Aphthous ulcer

Name = Aphthous ulcer

Caption = Mouth ulcer on the lower lip
DiseasesDB =
ICD10 = ICD10|K|12|0|k|00
ICD9 = ICD9|528.2
MedlinePlus = 000998
eMedicineSubj = ent
eMedicineTopic = 700
eMedicine_mult = eMedicine2|derm|486 eMedicine2|ped|2672
MeshID = D013281
An aphthous ulcer (aka canker sore) is a type of oral ulcer which presents as a painful open sore inside the mouth or upper throat, caused by a break in the mucous membrane. The condition is also known as aphthous stomatitis, and alternatively as "Sutton's Disease," especially in the case of multiple or recurring ulcers.

The term "aphtha" means ulcer; it has been used for many years to describe areas of ulceration on mucous membranes. Aphthous stomatitis is a condition which is characterized by recurrent discrete areas of ulceration which are almost always painful. Recurrent aphthous stomatitis (RAS) can be distinguished from other diseases with similar-appearing oral lesions, such as certain viral exanthems or Herpes simplex, by their tendency to recur, and their multiplicity and chronicity. Recurrent aphthous stomatitis is one of the most common oral conditions. At least 10% of the population suffers from it. Women are more often affected than men. About 30–40% of patients with recurrent aphthae report a family history.cite journal |author=Jurge S, Kuffer R, Scully C, Porter SR |title=Mucosal disease series. Number VI. Recurrent aphthous stomatitis |journal=Oral Dis |volume=12 |issue=1 |pages=1–21 |year=2006 |pmid=16390463 |doi=10.1111/j.1601-0825.2005.01143.x]


Aphthous ulcers are classified according to the diameter of the lesion.

Minor ulceration.

"Minor aphthous ulcers" indicate that the lesion size is between 3-10mm. The appearance of the lesion is that of an erythematous halo with yellowish or grayish color. Pain is the obvious characteristic of the lesion.

Major ulcerations.

"Major aphthous ulcers" have the same appearance as minor ulcerations, but are greater than 10mm in diameter and are extremely painful. They usually take more than a month to heal, and frequently leave a scar. These typically develop after puberty with frequent recurrences. They occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces. The lesions heal with scarring and cause severe pain and discomfort.

Herpetiform ulcerations.

This is the most severe form. It occurs more frequently in females, and onset is often in adulthood. It is characterized by small, numerous, 1–3 mm lesions that form clusters. They typically heal in less than a month without scarring. Palliative treatment is almost always necessary. cite journal |author=Bruce AJ, Rogers RS |title=Acute oral ulcers |journal=Dermatol Clin |volume=21 |issue=1 |pages=1–15 |year=2003 |pmid=12622264 |doi=10.1016/S0733-8635(02)00064-5]


Aphthous ulcers often begin with a tingling or burning sensation at the site of the future mouth ulcer. In a few days, they often progress to form a red spot or bump, followed by an open ulcer.

The aphthous ulcer appears as a white or yellow oval with an inflamed red border. Sometimes a white circle or halo around the lesion can be observed. The grey-, white-, or yellow-colored area within the red boundary is due to the formation of layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is often extremely painful, especially when agitated, may be accompanied by a painful swelling of the lymph nodes below the jaw, which can be mistaken for toothache.


The exact cause of many aphthous ulcers is unknown. Factors that provoke them include citrus (orange juice, lemons, acidic items, etc.), stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies, the foaming agent in toothpaste (sodium lauryl sulfate or SLS), and deficiencies in vitamin B12, iron, and folic acid. [cite journal |author=Wray D, Ferguson M, Hutcheon W, Dagg J |title=Nutritional deficiencies in recurrent aphthae |journal=J Oral Pathol |volume=7 |issue=6 |pages=418–23 |year=1978 |pmid=105102 |doi=10.1111/j.1600-0714.1978.tb01612.x] Some drugs, such as nicorandil, also have been linked to mouth ulcers. In some cases they are thought to be caused by an overreaction by the body's own immune system.

