CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Mouth ulcers, also known as aphthous ulcers or canker sores, are a prevalent oral health issue characterized
by painful sores on the mucous membranes inside the mouth. These lesions typically present as round or oval
sores with a white or yellowish center and a red border, causing significant discomfort and impacting daily
activities such as eating, speaking, and swallowing (Scully & Porter, 2018). These ulcers can occur as single or
multiple lesions and can range from minor to severe, with recurrent cases being particularly challenging for
affected individuals.

The etiology of mouth ulcers is multifactorial, with potential causes including local trauma, stress, hormonal
changes, nutritional deficiencies (particularly vitamins B12, folate, and iron), food allergies, and underlying
systemic conditions such as celiac disease, Crohn's disease, and Behçet's disease (Sreebny, 2010; Field &
Longman, 2015). In some cases, mouth ulcers may also be associated with viral infections like herpes simplex
or be drug-induced (Alpsoy et al., 2017). There is also evidence suggesting a genetic predisposition to
recurrent aphthous stomatitis, indicating that hereditary factors may play a significant role (Porter & Scully,
2016).

The incidence and management of mouth ulcers can vary significantly across different populations and
healthcare settings. Babcock Teaching Hospital, located in Ilishan-Remo, Ogun State, serves a diverse patient
population, providing an excellent setting for studying the incidence and management of mouth ulcers. The
hospital is part of Babcock University, a well-known institution for its healthcare services and academic
excellence. Despite the prevalence of mouth ulcers, there is a lack of comprehensive data on their
occurrence, causes, and treatment outcomes in this specific geographicand demographic context. Studies
conducted in other regions have shown varying prevalence rates, suggesting the influence of local factors
such as diet, socio-economic status, and healthcare access (Ship et al., 2018).

In Nigeria, the understanding and management of oral health issues, including mouth ulcers, are still
evolving. Limited research has been conducted on the prevalence and causes of mouth ulcers among adults
in the country, particularly in Ogun State. This gap in knowledge can hinder the development of effective
prevention and management strategies, potentially leading to prolonged patient discomfort and
complications (Arowojolu et al., 2019). Additionally, there is a need to assess whether cultural practices and
local dietary habits contribute to the occurrence of mouth ulcers in this region.

Effective management of mouth ulcers requires accurate diagnosis and tailored treatment strategies.
Common treatments include topical agents such as corticosteroids and antimicrobial mouthwashes, systemic
medications for underlying conditions, and dietary modifications to address nutritional deficiencies (Barrons,
2015). Recent advancements in treatment also explore the use of laser therapy and newer pharmacological
agents, which promise better outcomes for patients with recurrent and severe cases (Ylikontiola et al., 2020).
Evaluating the effectiveness of these treatments in the context of Babcock Teaching Hospital can provide
valuable insights into optimizing patient care.
Understanding the impact of mouth ulcers on patients' quality of life is also crucial. These sores can
significantly affect daily functioning and psychological well-being, leading to increased stress and reduced
productivity (Epstein et al., 2016). Chronic pain and discomfort can also lead to secondary issues such as
malnutrition and weight loss due to difficulties in eating (Jurge et al., 2018). Assessing these impacts within
the Babcock Teaching Hospital patient population can help in developing comprehensive care plans that
address both the physical and emotional aspects of the condition.

Given the importance of oral health to overall well-being and the potential complications associated with
untreated mouth ulcers, this study aims to fill the existing knowledge gaps by investigating the prevalence,
causes, treatment protocols, and impacts of mouth ulcers in adults at Babcock Teaching Hospital. The
findings will contribute to the improvement of healthcare services and patient outcomes in this region. This
study will also provide a foundation for future research and policy development in the management of oral
health issues in Nigeria.

1.2 STATEMENT OF THE PROBLEM

Despite being common, mouth ulcers are often underreported and inadequately managed in many
healthcare settings. There is limited data on the prevalence and causes of mouth ulcers among adults in
Nigeria, particularly in Ogun State. Additionally, the effectiveness of current treatment protocols and their
impact on patients' quality of life have not been thoroughly. This gap in knowledge can hinder the
development of effective prevention and management strategies, potentially leading to prolonged patient
discomfort and complications.

1.3 RESEARCH OBJECTIVES

1.3.1 BORAD OBJECTIVES

Investigating the mouth ulcer in adults at Babcock Teaching Hospital, located in Ilishan-Remo, Ogun
State, Nigeria.

