Canker Sores (Aphthous Ulcers)

Canker Sores (Aphthous Ulcers): Overview

Alternative Names: Aphthous stomatitis, aphthous ulcers, canker sores or mouth ulcers.

Recurrent aphthous stomatitis (RAS) is accepted as one of the most common diseases involving human oral tissues.  They are painful, small ulcers in the mouth or on the inner lips caused by an assortment of viruses.  They can appear on the tongue, the lips, the gums or the insides of the cheeks.

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Incidence; Causes and Development; Contributing Risk Factors

Up to two-thirds of people get bouts of recurrent mouth ulcers at some time in their life.  Young adults are most likely to be affected, but they are also common in children.  About 5-10% of children have recurrent mouth ulcers.

The exact cause of these tiny but quite painful mouth ulcers is unclear, but most research indicates that a virus is responsible.

Canker sores do not form blisters as cold sores (fever blisters) do.  The cold sore, commonly confused with the canker sore, is caused by the herpes simplex virus.  The canker sore, on the other hand, is an inflammation rather than an infection.

Canker sores often pop up when you're under stress or after you've eaten an irritating food (pineapple, nuts and chocolate are common culprits).

The following have shown to be related to recurrent mouth ulcers: flavoring agents; essential oils; cinnamon; gluten and wheat flour; cow's milk; coffee; chocolate; potatoes; figs; cheese; nuts (peanuts, almonds in particular); citrus fruits; certain spices; strawberries; tomatoes.

Some women develop mouth ulcers during their period, due to hormone changes taking place at this time.

Stopping smoking: When you first stop smoking, you may find that you develop more mouth ulcers than usual.  This is a normal reaction.  Your body is dealing with the change in chemicals in your body.

Occasionally, mouth ulcers are caused by a reaction to certain medications such as NSAIDs, Nicorandil (for treating angina) or beta-blockers.

A susceptibility to canker sores tends to run in families.  Around 40% of people with recurrent mouth ulcers have a family history of the condition.

Signs and Symptoms

The first sign of a canker sore may be a tingling, burning sensation inside the mouth, followed shortly by the appearance of a white or yellowish spot edged by a red halo.

Canker sores may range in size from the size of a pinhead to as large as a quarter.  They are usually about 1/8 of an inch (3mm) in diameter.

Treatment and Prevention

No totally successful conventional treatment is available.  The natural remedies may help relieve the symptoms of canker sores or may prevent sores from recurring.

However, for mild mouth ulcers there are things that can help an ulcer to heal more quickly:

  • use a soft toothbrush
  • avoid eating hard foods such as toast
  • reduce your stress level through relaxing activities

Antimicrobial mouthwash helps to kill microorganisms such as bacteria, viruses or fungi that can cause mouth infections.

Corticosteroids reduce inflammation and swelling.  Mouth ulcer medications usually contain a low dose of corticosteroid.

Painkillers should help if the mouth ulcer is very painful.

Prognosis

They appear suddenly and often leave suddenly, usually lasting from four to twenty days.

Signs, symptoms & indicators of Canker Sores (Aphthous Ulcers):

Symptoms - Head - Mouth/Oral

Counter-indicators

Risk factors for Canker Sores (Aphthous Ulcers):

Allergy

Allergy to Foods (Hidden)

Foods including wheat, oranges, tomatoes, chocolate, nuts, eggplant, tea and cola were dietary allergens that have been found to trigger ulcer initiation.  A study by Dr. Pelin Gürdal conducted in a dental university in Turkey concluded from previous studies [Oral Surg.  1984:57, pp.504-507] and his own that as many as 50% of RAS patients will improve when offending foods are identified and eliminated.  Without laboratory testing or patient insights, identifying these foods for individual sufferers can be challenging.  Food allergies continue to be a controversial cause of canker sores, and further research is necessary to resolve the issue.

Autoimmune

Gluten Sensitivity / Celiac Disease

In a study of 15 patients, 7 patients responded completely and two partially to diets excluding gluten (3 patients), azo compounds (3), milk (2), azo and milk (1).  Two failed to respond and three failed to complete the diet.  Responses were confirmed by re-challenge.  The patients in this study had relatively severe aphthous ulcers.  Gluten enteropathy had been excluded by biopsy in the patients who responded to the gluten-free diet.  [B Med J 1986; 292: pp.1237-8]

Crohn's Disease

Crohn's disease causes inflammation of the gut, leading to ulcers developing in both the stomach and mouth.