Trauma to the mouth is the most common trigger of aphthous ulcers. [http://www.patient.co.uk/showdoc/40024908/] [http://www.health-disease.org/skin-disorders/aphthous-ulcer.htm] [http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Mouth_ulcers?OpenDocument] Physical trauma, such as that caused by toothbrush abrasions, laceration with sharp or abrasive foods (toast) or objects, accidental biting (particularly common with sharp canine teeth), or dental braces can cause mouth ulcers by breaking the mucous membrane. Other factors, such as chemical irritants or thermal injury, may also lead to the development of ulcers. The large majority of toothpastes sold in the U.S. contains SLS, which is known to cause aphthous ulcers in certain individuals. Using a toothpaste without SLS will reduce the frequency of aphthous ulcers in persons who experience aphthous ulcers caused by SLS. [cite journal | author = Herlofson B, Barkvoll P | title = Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study | journal = Acta Odontol Scand | volume = 52 | issue = 5 | pages = 257–9 | year = 1994 | pmid=7825393 | url=http://www.wealthpartners.net/pdf/0535.pdf | format=PDF | doi = 10.3109/00016359409029036] [cite journal | author = Herlofson B, Barkvoll P | title = The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers | journal = Acta Odontol Scand | volume = 54 | issue = 3 | pages = 150–3 | year = 1996 | pmid=8811135 | doi = 10.3109/00016359609003515] [cite journal | author = Chahine L, Sempson N, Wagoner C | title = The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study | journal = Compend Contin Educ Dent | volume = 18 | issue = 12 | pages = 1238–40 | year = 1997 | pmid=9656847] However, some studies find no connection between SLS in toothpaste and mouth ulcers. [cite journal | author = Healy C, Paterson M, Joyston-Bechal S, Williams D, Thornhill M | title = The effect of a sodium lauryl sulfate-free dentifrice on patients with recurrent oral ulceration | journal = Oral Dis | volume = 5 | issue = 1 | pages = 39–43 | year = 1999 | pmid=10218040]

A possible cause of aphthous ulcers in a susceptible population is gluten intolerance (Celiac disease), whereby consumption of wheat, rye, barley and sometimes oats, results in chronic mouth ulcers. However, two small studies of patients with Celiac disease did not demonstrate a link between the disease and aphthous ulcers. cite journal | author = Bucci P, Carile F, Sangianantoni A, D'Angio F, Santarelli A, Lo Muzio L. | title = Oral aphthous ulcers and dental enamel defects in children with celiac disease | journal = Acta Paediatrica | volume = 95 | issue = 2 | pages = 203–7 | year = 2006 | pmid=16449028 | doi = 10.1080/08035250500355022] [cite journal | author = Sedghizadeh PP, Shuler CF, Allen CM, Beck FM, Kalmar JR. | title = Celiac disease and recurrent aphthous stomatitis: a report and review of the literature | journal = Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics | volume = 94 | issue = 4 | pages = 474–8 | year = 2002 | pmid=12374923 | doi = 10.1067/moe.2002.127581] On the other hand, one of the same studies concluded that one-third of its test group found relief from canker sores after eliminating gluten from the diet This means observing a strict diet, eliminating breads, pastas, cakes, pies, scones, biscuits, beers and so on from the diet and substituting gluten-free varieties where available. The opportunity to go into such a drastic measure is to be balanced with its potential benefits.

Although the exact cause is not known, aphthous ulcers are thought to form when the body becomes aware of and attacks molecules which it does not recognize.cite journal |author=Lewkowicz N, Lewkowicz P, Banasik M, Kurnatowska A, Tchorzewski H.|title=Predominance of Type 1 cytokines and decreased number of CD4(+)CD25(+high) T regulatory cells in peripheral blood of patients with recurrent aphthous ulcerations |journal=Immunol Lett. |volume=99 |issue=1 |pages=57–62 |year=2005 |pmid=15894112|doi=10.1016/j.imlet.2005.01.002] The presence of the unrecognized molecules garners a reaction by the T-cells, which trigger a reaction that causes the damage of a mouth ulcer. People who get these ulcers have lower numbers of regulatory T-cells.cite journal |author=Lewkowicz N, Lewkowicz P, Banasik M, Kurnatowska A, Tchorzewski H.|title=Predominance of Type 1 cytokines and decreased number of CD4(+)CD25(+high) T regulatory cells in peripheral blood of patients with recurrent aphthous ulcerations |journal=Immunol Lett. |volume=99 |issue=1 |pages=57–62 |year=2005 |pmid=15894112|doi=10.1016/j.imlet.2005.01.002]

