the mucosal defense system.³⁶

Importance of Herbal Medicine:

The comparison to chemical medications, the herbal medicines which is simple to use, require no processing, and have very few side effects.³⁷ The only the reliable source of affordable drugs that can keep up with the world's growing population is herbal medicine, which functions as a reversible source. Herbal products and medicinal plant cultivation are environmentally benign and sustainable processes. Many of the most advantageous, practical, and varied drugs used in modern medicine today have their roots in herbal medicine.²⁸ Recent chemical and pharmacological developments have enhanced understanding of new therapeutically active compounds derived from natural sources. These compounds can serve as starting points for creating new drugs or as tools for identifying other effective compounds. These items have the potential to save lives entirely or enhance the quality of life in chronic illnesses.³⁸

Advantages of Herbal Medicine:

Herbal remedies have been utilized for an extended period and are more readily accepted by patients and the public. Medical plants offer a replenishable source, enabling us to maintain sustainable access to affordable medications for the increasing global population.³⁹

Several herbal plants have also demonstrated anti-ulcer properties.^37,40

Figure 2: Advantages of Herbal Medicine

The Study of Specific Herbal Plants for the Treatment of Mouth Ulcers:

Table 5: Herbal Plants for the Treatment of Mouth Ulcers

S. No.	Herbs	Plant	Scientific Name	Family	Chemical Constituents	Additional Uses	Ref.
1.	Aloe vera	Figure 3:	Aloe Barbadensis	Family: Liliaceae	Polysaccharides, monosaccharides, saponins, anthraquinones, lignins, enzymes, sterols, and vitamins and minerals	anti-inflammatory anti-ulcer, healing, anti-diabetic, antioxidant and anti-cancer	18, 41, 42
2.	Guava leaves, (Amrood)	Figure 4:	Psidium guajava	Family: Myrtaceae	Saponin, oleanolic acid tannins, flavonoids (Quercetin and its glycosides), and tannis.	analgesic, antispasmodic, anthelmintic, antimalarial, and antiulcer	18,43
3.	Propolis	Figure 5:	Apis mellifera	Family- Rhytisma taceae	Phenol, minerals, sugars, Resin, oil and wax, pollen) acids, vitamins B, C and E, flavonoids, terpenes and aminoacid	Beewax/ resin Anti-inflammatory, Antioxidant, Immunostimulant, Wound healing, Antibacterial, Antiviral, Antifungal, Antitumor	17, 44–46 47
4.	Capsicum	Figure 6:	Capsicum annuum L.	Family - Solanaceae	Capsaicin, oleoresin, paprika and dihydrocapsaicin	Mouth ulcer, GI disorder include stomachcramps, stomach pain, diarrhoea among others	11,28
5.	Chamomilla (Matricaria Chamomilla)	Figure 7:	Matricaria chamomilla L.	Family- Daisy	Chamazulene, αbisabolol oxide A,α-bisabolol oxide B,αbisabolone oxide A, βbisabolene, α-bisabolol, α farnesene, β farnesene.	flavonoids, terpenes, coumarins, volatile oils, sterols, organic acids, and polysaccharides, among other compounds	17, 48, 49 50
6.	Papaya	Figure 8:	Carica papaya L	Family: Caricaceae	Papain, chymopapain, carotenoids, pectin, carposide, carpaine, and the antheraxanthin. Vitamin A, vitamin B, vitamin C	Papaya contains enzymes like papain that may help in reduce the inflammation and promote wound healing	23,51, 52
7.	Lady mantle	Figure 9:	Alchemilla vulgaris	Family: Rosaceae	Rutin, hyperoside, ellagic acid, luteolin, kaempferol, morin, quercetin isoquercetin, luteolin-7-O-glucoside kaempferol-3-O-glucoside (7), apigenin-7-O-glucoside, and tiliroside	Wound healing, treat mouth ulcer	17,53
8.	Custard apple (Sitapalam)	Figure 10:	Annona squamosa	Family: Annonaceae	Alkaloids, saponins, tannins, Seeds, flavonoids, and resin; seeds, leaves, and immature fruit containgthe acrid principle	diabetic patients and preventing chronic hyperglycemia-induced platelet malfunction	23,54, 55
9.	TULSI: Holy basil	Figure 11:	Ocimum sanctum linn	Family: lamiaceae.	Essentialoils, beta- caryophyllene, methyl chavical, linalool eugenol, methyl, and 1,8-cineole	anti-microbial, Antioxidant, anti-inflammatory, anti-ulcer, Anti-helminthic, anti-pyretic, immune stimulant,	45, 56–58
10	Neem margosa, indian Lilac	Figure 12:	Azadirachta indica	Family: Meliaceae	Quercetin, nimbin, DPPH, nimbosterol, kaempferol nimbosterol, nimbidin, nimbosterol, Azadirachtin, vepinin, Azadiradione, gueraceatin, ascorbic acid, amino acid, polyphenolic flavonoids.	Anti ulcer Antifungal, Antihyperglycemic Anticarcinogenic, Anti oxidant, anti mutagenic, Anti bacterial, Antiviral, anti-inflammatory	11,59, 60

CONCLUSION:

Herbal plant medicine is a natural remedy for mouth ulcers with proven benefits. Traditional therapies like corticosteroids can have adverse effects, high costs, and the limited availability. On the other hand, herbs like licorice and aloe vera and others herbs offering the healing properties with fewer negative reactions. Their use aligns with both traditional and modern medicine practices, providing effective relief with minimal side effects. More research is needed to confirm their efficacy, but incorporating herbal treatments into healthcare protocols can expand options for treating the mouth ulcers and improve overall patient well-being

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Received on 15.10.2024 Revised on 14.11.2024

Accepted on 10.12.2024 Published on 05.03.2025

Available online from March 11, 2025

Res. J. Pharmacognosy and Phytochem. 2025; 17(1):49-55.

DOI: 10.52711/0975-4385.2025.00009

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