Circulation

Megaloblastic Anemia / Pernicious Anemia

Vitamin B12, folate, zinc and iron have been shown to be effective in up to 60% of patients with canker sores when such a vitamin or mineral deficiency has been documented.  [Dermatologic Clinics 1996:14, pp.243-256, British Dental Journal 1985:159, pp.361-367]

Environment / Toxicity

Immunity

HIV/AIDS

Any condition that attacks or suppresses the body's immune system can cause you to develop mouth ulcers.

Nutrients

Zinc Requirement

Tissue damaged by canker sores has demonstrated an enhanced recovery rate with adequate zinc intake.  Total prevention or reduced frequency also occurs when zinc is supplemented in those with zinc deficiency.

Folic Acid Deficiency

Vitamin B12, folate, zinc and iron have been shown to be effective in up to 60% of patients with canker sores when such a vitamin or mineral deficiency has been documented.  [Dermatologic Clinics 1996:14, pp.243-256, British Dental Journal 1985:159, pp.361-367]

Iron Requirement

Vitamin B12, folate, zinc and iron have been shown to be effective in up to 60% of patients with canker sores when such a vitamin or mineral deficiency has been documented.  [Dermatologic Clinics 1996:14, pp.243-256, British Dental Journal 1985:159, pp.361-367]

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Canker Sores (Aphthous Ulcers) suggests the following may be present:

Allergy

Allergy to Foods (Hidden)

Foods including wheat, oranges, tomatoes, chocolate, nuts, eggplant, tea and cola were dietary allergens that have been found to trigger ulcer initiation.  A study by Dr. Pelin Gürdal conducted in a dental university in Turkey concluded from previous studies [Oral Surg.  1984:57, pp.504-507] and his own that as many as 50% of RAS patients will improve when offending foods are identified and eliminated.  Without laboratory testing or patient insights, identifying these foods for individual sufferers can be challenging.  Food allergies continue to be a controversial cause of canker sores, and further research is necessary to resolve the issue.

Autoimmune

Lupus, SLE (Systemic Lupus Erythematosus)

Mouth or nose ulcers have been reported by between 12% and 30% of lupus patients, depending on the study.  They most often occur in the mouth on the hard or soft palate but may also be found on the nasal septum.

Recommendations for Canker Sores (Aphthous Ulcers):

Amino Acid / Protein

L-Lysine

Some nutritionally-oriented physicians and dentists recommend taking lysine during an outbreak of canker sores to speed healing.  However, there have been almost no clinical trials using lysine as a remedy for canker sores.  Take 1,000mg L-lysine three times a day with meals while a canker sore is present.  Reduce the dose to 500mg three times a day for one week following healing.  Take 1,000mg L-lysine three times a day with meals while a canker sore is present.  Reduce the dose to 500mg three times a day for one week following healing.

Animal-based

Lactobacillus Acidophilus

Acidophilus/bifidus consumption has been found to be useful for the prevention of canker sores in some individuals.  Topical use, by chewing lactobacillus tablets several times each day, may also reduce the soreness in some cases.  [CIBA Clin Symposia 1967;19: pp.38-64, Oral Surg 1970;30: pp.196-200]

Botanical

Licorice Root

For acute treatment, DGL (de-glycerrizinated licorice root) topically may prove to be of benefit.  A mixture of DGL and warm water applied to the inside of the mouth may shorten the healing time for mouth ulcers.  This DGL mixture is made by combining 200mg of powdered DGL and 1 cup or less (250ml) of warm water.  Swish in the mouth for 2 to 3 minutes twice per day for one week.  The use of ordinary licorice root powder may provide benefit also.  [J Assoc Physicians India 1989; 37: p.647]

Mineral

Nutrient

Preventive measures against Canker Sores (Aphthous Ulcers):

Habits

Personal Hygiene Changes

It may be a good idea to avoid toothpaste that contains sodium lauryl sulfate because it breaks up a protective barrier on the teeth and gums, which results in a greater frequency of ulcers.  The frequency was reduced in one study by 67%.  It is hard to find a toothpaste without it, but people with canker sores should make the effort if the problem does not resolve by other means.  Weleda pharmacy in New York manufactures such a toothpaste, and other varieties can generally be found in health food stores.

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