Repeat episodes of aphthous ulcers can be indicative of an immunodeficiency, signalling low levels of immunoglobulin in the mucous membrane of the mouth.Fact|date=February 2007 Certain types of chemotherapy cause mouth ulcers as a side effect. cite web | title=Non Hodgkin's Lymphoma Cyberfamily — Side effects | url=http://www.nhlcyberfamily.org/effects.htm | publisher=NHL Cyberfamily | accessdate=2006-08-10] Mouth ulcers may also be symptoms or complications of several diseases listed in the following section. The treatment depends on the believed cause.


Non-prescription treatments

Suggestions to reduce the pain caused by an ulcer include avoiding spicy food, eating plain vanilla yogurt, rinsing with salt water or over-the-counter mouthwashes, proper oral hygiene and non-prescription local anesthetics.cite web|url=http://www.nlm.nih.gov/medlineplus/ency/article/000998.htm#Treatment|title=Canker sores: Treatment|last=Rauch|first=D|publisher=MedlinePlus|accessdate=2008-05-08] Active ingredients in the latter generally include benzocaine,eMedicine|ped|2672] benzydamine or choline salicylate. [cite web |title=Aphthous Mouth Ulcers |url=http://www.patient.co.uk/showdoc/23068855/ |date=February 2007 |publisher=Patient UK |accessdate=2008-05-09] Anaesthetic mouthwashes containing benzydamine hydrochloride have not been shown to reduce the number of new ulcers or significantly reduce pain,cite web |title=Aphthous ulcer - Evidence: Evidence on topical analgesics | url = http://cks.library.nhs.uk/aphthous_ulcer/evidence/supporting_evidence/topical_analgesics# |date= |work=Clinical Knowledge Summaries (Prodigy) |publisher=National Library for Health |accessdate=2008-05-10] and evidence supporting the use of other topical anaesthetics is very limited though some individuals may find them effective.cite web |title=Aphthous ulcer - Management |url=http://cks.library.nhs.uk/aphthous_ulcer/management/detailed_answers/managing_aphthous_ulcers# |date= |work=Clinical Knowledge Summaries (Prodigy) |publisher=National Library for Health |accessdate=2008-05-09] In general their role is limited; their duration of effectiveness is generally short and does not provide pain control throughout the day; the medications may cause complications in children. [cite book |title=British National Formulary for Children |year=2006 |chapter=12.3.1 Drugs for oral ulceration and inflammation |pages=601-4 |publisher=British Medical Association, the Royal Pharmaceutical Society of Great Britain , Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group] Evidence is limited for the use of antimicrobial mouthwashes but suggests that they may reduce the painfulness and duration of ulcers and increase the number of days between ulcerations, without reducing the number of new ulcers.cite web |title=Aphthous ulcer - Evidence: Evidence on antimicrobial mouthwash | url = http://cks.library.nhs.uk/aphthous_ulcer/evidence/supporting_evidence/antimicrobial_mouthwash# |date= |work=Clinical Knowledge Summaries (Prodigy) |publisher=National Library for Health |accessdate=2008-05-10] Liquorice root extract may help heal or reduce the growth of canker sores if applied early on and is available in over-the-counter patches. [cite web | url = http://www.webmd.com/oral-health/news/20070322/patch-may-help-heal-canker-sores | title = Patch May Help Heal Canker Sores | last = Chang | first = L | date = 2002-03-22 | publisher = WebMD | accessdate = 2008-05-08] A mixture of equal parts water and 3% hydrogen peroxide, forming a 1.5% hydrogen peroxide solution, applied to the ulcer may speed healing, and applying Milk of Magnesia after this treatment can relieve discomfort.

