Mouth Ulcers

We first must distinguish between a mouth ulcer (canker sore) and a fever blister (cold sore).

Ulcers are typically found inside the mouth and are not contagious, while Fever blisters are found outside, typically on the lips, and are very contagious.

Fever blisters are caused by the herpes virus, and are most effectively treated by acyclovir, denovir or penciclovir.

The discussion here will concern the cause and treatment of Apthous ulcers, which is much more controversial.

The following comments have been collected over the years from dentists on the Internet dental forum. Some comments are anecdotal. Some have research to back up the assertions. Some have commercial undertones. Still others belong in left field at "the ballpark in Arlington". Truthfully, this subject is best summed up by Michael Miller, DMD, from the University of Pennsylvania:

"I read with some amusement these multiple letters (see following comments) regarding the etiology and treatment for aphthous ulcers. I say this because when I was involved in my oral medicine-training program at the University of Pennsylvania in the early 70's, we were heavily involved in both epidemiologic and basic science investigations of aphthous ulcers. I firmly believe that the disease is an auto-immune phenomenon; that the predisposition to the condition is genetically conferred; that all sorts of factors can elicit their occurrence including trauma, chemicals, hormonal cycles, stress, smoking, etc.; that many treatments have been proposed for aphthous ulcers and many work, from vegetable milkshakes, to rinses with chlortetracycline, to topically applied steroids. Why some work in some individuals, and others don't goes unanswered. I'm sure it is related to the etiology. What I have found is that you must be prepared to try a multitude of treatment modalities in some aphthous sufferers. Even then, sometimes, nothing works."

Keep in mind that the final common pathway of mucosal damage is the ulceration, which is often nonspecific in nature, giving us little clue to its exact etiology. Someday the specific treatment may be found. But, in the meantime, with the more severe cases, if you find a treatment that works, Good luck!

The following is an essay from a well-respected expert on mouth ulcers, Dr. Dennis Lynch:

Aphthous ulcers or canker sores are the most common oral ulcers in man and are estimated to affect one-fourth of the population worldwide. The specific etiology of aphthous ulcers remains unknown. While the underlying immunologic process has been well-described, it is unclear whether the lesions are due to cross reactivity with intermediate, transitional forms of normal oral bacteria, localized autoimmune phenomena involving mucosal epithelium, or other, as yet undescribed, factors. An HLA association (HLA B12 and HLA-B51) has been reported in familial cases of aphthous ulcers. Mechanical trauma, emotional stress, food allergies and hypersensitivity to dentifrice components may play a contributory role in some patients. There is no evidence to suggest an infectious etiology of any kind.

Clinically aphthous ulcers can be divided into three general categories:

• Minor aphthae, which comprise over 80% of reported cases, are small (<1.0 cm), usually solitary, exquisitely painful, shallow ulcers which are covered by pseudomembrane, surrounded by an erythematous halo, and heal without scarring in 7-10 days.
• Major aphthae, which account for less than 10% of reported cases, are bigger, deeper, and heal with scar formation over a period of 2-3 weeks.
• Herpetiform aphthae are small, clustered lesions, which may occur on keratinized mucosa and resemble herpes simplex or other viral lesions.

There is considerable overlap between the various types of aphthae and more than one type can be present at one time.

Behcet's Syndrome consists of a triad of oral, ocular and genital ulcers, with a specific surveillance definition, which describes the syndrome. It is more common in young adults of Mediterranean or Japanese ancestry. The oral lesions are classified as minor aphthae; however, they tend to be continuously present or recur at the same site, multiple in number and of varying sizes, involve the soft palate and oral pharynx and heal with scar formation.

Most aphthae are first noted in adolescence or young adulthood and decrease in severity after menopause. They are more common in women. The frequency of occurrence is variable, ranging from several weeks to several years between episodes. Minor aphthae occur on non-keratinized mucosa, most often the labial and buccal mucosa, lateral tongue and floor of the mouth. Major aphthae are common on the lips, soft palate and oral pharynx.