1.3.2 SPECIFIC OBJECTIVE

The primary objectives of this study are:

1. To identify the prevalence of mouth ulcers in adults at Babcock Teaching Hospital.

2. To analyze the common causes of mouth ulcers in this population.

3. To evaluate the treatment protocols used and their effectiveness.

4. To assess the impact of mouth ulcers on the quality of life of the affected individuals.

5. To propose recommendations for better management and prevention of mouth ulcers.

1.4 RESEARCH QUESTIONS

This study aims to address the following research questions:

1. What is the prevalence of mouth ulcers among adults at Babcock Teaching Hospital?

2. What are the common causes of mouth ulcers in this population?

3. How effective are the current treatment protocols used at Babcock Teaching Hospital?

4. What impact do mouth ulcers have on the quality of life of affected individuals?

5. What recommendations can be made for the improved management and prevention of mouth ulcers?

1.5 SIGNIFANCE OF THE STUDY

icThis study is significant for several reasons:

Healthcare Improvement: By identifying the prevalence and causes of mouth ulcers, the study can inform
better diagnostic and treatment protocols, improving patient care.

Public Health Policy: Insights from this study can help in formulating public health policies and preventive
strategies to reduce the incidence of mouth ulcers.

Academic Contribution: The study will add to the existing body of knowledge on oral health, particularly in
the Nigerian context, serving as a reference for future research.

Patient Welfare: Understanding the impact of mouth ulcers on quality of life can lead to more holistic patient
care, addressing both physical and psychological aspects.

1.6 SCOPE OF THE STUDY

The study will focus on adults who seek medical attention for mouth ulcers at Babcock Teaching Hospital. It
will include patients from various demographics and socio-economic backgrounds to ensure a comprehensive
understanding of the issue. Data collection will involve both clinical assessments and patient interviews,
covering a period of six months to capture sufficient cases for analysis.

1.7 DEFINITION OF TERMS

Mouth Ulcer: A sore or open lesion in the mouth, also known as an aphthous ulcer or canker sore.

Prevalence: The proportion of a population found to have a condition at a specific time.

Etiology: The cause or origin of a disease or condition.

Quality of Life: The general well-being of individuals, encompassing physical, psychological, and social
aspects.

Treatment Protocol: A standard procedure for the treatment of a medical condition.

 CHAPTER TWO

LITERATURE REVIEW

2.1 CONCEPT OF MOUTH ULCERS

The study of mouth ulcers, particularly in adults, encompasses a broad array of research areas including
epidemiology, pathophysiology, clinical features, and management strategies. Mouth ulcers are a common
clinical condition that can cause significant morbidity. They are frequently seen in clinical practice, yet their
exact etiology remains unclear in many cases. This chapter reviews the existing literature on mouth ulcers,
with a particular focus on their prevalence, causes, diagnosis, treatment options, and impacts on quality of
life. Additionally, it seeks to identify gaps in the current body of knowledge, especially as it pertains to the
Nigerian context and Babcock Teaching Hospital in Ilishan-Remo, Ogun State.

2.2 PREVALENCE OF MOUTH ULCERS

Mouth ulcers are widely recognized as a common condition affecting a significant portion of the population
at various stages of life. Global prevalence rates suggest that about 20% of the population will experience
mouth ulcers at some point in their lives (Scully & Porter, 2018). These prevalence rates, however, vary
significantly depending on the population studied and the diagnostic criteria used. For instance, Shulman et
al. (2004) reported a prevalence of 4.1% in a study of U.S. adults, while a study in India reported a higher
prevalence rate of 25% (Patil et al., 2014).

In Nigeria, epidemiological data on mouth ulcers is limited. Arowojolu et al. (2019) found that the prevalence
of recurrent aphthous stomatitis (RAS) in a Nigerian professional group was 7%, but this may not be
representative of the broader population. This disparity underscores the need for more comprehensive,
population-based studies in different regions and demographics within Nigeria to better understand the
prevalence and distribution of mouth ulcers.

Mouth ulcers are a prevalent condition affecting a substantial portion of the global population. The
prevalence varies significantly across different regions, populations, and age groups. This section delves
deeper into the prevalence of mouth ulcers, exploring various studies conducted worldwide, with a particular
focus on different demographic and geographic variations.

