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!
Before we move on, I suppose you need to know how we treat these in our office. Our first action is typically the use of our Nd:YAG laser, which is relatively pain free. On the tougher ulcers, and for those who want to rid themsleves of a painful ulcer as quickly as possible, we use Debacterol®, which is a semi-viscous liquid chemical cautery agent. This can be somewhat uncomfortable to apply, but it is rather quick, and it is possible to anesthetize the area with a topical anesthetic, or with a local anesthesia. If you find yourself too uncomfortable, and are not too far from our office, give us a call (972.255.3712), or email us at ulcers@21stCenturyDental.com.
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.
Dr. Weil has the following suggestions:
If stress, fatigue, or other factors tend to result in canker sores in your mouth, you aren't alone. Mouth ulcers (aphthous ulcers) are common and can be very painful, even if they are barely visible. The cause of canker sores remains unknown, although a popular theory holds that they are autoimmune in nature - the result of an attack by the immune system on the body's own tissues. They may also be a result of deficiencies of folic acid, iron or vitamin B12.
Canker sores are often triggered by stress, fatigue, certain foods (including nuts, acidic foods and sweets) and occasionally by toothpaste containing the additive sodium lauryl sulfate. While they are painful, there are ways to reduce discomfort and speed the healing process. Try making a tablet of DGL (deglycyrrhizinated licorice) extract into a paste, or make a paste from DGL powder and coat the paste over the sore. Do this four times a day until the sore has disappeared. A daily B-100, B-complex vitamin supplement may also help prevent canker sores.
Perhaps most important are mind-body approaches, such as visualization, hypnosis or relaxation techniques, which can reduce the frequency and severity of outbreaks. Join Dr. Weil on Healthy Aging for videos, music and information to help you effectively manage stress.
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.
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 Behçet'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.
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:
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.
ORA5 kills bacteria and decreases tissue sensitivity and the possibility
of infection.
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:
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.
After any dental procedure, where the gum is lacerated the use of
ORA5 will help fight post surgery infection.
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!
