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Mouth ulcers can be caused by

Recurrent aphtous stomatitis: This is the most common cause of mouth ulcers that have a tendency to recur for no apparent reason. These are more common in younger people (10-29 yoa). They can lead to small, large or a cluster of ulcers which are quite painful. The  most common underlying cause for recurrent aphtous ulcers are genetic factors, stress and nutritional deficiencies (mainly of iron, folic acid and vitamin B12). Rinsing with salt water can help heal the smaller and less painful ulcers. Otherwise, topical steroid ointment can be helpful and must be prescribed by a health professional. 

Trauma: cheek biting or chewing, rubbing against a sharp tooth/ ill-fitting dentures and piercings, foods that are too hot or hard-textured are all possible causes of ulceration. Usually these ulcers are once-off and disappear once the cause is removed.  

Chemical: Ulcers can be caused by a chemical irritant, such as keeping a tablet of aspirin against a tooth in the hope that it will alleviate a toothache (please note that aspirin must be swallowed for any pain-relief result). Another example is the improper use or application of teeth bleaching gel. These contain high levels of peroxide that when in contact with the mucosa for too long, will lead to ulcerative burns.

Medication-related: Chemotherapy medications used in cancer cause oral ulceration while radiotherapy cause ulcers only when used in the head and neck region. Medications used to prevent transplant rejection also have this effect. It is usually recommended that patients ensure that their dental health is good prior to starting such medical treatments. This is because dental treatment is made more difficult and uncomfortable due to the presence of ulcers in the mouth and there are higher risks of infection.

Infections: Viral infections can cause of recurrent mouth ulcers. For example, first-time infection by the Herpes virus can cause red, sore gums and blisters that rupture to form ulcers. In Hand, food and mouth disease, a different virus is responsible (coxsackier virus). The patient develops malaise and fever and ulcers can appear anywhere in the mouth.

Mucocutaneous and autoimmunce diseases:

Mucocutaneous diseases are disorders directly affecting  the soft tissues of the mouth. The oral soft tissues are hypersensitive and hyper-reactive. An example is Lichen Planus, a rare condition affecting only 1-2% of the population, where manifestations are sloughing and bleeding gums, ulcerations, altered taste and sensitivity to spicy foods. 

Autoimmune diseases include inflammatory bowel diseases such as celiac disease, Crohn's disease and Ulcerative colitis. These can have oral manifestations including mouth ulcers which usually resolve when the underlying disease is treated. Other autoimmune diseases such a Behcet's disease and SLE (systemic lupus erythematous) affect multiple systems in the body, including the oral cavity, leading to ulcerations. 

Reference: Recurrent oral ulceration. Aetiology, classification, management and diagnostic algorith. Elizabeth A. Bilodeau, Lalla R.V. Periodontology 2000 (Volume 80, issue 1, pg 49-60) June 2019

They are necessary for a variety of reasons:

For decay detection

During an examination, decay in a tooth can be seen if it is in an area that is visible in the mouth. Often, however, the decay between teeth or in areas where it cannot be easily visualised with the naked eye and hence remain undetected.  The following images illustrate how taking a radiograph allows detection of decay otherwise not visible to the naked eye.

For root canal treatment

During root canal treatment, radiographs are an absolute necessity as the dentist is operating inside the tooth within the root system. 

For pre-assessement before major dental treatment such as:      

Orthodontics

Implant placement

Crown and bridge work

Prior to extraction of teeth

Radiographs show the hidden root structure of a tooth and also its position relative to other teeth and other anatomical structures. 

For general diagnosis of pathology and gum disease

Pain in the oro-facial region is often dentally related. Radiographs can be helpful in confirming the diagnosis. Simple visual examination might not provide enough information to allow the dentist to reach a definite diagnosis.

Radiographs also allow assessment of gum disease severity.

The recommendations are:

For decay assessment:

If it is your first visit at the dentist and you have had a lot of fillings in the past or decay is detected in your teeth, radiographs are recommended.  

If it is a recall visit and you have had decay in the past and considered high risk of recurring decay, radiographs are recommended at 6-18 months interval for adults and 6-12 months interval for children of up to 11 years of age.
If it is a recall visit and you have not had fillings and is considered at low risk of decay, radiographs are recommended at 24- 36 months interval for adults and 12-24 months interval for children.

For gum disease monitoring:

When gum disease is present, specific radiographs a required to assess its severity atdifferent intervals depending on the case to determine whether there is progression or stabilisation of the disease. The frequency is decided by the dentist based on clinical judgement.

For post-treatment monitoring:

In cases where a patient has received more complex treatment like implants, root canal treatment or crown and bridge work, radiographs might be necessary to ensure the restoration  or treatment site is being maintained in good health. Again, frequency is determined by clinical judgement.

Reference: Dental radiographic examinations: recommendations for patient selection and limiting radiation exposure. American Dental Association. Council on Scientific Affairs. 2012

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