Globally, mouth ulcers, particularly recurrent aphthous stomatitis (RAS), affect approximately 20% of the
population at some point in their lives (Scully & Porter, 2018). This figure, however, varies widely in different
studies due to differences in diagnostic criteria, population characteristics, and study methodologies. For
example, Shulman et al. (2004) reported a prevalence of 4.1% in U.S. adults based on data from the Third
National Health and Nutrition Examination Survey (NHANES III), conducted from 1988 to 1994.

Prevalence in Specific Regions

1. United States: According to Shulman et al. (2004), the prevalence of oral mucosal lesions, including mouth
ulcers, was found to be 4.1% in the U.S. adult population. Another study by Rivera-Hidalgo et al. (2004)
corroborated these findings, reporting a prevalence rate of 5%.
2. Europe: In Europe, prevalence rates also vary. A study in the UK found that 25% of the population
experienced mouth ulcers at some point in their lives, with recurrent cases being reported in about 10% of
the population (Scully & Porter, 2018). Similarly, a study in Italy reported a prevalence of 19% among
university students (Migliario et al., 2006).

3. Africa: In Africa, prevalence data is sparse, but available studies suggest a wide range of prevalence rates.
For instance, a study in Sudan reported a prevalence of 8.5% among dental patients (Osman et al., 2010). In
Nigeria, a study by Arowojolu et al. (2019) reported a prevalence of 7% among a professional group,
indicating the need for more extensive research across diverse populations.

Age and Gender Differences

Prevalence of mouth ulcers also varies with age and gender. Generally, mouth ulcers are more common in
younger individuals and tend to decrease with age (Scully & Porter, 2018). Women are slightly more affected
than men, which may be attributed to hormonal influences, particularly during menstrual cycles and
pregnancy (Field & Longman, 2015).

1. Children and Adolescents: Mouth ulcers are particularly common in children and adolescents. Studies
suggest that up to 40% of school-aged children may experience mouth ulcers (Khandwala et al., 2009). The
prevalence tends to peak in the second decade of life and gradually decreases with age.

2. Adults: Among adults, the prevalence is generally lower but still significant. Recurrent aphthous stomatitis
is reported in approximately 10% of adults, with a slightly higher prevalence in women (Scully & Porter,
2018).

3. Elderly: In the elderly population, the prevalence of mouth ulcers decreases. However, the presence of
underlying systemic conditions and the use of multiple medications can contribute to the occurrence of oral
ulcers in this age group (Ship et al., 2018).

Socioeconomic and Lifestyle Factors

Socioeconomic status and lifestyle factors also influence the prevalence of mouth ulcers. Individuals from
lower socioeconomic backgrounds may have higher prevalence rates due to factors such as poor nutrition,
inadequate oral hygiene, and limited access to healthcare (Field & Longman, 2015). Stress, smoking, and
dietary habits are also significant contributors to the development of mouth ulcers. For instance, studies have
shown that stress and smoking can exacerbate the frequency and severity of ulcers (Jurge et al., 2018).

Prevalence In Special Populations

Certain populations are at a higher risk of developing mouth ulcers due to specific risk factors or underlying
conditions:

1. Patients with Systemic Diseases: Individuals with systemic conditions such as Crohn's disease, celiac
disease, and Behçet's disease are more prone to recurrent mouth ulcers. Studies have shown that the
prevalence of mouth ulcers in these populations can be as high as 30% to 60% (Field & Longman, 2015).
2. HIV/AIDS Patients: Mouth ulcers are common in patients with HIV/AIDS due to immunosuppression and
the higher susceptibility to opportunistic infections. The prevalence in this group can range from 10% to 50%,
depending on the stage of the disease and the level of immunosuppression (Scully & Porter, 2018).

3. Chemotherapy and Radiation Therapy Patients: Patients undergoing chemotherapy or radiation therapy
for cancer treatment often experience mouth ulcers as a side effect of the treatment. The prevalence in this
group can be as high as 40% to 80%, significantly impacting their quality of life (Epstein et al., 2016).

2.3 ETIOLOGY OF MOUTH ULCERS

The etiology of mouth ulcers is complex and multifactorial, encompassing a wide range of potential causes.
Understanding these underlying factors is crucial for effective diagnosis, management, and prevention. This
section provides an in-depth analysis of the various etiological factors associated with mouth ulcers.