While recurrent aphthous ulcers are usually easy to distinguish from recurrent intraoral herpes simplex lesions on the basis of location, i.e., not occurring on the hard palate and attached gingiva, clinically similar oral ulcers are a component of other systemic diseases, including vitamin B12 and folate deficiencies, inflammatory bowel disease, cytomegalovirus induced ulcers in HIV disease, herpangina, hand foot and mouth disease and cyclic neutropenia. The microscopic findings of recurrent aphthae are nonspecific; therefore, a biopsy is only useful to rule out other etiologies.

The treatment of aphthous ulcers is palliative in nature. Oral rinses containing local anesthetic agents, e.g., diphenhydramine (Benadryl), promethazine (Phenergan), dyclonine (Dyclone) or lidocaine (Xylocaine) combined with coating agents, e.g., Kaopectate, Milk of Magnesia, Maalox or sucralfate (Carafate) are useful for mild, widespread or inaccessible lesions. Chlorhexidine-containing rinses (Peridex) are also reported to be efficacious, as is tetracycline suspension. Topical corticosteroids are the primary therapeutic agents used to treat aphthous ulcers. Fluocinonide (Lidex) or other intermediate strength topical corticosteroids can be applied to individual lesions and covered with an occlusive dressing (Zilactin-B). Super-potent topical corticosteroids, e.g., clobetasol (Temovate) and halobetasol (Ultravate), are useful to treat major aphthae, although systemic corticosteroids are often required, e.g., prednisone, in combination with intralesional steroid injections, to achieve healing. Colchicine, dapsone, and pentoxifylline (Trental) have all been reported as effective; however, confirmatory double-blind studies are currently lacking. Severe episodes of aphthae also respond to azathioprine (Imuran), thalidomide, and cyclosporine (Sandimmune).The prognosis of aphthous ulcers is good to excellent; however, there is no permanent cure. Once an individuals have had one episode of aphthous ulcers, they are more likely to have a second episode. Unfortunately, it is impossible to predict when that episode might occur.

More suggestions follow:

I've read that cinnamon oil or flavoring, sodium lauryl sulfate, and citric acid (especially in candies) can be triggers, especially if a minor tissue trauma, such as a scrape or a bump with a toothbrush, occurs. When my 10-year-old daughter gets them, I step up the hygiene (hers can be pretty bad, I guiltily admit) and have her use periogard. Seems to help. My 18-year-old son doesn't get them much anymore, but fresh, not canned, pineapple was almost a 100% aphthous ulcer inducer. My 15-year-old daughter has never had one. This leads me to suspect a genetic predisposition. Michael Myers comment about B vitamins strikes a chord. I suspect that as well as subclinical deficiency; there exist absorption problems in certain people under certain conditions. For example, after an episode with an enterovirus, aphthous lesions and angular cheilitis seem more common. High carbohydrate intake may also increase the need for the B vitamins used in their metabolism. I usually recommend stopping the ingestion of trigger foods and substances, improving nutrition and hygiene, and taking a B and C complex vitamin. Can't hurt, even if it doesn't help, and doesn't cost much.

A list of SLS free toothpaste includes: Retardent by RowparBiotene "Dry Mouth Toothpaste" by LacledePeri-Gel by ZilaRembrandt NaturalFirst Teeth by Laclede. This list is a few years old and these may not all still be on the market

In the Acta Odontol Scand 1996: 54: 150-3 a study is published about the effect of two toothpaste detergents on the frequency of recurrent aphtous ulcers. Three toothpastes were compared: one with SLS (natriumlaurylsulphate), one without any detergent and one with a mild detergent, cocoamidopropyl (CAPD). Conclusion: in a group of frequent aphtous ulcer sufferers the amount of ulcers decreased for 46% after switching from SLS to none SLS-toothpaste.

