Articles written by me on Self-care and Palliative Medicine
On Self-Care & Palliative Medicine

Aphthous Agony

Aphthous ulcers (aka Canker Sores) are those painful, shallow ulcers that occur periodically on the mucosal surfaces of the mouth. . .sites which include the soft palate, the inside of lips and cheeks, and the tongue. They’re painful in their own right, but just add a spicy food or beverage to the equation–and you take the sensations to a whole new level! Most often, they begin with a burning sensation followed by a red spot or bump that ulcerates. Usually, a canker sore will last 7 to 10 days, and they will heal without scarring. Aphthous ulcers may occur at any age, but they usually appear sometime between the ages of 10 to 40. Unfortunately for the fairer sex, these shallow painful ulcerations seem to occur more frequently in women than men.

The cause of these mouth ulcers is unknown. Numerous studies have not supported an infectious etiology for canker sores, and along these lines, there’s no evidence that you can “give” these as a painful present to your favorite kissing buddy. Additionally, you can’t spread them to other parts of your body. However, if they’re severe or prolonged, they can become secondarily infected with bacteria or yeast, and their healing time would be prolonged accordingly.

There may be an inherited predisposition to the development of canker sores. Though no exact etiology has been identified, best evidence suggests these mouth ulcers result from an altered local immune response associated with stress, trauma, or eating certain highly acidic foods. “An altered local immune response” is a fancy way of saying that our own lymphocytes decide that there’s a place in the mouth or on the tongue that needs to be attacked and destroyed; and their ‘attack’ leads to the painful shallow ulcers we call canker sores. Minor mouth injuries, such as a hot cheese pizza burn, overly crisp chips, dental cleanings, aggressive tooth brushing,and accidental bites of cheek and tongue can start them up. Other triggering factors can be dietary deficiencies (especially iron, folic acid, and vitamin B 12), hormonal shifts (including menstrual periods), and food allergies. Interestingly, researchers have felt that there might be relationships between aphthous ulcers outbreaks and the following foods: cereal grains (such as buckwheat, rye, and barley), citrus fruits, pineapples, figs, tomatoes, and strawberries; milk and some cheeses; and nuts, chocolate, shellfish, soy, vinegar, and French mustard. How’s that for narrowing it down for you!? And, it appears that even a generous dose of physical and emotional stress can get an aphthous ulcer brewing.

SODIUM LAURYL SULFATE; remember this ingredient! SLS, a common ingredient in many toothpastes (especially Tartar control ones), removes a protective coating (mucin) from the lining of the mouth. Certainly, people with recurrent canker sores should avoid toothpaste containing this ingredient. In one study, the majority of recurrent aphthous ulcers were eliminated just by avoiding SLS for three months. Food sensitivities and/or allergies can make canker sores worse/more of a problem. . .though double blind studies have not shown allergy to be a major factor in the development of these painful sores. In any case, if you suffer from frequent bouts, you should analyze your dietary intake around the times of the recurrences. You might see a pattern with certain foods, beverages, etc.

Affecting 20 to 60% of folks at some point in their lives, aphthous ulcers are the most common oral irritation of young adults. However, another frequent kind of mouth sore has very different causes. Cold sores (or fever blisters) are fluid-filled blisters that most commonly occur on the lips. A tingling discomfort may precede the appearance of these blisters by one to three days. The blisters generally break spontaneously within hours and form a crusting scab. Recurrences tend to occur in approximately the same location as previous blisters. Their duration is usually 7-10 days. Unlike canker sores, cold sores are infectious. They are caused by herpes simplex virus which has become active. As a viral infection, they can be spread to one’s own eyes, genitals, and other body parts. . .as well as to other people. The greatest risk for spreading is from the time the blisters rupture until they heal completely, although the herpes simplex virus can be spread even when blisters are not present.

Whereas the treatment of fever blisters is use of antiviral ointments and tablets aimed at treating the herpes simplex virus, the treatment of canker sores is basically symptomatic–aimed at controlling pain while the ulcers heal. Avoid, spicy, salty, and citrus foods. . .if you don’t remember this advice, your mouth will remind you! Topical ice or covering the ulcers with a protective coating called orabase can decrease the pain temporarily. Viscous xylocaine is a prescription topical anesthetic that can be applied to specific ulcers with a Q-tip to provide excellent temporary numbing of very painful sores. Oral rinses several times a day with a Benadryl/Kaopectate mixture, Peridex, or swabbing the ulcers with a dilute hydrogen peroxide mixture followed by milk of magnesia all seem to help with soothing and appear to help healing as well. Topical steroids can be applied in a paste form or injected directly into large, persistent ulcers to decrease inflammation and aid healing. Swishing a Tetracycline solution several times a day has been beneficial to some. And, there is a prescription oral paste called Aphthasol that might be helpful in reducing pain, swelling, and duration of canker sores as well.

For the herb and vitamin enthusiasts among you, the following remedies are also touted. Supplementing Thiamine (B 1) might help decrease recurrences. Chewing four lactobacillus tablets three times/day may aid in reducing pain and duration of sores. Herbs?? DGL mixture . .as a mouth rinse twice a day for 5 to 7 days may shorten the healing time of canker sores. This is deglycyrrhinzinated licorice; combine 200 mg of this powder with 200 ml of warm water and swish in the mouth for two to three minutes several times per day. Echinacea may also help since it enhances immune function and wound healing. The liquid preparation (about 4ccs) can be swished then swallowed three times per day during an outbreak. Since chamomile has a soothing and healing effect on mucous membranes, a strong chamomile tea swished and swallowed three to four times per day may be beneficial. Aloe vera juice can be used as a mouth rinse 2 to 3 times/day. And finally, some wise men have found that Myrrh mixtures as a mouth rinse have also helped their recovery–again because of its wound-healing properties.

For the worst of the worst cases, or in situations where people have frequent, severe recurrences, regimens of oral Prednisone (a steroid), colchicine (a gout medicine), or even thalidomide have been helpful. And, if you have a large canker sore that just doesn’t seem to heal, schedule a check up with your doctor or dentist to make sure that you don’t have something worse going on. . .such as an early mouth cancer.

I realize this has been a sore subject. But, with tomato season just about here, I hope some of the above information will help you avoid your own Aphthous Agony this year.

Stephen L. Hines, M.D.
June 2001

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