2.3.1 Local Trauma

Local trauma is one of the most common causes of mouth ulcers. Mechanical injuries to the oral mucosa can
occur from accidental cheek or tongue biting, the use of orthodontic appliances, ill-fitting dentures, or even
aggressive tooth brushing. These injuries can lead to the development of ulcers by disrupting the mucosal
barrier and initiating an inflammatory response (Sreebny, 2010).

2.3.2 Systemic Conditions

Mouth ulcers are often associated with a variety of systemic diseases and conditions. Some of the most
significant include:

Gastrointestinal Diseases: Conditions such as Crohn's disease and celiac disease are frequently linked with
mouth ulcers. In Crohn's disease, the ulcers are often deep and resemble those found in the gastrointestinal
tract (Zhang et al., 2015). Celiac disease, a gluten-sensitive enteropathy, can also present with recurrent
aphthous stomatitis (RAS) as an extraintestinal manifestation (Lebwohl et al., 2018).

Autoimmune Disorders: Autoimmune diseases, including systemic lupus erythematosus (SLE) and Behçet's
disease, can cause recurrent mouth ulcers. In SLE, ulcers are often painless and occur on the hard palate (Lam
& Leong, 2014). Behçet's disease is characterized by multiple, painful ulcers that recur frequently and can
affect other mucosal surfaces and skin (Yurdakul & Yazici, 2017).

Hematological Disorders: Blood disorders such as iron deficiency anemia, vitamin B12 deficiency, and folate
deficiency can lead to the development of mouth ulcers. These deficiencies impair the integrity of the oral
mucosa and the immune system, making individuals more susceptible to ulcer formation (Field & Longman,
2015).

2.3.3 Immunological Factors

The immune system plays a critical role in the pathogenesis of mouth ulcers, particularly in cases of recurrent
aphthous stomatitis (RAS). Several immunological abnormalities have been identified:
T-Cell Mediated Response: RAS is associated with an abnormal T-cell mediated immune response. This
includes an imbalance between helper T cells (Th1 and Th2) and an increase in cytotoxic T cells, which leads
to mucosal damage (Scully & Porter, 2018).

Cytokine Imbalance: Elevated levels of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-
α), interleukin-6 (IL-6), and interleukin-1 beta (IL-1β) have been found in patients with RAS. These cytokines
contribute to the inflammatory process and the formation of ulcers (Alpsoy et al., 2017).

2.3.4 Nutritional Deficiencies

Nutritional deficiencies are well-established risk factors for mouth ulcers. Key deficiencies include:

Iron: Iron deficiency, even in the absence of anemia, can lead to mouth ulcers. Iron is essential for
maintaining the health of epithelial cells, and its deficiency can compromise mucosal integrity (Porter &
Scully, 2016).

Vitamin B12: Vitamin B12 is crucial for DNA synthesis and the maintenance of nervous system health. Its
deficiency can result in megaloblastic anemia and neurological symptoms, including mouth ulcers (Field &
Longman, 2015).

Folate: Folate deficiency, similar to vitamin B12 deficiency, affects DNA synthesis and cell division. This
deficiency is commonly seen in populations with poor dietary intake and can lead to ulcer formation
(Barrons, 2015).

2.3.5 Genetic Predisposition

Genetic factors also play a significant role in the development of mouth ulcers, particularly RAS. Studies have
shown that individuals with a family history of RAS are more likely to develop the condition themselves.
Genetic studies have identified several potential susceptibility loci, including certain human leukocyte antigen
(HLA) types that may predispose individuals to RAS (Porter & Scully, 2016).

HLA Association: Specific HLA types, such as HLA-B12 and HLA-DR2, have been associated with an increased
risk of RAS. These genetic markers are thought to influence the immune response and the propensity for
developing mucosal ulcers (Scully & Porter, 2018).

Genetic Polymorphisms: Variations in genes involved in immune regulation and mucosal integrity, such as
TNF-α and interleukin-1 (IL-1), have been implicated in the susceptibility to mouth ulcers (Shulman et al.,
2004).

2.3.6 Infectious Agents

Certain infectious agents have been proposed as potential triggers for mouth ulcers, although the evidence is
not conclusive.
Viral Infections: Herpes simplex virus (HSV) is known to cause herpetic stomatitis, which presents with painful
ulcers. Other viruses, such as cytomegalovirus (CMV) and varicella-zoster virus (VZV), can also cause oral
ulcerations, particularly in immunocompromised individuals (Jurge et al., 2018).