Switching from SLS to CAPD toothpaste decreased the ulcer amount for 32 %. 96% of the tested group benefited from using non-SLS toothpaste. SLS seems to attack the upper layers of the mucosa and denaturates the mucine layer.

Full text of article is available at: Medscape

Clinical Applications of ThalidomideNon-HIV-associated diseases. Following the reported efficacy of thalidomide in the management of ENL, there have been studies of its use in several other non-HIV associated diseases. There is much interest in the use of thalidomide in chronic graft-versus-host disease, as the drug has been shown to increase the survival of patients with disease refractory to conventional therapy.[17] Thalidomide also has been used, often with dramatic effectiveness, in treating oral aphthous ulceration, usually complicating Behcet's disease.[18] Thalidomide has possible efficacy in a number of immunologic diseases, including rheumatoid arthritis, cutaneous lupus erythematosus, inflammatory bowel disease, and sarcoidosis.[19-22] However, most of these reports are anecdotal cases, small series, or small controlled trials.

Silver nitrate works great on ulcers. It stains like crazy, though. Turns your fingers black. The stain is delayed, so you don't see it until later. Countertops are bad too, so be careful. Had a kid who got ulcers all the time. He was later diagnosed with a hiatal hernia. Keep that in mind.

Whenever I see aphthous ulcers or are asked about them I invariably find that there is some nutrient missing from the patient's diet. 9 out of 10 times they have had no dairy or meat products recently; both good sources of B vitamins.

There is no research to support this, only my observations over more than 20 years. The reason you are likely not to see research supporting this hypothesis is it is extremely difficult if not impossible to measure. Patients will not readily admit they eat poorly; you have to watch their reactions to your carefully worded questions. Don't say, "you have a vitamin deficiency," rather, "there appears to be some nutrient you're not getting in your diet." You don't need to see scurvy or rickets- there are many gradations and clinical manifestations of vitamin deficiencies.

Some may say the lesions occur during stressful times. To this I would say that people under stress don't usually eat right and I still am convinced that the nutrient deficiency is the primary factor in aphthous lesions. I believe the virus is always present but the person's normal defenses will keep them from activating. When resistance is down the lesions occur.

To those who may say, "I want to see controlled clinical trials before I'll even consider what you're saying," let me remind them that many of the principles of modern dentistry were born to personal observations and acceptance of logic.10.Most commercial toothpastes contain the detergent sodium lauryl sulphate(SLS). SLS has been implicated in exacerbating oral ulceration. SLS free toothpastes include Biotene "Dry Mouth Toothpaste" by Laclede and Rembrandt "Natural". References available.

Nicorette Chewing Gum Used to help people give up smoking. In nonsmokers, this has been found to cure, not just alleviate the symptoms of oral ulcers. The following is one of the early articles by Renee Bittoun. Many more are available.

Source Med J Aust, 154(7): 471-2 1991 Apr 1 Abstract OBJECTIVE:

The aim of this study was to investigate the effect of nicotine, in the form of Nicorette tablets, on aphthous ulcers in nonsmoking patients. The study was prompted by the observations that smokers are less likely to suffer from mouth ulcers, that some smokers on quitting develop them, and that patients on nicotine replacement therapy are less likely to develop ulcers than those having other types of smoking cessation therapy. CLINICAL FEATURES: The three nonsmoking patients who were selected for the study each had a long history of recurrent aphthous ulcers with no remissions. INTERVENTION AND OUTCOME: Each patient was given up to four 2 mg Nicorette chewing tablets per day. After one month of this regimen each patient was weaned off the tablets. In each case the ulcers healed and new ulcers did not appear during Nicorette therapy. Two of the patients relapsed when weaned off the tablets. CONCLUSIONS: This preliminary trial shows that nicotine may have a beneficial effect on aphthous ulcers. Further studies are necessary to elucidate the mechanism.