Bacterial Infections: Although less common, bacterial infections such as those caused by Streptococcus
species can lead to ulcerative lesions in the oral cavity. Secondary bacterial infections can complicate existing
ulcers and delay healing (Field & Longman, 2015).

2.3.7 Hormonal Factors

Hormonal changes, particularly in women, have been associated with the occurrence of mouth ulcers.
Fluctuations in estrogen and progesterone levels during the menstrual cycle, pregnancy, and menopause can
influence mucosal immunity and increase susceptibility to ulcer formation (Jurge et al., 2018).

Menstrual Cycle: Many women report the onset or worsening of mouth ulcers during the luteal phase of their
menstrual cycle when progesterone levels are high (Field & Longman, 2015).

Pregnancy: Pregnancy-related hormonal changes can also predispose women to mouth ulcers, although the
exact mechanisms are not fully understood (Scully & Porter, 2018).

2.3.8 Environmental Factors

Environmental factors, including tobacco use, alcohol consumption, and exposure to certain chemicals, can
also contribute to the development of mouth ulcers.

Tobacco Use: Smoking and the use of smokeless tobacco products can cause direct mucosal injury and
increase the risk of ulcer formation (Jurge et al., 2018).

Alcohol Consumption: Excessive alcohol intake can irritate the oral mucosa and disrupt its integrity, leading
to ulcers (Scully & Porter, 2018).

Chemical Exposure: Exposure to certain chemicals and irritants, such as those found in some occupational
settings, can cause mucosal damage and ulcers (Field & Longman, 2015).

2.4 DIAGNOSIS OF MOUTH ULCERS

Diagnosing mouth ulcers involves a combination of clinical evaluation, patient history, and, when necessary,
laboratory tests. Accurate diagnosis is essential to distinguish between different types of ulcers and to
identify any underlying conditions that may be contributing to their occurrence. This section explores the
comprehensive approach to diagnosing mouth ulcers.

2.4.1 Clinical Evaluation

The initial step in diagnosing mouth ulcers is a thorough clinical evaluation. This includes a detailed
examination of the oral cavity and an assessment of the ulcer's characteristics:

Appearance and Location: Clinicians evaluate the ulcer's size, shape, color, and location within the oral cavity.
Common characteristics include round or oval ulcers with a white or yellowish center and a red halo. Ulcers
can be found on the mucosal surfaces such as the inside of the cheeks, lips, tongue, floor of the mouth, and
soft palate (Porter & Scully, 2016).

Number and Distribution: The number of ulcers and their distribution can provide diagnostic clues. Single
ulcers are often traumatic, while multiple ulcers may indicate conditions like recurrent aphthous stomatitis
(RAS) or systemic diseases (Field & Longman, 2015).

Pain and Duration: Assessing the level of pain and the duration of the ulcer is crucial. Painful ulcers that last
for more than two weeks may warrant further investigation for potential underlying systemic causes or
malignancies (Scully & Porter, 2018).

2.4.2 Patient History

A comprehensive patient history is vital for diagnosing mouth ulcers. Key aspects include:

Medical History: A detailed medical history helps identify any systemic conditions, such as gastrointestinal
diseases, autoimmune disorders, or hematological abnormalities, that may be associated with mouth ulcers
(Sreebny, 2010).

Family History: A family history of similar ulcers can suggest a genetic predisposition, particularly in cases of
recurrent aphthous stomatitis (Porter & Scully, 2016).

Diet and Nutrition: Evaluating the patient's diet and nutritional status can reveal deficiencies in vitamins and
minerals, such as iron, vitamin B12, and folate, which are linked to mouth ulcers (Field & Longman, 2015).

Lifestyle Factors: Information on smoking, alcohol consumption, stress levels, and oral hygiene practices can
provide insights into potential contributing factors (Barrons, 2015).

Medication History: Reviewing current and past medications can identify drugs that may cause or exacerbate
mouth ulcers, such as NSAIDs, beta-blockers, and chemotherapeutic agents (Jurge et al., 2018).

Allergies and Sensitivities: Documenting any known allergies or sensitivities, including food, medication, and
dental products, can help identify potential triggers (Field & Longman, 2015).

2.4.3 Laboratory Tests

Laboratory tests are often employed to confirm the diagnosis and identify underlying causes when the clinical
evaluation and patient history suggest systemic involvement or when ulcers do not respond to standard
treatments:

Blood Tests: Common blood tests include a complete blood count (CBC), iron levels, vitamin B12 and folate
levels, and inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).
These tests help detect hematological disorders, nutritional deficiencies, and inflammatory conditions (Porter
& Scully, 2016).

Serological Tests: Serological tests can identify specific autoimmune conditions. For instance, tests for
antinuclear antibodies (ANA), anti-dsDNA antibodies, and anti-SSA/Ro antibodies can help diagnose systemic
lupus erythematosus and Sjogren's syndrome (Lam & Leong, 2014).
Microbiological Tests: Swabs or biopsies of the ulcer may be taken to identify bacterial, viral, or fungal
infections. Polymerase chain reaction (PCR) tests can detect viral DNA, such as herpes simplex virus (HSV) or
cytomegalovirus (CMV) (Jurge et al., 2018).

Biopsy: A biopsy may be necessary for persistent or atypical ulcers to rule out malignancies or specific
diseases such as oral lichen planus or pemphigus vulgaris. Histopathological examination can provide
definitive diagnostic information (Scully & Porter, 2018).

Endoscopy and Imaging: In cases where gastrointestinal diseases are suspected, endoscopic examination of
the gastrointestinal tract may be recommended. Imaging studies such as X-rays, MRI, or CT scans can be used
to investigate any associated systemic conditions (Zhang et al., 2015).

2.4.4 Differential Diagnosis

Differential diagnosis is crucial to distinguish mouth ulcers from other similar-appearing oral lesions. Some
conditions that must be considered include:

Herpetic Stomatitis: Caused by the herpes simplex virus, these ulcers are typically multiple and present with
systemic symptoms such as fever and lymphadenopathy. They are often preceded by vesicles (Jurge et al.,
2018).

Oral Candidiasis: This fungal infection presents with white patches that can be wiped off, leaving a red,
sometimes ulcerated surface underneath. It is common in immunocompromised individuals (Sreebny, 2010).

Erythema Multiforme: This condition presents with target lesions on the skin and mucous membranes,
including the mouth, often following an infection or medication exposure (Field & Longman, 2015).

Oral Lichen Planus: This chronic inflammatory condition presents with reticular, white, lace-like patterns on
the mucosa, often accompanied by painful erosions or ulcers (Porter & Scully, 2016).

Pemphigus Vulgaris: An autoimmune blistering disorder that causes painful, persistent ulcers and erosions in
the mouth and other mucosal surfaces. It is confirmed by biopsy and immunofluorescence studies (Lam &
Leong, 2014).

Squamous Cell Carcinoma: Persistent, non-healing ulcers in the mouth, especially in high-risk individuals (e.g.,
smokers, heavy alcohol users), may indicate oral cancer and require biopsy for confirmation (Scully & Porter,
2018).

2.5 TREATMENT OF MOUTH ULCERS

Effective treatment of mouth ulcers depends on accurate diagnosis and understanding of the underlying
cause. Treatment strategies aim to reduce pain, promote healing, and prevent recurrence. This section
explores various treatment modalities for mouth ulcers, including topical treatments, systemic medications,
and adjunctive therapies.

2.5.1 Topical Treatments

Topical treatments are often the first line of therapy for mouth ulcers due to their direct application to the
affected area, minimizing systemic side effects.

Topical Corticosteroids: Topical corticosteroids are commonly used to reduce inflammation and pain.
Examples include triamcinolone acetonide, fluocinonide gel, and hydrocortisone ointment. These agents are
applied directly to the ulcer to reduce local inflammation and expedite healing (Barrons, 2015).

Topical Anesthetics: Agents such as benzocaine, lidocaine, and tetracaine provide temporary pain relief by
numbing the ulcerated area. These are often used before meals to reduce discomfort during eating (Jurge et
al., 2018).

Antimicrobial Mouthwashes: Antimicrobial mouthwashes, including chlorhexidine gluconate and

cetylpyridinium chloride, help prevent secondary bacterial infections and reduce inflammation. They are
particularly useful in cases of multiple or recurrent ulcers (Sreebny, 2010).