Thalidomide Used in HIV infection for intractable pain from ulcersCO2 Laser: I sometimes lase the surface of an ulcer using our CO2 laser. Obliterates all local bugs and allows for healing

Renee Bittoun from our hospital's smokers clinic has had significant success with Nicorette gum, but only in non smokers. The amount of nicotine in one Nicorette is very small and not likely to encourage smoking. I'm sure you will find her protocol on Medline. Initially written up late 80's or early 90's.

WARNING: The following comments are from a dentist with a commercial interest in ORA5.

Today health conscious consumers realize that their mouth, like any other part of their body, deserves special attention. In the treatment of painful mouth sores, oral ulcers or infection, ORA5 provides a unique combination of natural properties to kill bacteria, reduce infection and pain.

For many years, ORA5 has been the topical antibacterial choice of dentists around the country for treating oral sores and infections. The primary natural healing agents in ORA5 are the minerals - copper sulfate and iodine. The copper sulfate helps reduce mouth sore pain. The iodine works as an antibacterial and antiviral agent. It is a true antibacterial liquid that acts gently and effectively on lacerations inside your mouth. ORA5 works its wonders in many ways:

1. ORA5 stops pain. In a non-toxic way, ORA5 creates a healing membrane to cover the sensitive tissue and tender nerve endings that can cause pain.
2. ORA5 kills bacteria and decreases tissue sensitivity and the possibility of infection.
3. ORA5 uncovers hidden sores.

Small and hard to see sores will turn white when ORA5 is applied. Who will benefit most by using ORA5? Men and women (some studies indicate women are affected more than men) who are suffering with common mouth sores and mouth ulcers will experience beneficial results with the use of ORA5. Also, college students who are plagued with mouth ulcers during stressful exam periods. And, many dental patients are treated with ORA5.

For example:

1. Patients (many are seniors) with mouth sores caused by new dentures get beneficial results when using ORA5 during their denture adjustments and in-between dental visits.
2. After any dental procedure, where the gum is lacerated the use of ORA5 will help fight post surgery infection.
3. ORA5 is frequently used on patients with gum disease or patients who are having dental implant surgery. ORA5 works as an antibacterial agent and kills most germs.

One of my dental school instructors once told me that ice works well when the pt first notices the onset of canker sores. I have given this advice and had some good results. Fifteen minutes (five on, five off) every two hours when the pt notices itching or burning seems to work. I have one pt that breaks out after all dental treatment. Even brushing has caused them. Ice has worked well for her.

LIDEX gel contains fluocinonide 0.5 mg/g in a specially formulated gel base consisting of carbomer 940, edetate disodium, propyl gallate, propylene glycol, sodium hydroxide and/or hydrochloric acid (to adjust the pH), and water (purified). This clear, colorless thixotropic vehicle is greaseless, non- staining and completely water miscible. In this formulation the active ingredient is totally in solution.

I have found that application of alcohol to the lesion shortens the healing process. I have also found that 30-second exposure to red laser pointer light will reduce pain immediately and effect good healing in 1-2 days. I published some studies on the subject. (Check "neiburger" on medline)

This was published in the AGD Journal a few years back: The whole concept (no matter what physical agent, H2O2, laser etc.) is take a lesion that hurts and replace it with a lesion that does not hurt.

Now there's a concept! If you got this far, your ulcer is probably already gone!

Here is a great site with more info: click here for great ulcer site for the diligent among you, here is my opinion:

Aphthasol (Amelexanox), which is in a paste form, has been approved by FDA for treatment of Aphthous ulcers (canker sores) in patients with a normal immune system (not tested in AIDS patients). There is a study with Aphthasol that showed faster pain relief and healing of the ulcer by one to one and half days in those who were treated. I would try this first.

Rembrandt also makes a toothpaste specifically designed to combat apthous ulcers. At least one patient of mine swears by it, so you might check this out at your local library... er... grocery store. GOOD LUCK!