Barrier Pastes and Gels: Protective barrier pastes and gels, such as carboxymethylcellulose paste and
hyaluronic acid gels, form a protective coating over the ulcer, shielding it from irritants and promoting
healing (Field & Longman, 2015).

Topical Immunomodulators: Medications like amlexanox paste and tacrolimus ointment can be used to
modulate the local immune response and reduce the severity of ulceration, particularly in cases of recurrent
aphthous stomatitis (Porter & Scully, 2016).

2.5.2 Systemic Medications

Systemic medications are considered when topical treatments are insufficient, particularly in severe or
refractory cases, or when ulcers are associated with systemic conditions.

Systemic Corticosteroids: Oral corticosteroids, such as prednisone, are used for severe or extensive ulcers,
particularly those associated with autoimmune conditions. These medications reduce systemic inflammation
and can significantly improve symptoms (Alpsoy et al., 2017).

Immunosuppressants: For chronic or severe cases not responsive to corticosteroids, immunosuppressive

agents such as azathioprine, methotrexate, and cyclosporine may be prescribed. These medications suppress
the overactive immune response contributing to ulcer formation (Scully & Porter, 2018).

Thalidomide: Thalidomide is effective in treating severe recurrent aphthous stomatitis, particularly in HIV-
positive patients. However, its use is limited by significant side effects and teratogenic potential, requiring
careful monitoring (Field & Longman, 2015).

Colchicine: Colchicine, traditionally used for gout, has shown efficacy in reducing the frequency and severity
of recurrent aphthous ulcers. It works by reducing inflammation and altering immune responses (Barrons,
2015).

Biologic Agents: In cases of severe autoimmune-related ulcers, biologic agents such as tumor necrosis factor-
alpha (TNF-α) inhibitors (e.g., infliximab, etanercept) are used. These agents target specific components of
the immune system, reducing inflammation and promoting healing (Porter & Scully, 2016).
2.5.3 Adjunctive Therapies

Adjunctive therapies support the primary treatment modalities and contribute to overall oral health and
ulcer management.

Nutritional Supplementation: Addressing nutritional deficiencies through dietary modifications or

supplementation is crucial. Iron, vitamin B12, and folate supplements are commonly prescribed for patients
with identified deficiencies (Field & Longman, 2015).

Oral Hygiene Practices: Maintaining good oral hygiene helps prevent secondary infections and reduces the
risk of new ulcers. Patients are advised to use soft-bristled toothbrushes, avoid toothpaste with sodium lauryl
sulfate, and rinse their mouth with saline or antimicrobial solutions (Sreebny, 2010).

Stress Management: Psychological stress is a known trigger for mouth ulcers. Stress management techniques,
including cognitive-behavioral therapy, relaxation exercises, and mindfulness, can help reduce the frequency
and severity of ulcers (Jurge et al., 2018).

Avoidance of Triggers: Identifying and avoiding known triggers such as certain foods, medications, and oral
products can help prevent ulcer recurrence. Patients may be advised to keep a food diary to identify potential
dietary triggers (Scully & Porter, 2018).

Laser Therapy: Low-level laser therapy (LLLT) has been shown to reduce pain and accelerate healing of mouth
ulcers. This non-invasive treatment modality works by promoting cellular regeneration and reducing
inflammation at the ulcer site (Alpsoy et al., 2017).

2.5.4 Treatment of Underlying Conditions

Addressing any underlying systemic conditions is essential for the effective management of mouth ulcers:

Gastrointestinal Disorders: Treating underlying gastrointestinal conditions such as Crohn's disease or celiac
disease can reduce the occurrence of associated mouth ulcers. This includes the use of specific medications,
dietary modifications, and in some cases, surgical interventions (Zhang et al., 2015).

Autoimmune Diseases: Management of autoimmune conditions like systemic lupus erythematosus or

Behçet's disease involves immunosuppressive therapy and close monitoring to control disease activity and
prevent ulcers (Lam & Leong, 2014).

Infectious Diseases: In cases where ulcers are caused by infections (e.g., herpetic stomatitis), antiviral
medications such as acyclovir or valacyclovir are prescribed to reduce viral load and promote healing (Jurge
et al., 2018).

2.6 IMPACT OF MOUTH ULCERS ON QUALITY OF LIFE

Mouth ulcers can significantly impact an individual's quality of life, affecting physical, psychological, and
social aspects.

Physical Impact: Pain and discomfort from mouth ulcers can interfere with eating, speaking, and oral hygiene,
potentially leading to malnutrition and weight loss (Epstein et al., 2016).
Psychological Impact: Chronic pain and recurrent episodes can lead to increased stress, anxiety, and reduced
overall well-being. Patients may also experience embarrassment and self-consciousness about their condition
(Jurge et al., 2018).

Social Impact: The limitations imposed by mouth ulcers can affect social interactions and professional life,
reducing productivity and social engagement (Epstein et al., 2016).

2.7 APPRAISAL OF LITERATURE

Despite extensive research on mouth ulcers, several gaps remain, particularly in the context of developing
countries like Nigeria.

There is a need for large-scale, population-based studies to accurately determine the prevalence of mouth
ulcers across different demographics and regions in Nigeria.

More comprehensive studies are required to explore the local factors contributing to the development of
mouth ulcers in Nigeria, including dietary habits, cultural practices, and environmental influences.

There is limited data on the effectiveness of various treatment protocols in Nigerian healthcare settings.
Research is needed to evaluate the outcomes of commonly used treatments and explore newer therapeutic
options.

Insufficient research has been conducted on the impact of mouth ulcers on the quality of life of affected
individuals in Nigeria. Studies focusing on the physical, psychological, and social dimensions of the condition
are essential for developing holistic management strategies.

CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Introduction

This chapter outlines the research methodology employed in investigating mouth ulcers in adults at Babcock
Teaching Hospital, Ilishan-Remo, Ogun State. It includes details on the research design, population and
sample, data collection methods, data analysis techniques.

3.2 Research Design

The study utilizes a descriptive cross-sectional design to assess the prevalence, etiology, diagnosis, and
treatment of mouth ulcers in adults. This design allows for the collection of data at a single point in time,
providing a snapshot of the current situation and enabling the identification of patterns and associations.

3.2 Description of the Study Area

Babcock University Teaching Hospital (BUTH) is a modern, private teaching hospital located in the serene and
picturesque town of Ilishan-Remo, Ogun State, Nigeria. Established in 2012, the hospital is situated on the
campus of Babcock University and has since become a renowned center for healthcare delivery and medical
education. With its state-of-the-art facilities and equipment, BUTH offers a wide range of medical services.
The hospital's architecture is designed to promote a sense of calm and comfort, creating a welcoming
atmosphere for patients, staff, and students alike.

3.3 Population of the Study Area

The population for this study includes all adult patients attending the dental and medical clinics at Babcock
Teaching Hospital. The inclusion criteria are adults aged 18 years and above who have been diagnosed with
mouth ulcers.

3.4 SAMPLE AND SAMPLING TECHNIQUE

To achieve the accurate analysis of the subject in focus, the researcher will make use of one hundred (100)
respondents. The researcher will adopt the use of simple random sampling technique in selecting the
respondents. The researcher will chose this method so as to remove bias.

3.5 INSTRUMENTATION/TECHNIQUE FOR DATA ANALYSIS

One hundred (100) well structured questionnaires will be distributed to all adults patient attending dental
and medical clinics and Babcock University Teaching Hospital. Also the researcher will make use of textbook,
Journals, Newspaper, internet and libraries.

3.6 VALIDITY AND RELIABILITY OF THE INSTRUMENT

The researcher will present the research instrument the supervisor and some other experts for scrutiny, the
supervisor will evaluate the content properly and her suggestion and necessary corrections were
implemented.

3.7 DATA COLLECTION PROCEDURE

Data which form the basis of this research will be collected through administration method ie the researcher
personally will distribute the 100 well structured questionnaires to the respondents, filling and retrieved
through a thorough follow up.
 POGIL COLLEGE OF HEALTH TECHNOLOGY

OKE-ERI VIA IJEBU-ODE OGUN STATE.

DEPARTMENT OF DENTAL SUNGERY TECHNICIAN

Dear Respondent,

I am a final year student of the above named college in the department of Dental Surgery Technician.
As part of the requirement for the award of National Diploma (ND) after the completion of the program. I an
undertaking a research work titled “Investigating mouth ulcer in adults" (a case study of Babcock teaching
hospital). Your input is highly required and information given in the questionnaire will be strictly for research
purpose. Your response will be treated with full confidentiality, please tick the right alternative.

Thank you.