Prescription treatments

Corticosteroid preparations containing hydrocortisone hemisuccinate or triamcinolone acetonide to control symptoms are effective in treating severe aphthous ulcers. However, if the ulceration is caused by a virus, steriods are contraindicated. cite journal |author=Scully C |title=Clinical practice. Aphthous ulceration |journal=N. Engl. J. Med. |volume=355 |issue=2 |pages=165–72 |year=2006 |month=July |pmid=16837680 |doi=10.1056/NEJMcp054630 |url= Commented in: cite news |title=Clinical review - aphthous ulceration | url = http://www.ukmicentral.nhs.uk/headline/database/printstory.asp?NewsID=5369 | date=2006-07-13 |work=Medicines Information Web Site |publisher=Trent and West Midlands regional Medicines Information services |accessdate=2008-05-09] cite journal |author=Scully C, Shotts R |title=ABC of oral health. Mouth ulcers and other causes of orofacial soreness and pain |journal=BMJ |volume=321 |issue=7254 |pages=162–5 |year=2000 |month=July |pmid=10894697 |doi= 10.1136/bmj.321.7254.162|url=http://www.bmj.com/cgi/content/full/321/7254/162]

Multiple ulcers may be treated with an antiviral medication. The application of silver nitrate will cauterize the sore; a single treatment reduces pain but does not affect healing time.cite journal |author=Alidaee MR, Taheri A, Mansoori P, Ghodsi SZ |title=Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial |journal=Br. J. Dermatol. |volume=153 |issue=3 |pages=521–5 |year=2005 |month=September |pmid=16120136 |doi=10.1111/j.1365-2133.2005.06490.x]

Ulcers larger than 1 cm or lasting longer than two weeks may require treatment with tetracycline [ cite journal | author=Jain A, Sangal L, Basal E, Kaushal GP, and Agarwal SK | title=Anti-inflammatory effects of Erythromycin and Tetracycline on Propionibacterium acnes induced production of chemotactic factors and reactive oxygen species by human neutrophils | journal=Dermatology Online Journal | volume=8 | issue=2 | url=http://dermatology.cdlib.org/DOJvol8num2/original/antibiotics2/jain.html ] though in children it can cause tooth discoloration if the teeth are still developing. The use of tetracyclin is controversial, as is treatment with levamisole, colchicine, gamma-globulin, dapsone, estrogen replacement and monoamine oxidase inhibitors.

* Severe outbreaks are sometimes treated with a corticosteroid such as prednisone and anti-viral medications such as acyclovir.

* Severe pain symptoms are treated with prescription analgesics and a prescription mouthwash that contains a mixture of diphenhydramine, lidocaine, and milk of magnesia (see: [http://www.drugstore.com/qxa1388_333181_sespider_there_any_prescription_treatments_for_canker_sores.htm/ Prescription Treatments for Cankersores] for additional info and references).

* For patients with severe, repeated outbreaks in the same location(s), doctors can cauterize the sores with a solution of silver nitrate. This solution destroys the sensatory nerve endings under the ulcerous area (see: [http://www.drugstore.com/qxa1388_333181_sespider_there_any_prescription_treatments_for_canker_sores.htm/ Prescription Treatments for Cankersores] for additional info and references).


Oral and dental measures

* Regular use of mouthwash may help prevent or reduce the frequency of sores. In fact, informal studies suggest that mouthwash may help to temporarily relieve pain. [Studies mostly agree that antiseptic mouthwashes can help prevent recurrences: * cite journal |author=Meiller TF, Kutcher MJ, Overholser CD, Niehaus C, DePaola LG, Siegel MA |title=Effect of an antimicrobial mouthrinse on recurrent aphthous ulcerations |journal=Oral Surg. Oral Med. Oral Pathol. |volume=72 |issue=4 |pages=425–9 |year=1991 |pmid=1923440 |doi=10.1016/0030-4220(91)90553-O * cite journal |author=Skaare AB, Herlofson BB, Barkvoll P |title=Mouthrinses containing triclosan reduce the incidence of recurrent aphthous ulcers (RAU) |journal=J. Clin. Periodontol. |volume=23 |issue=8 |pages=778–81 |year=1996 |pmid=8877665 |doi=10.1111/j.1600-051X.1996.tb00609.x But this is not accepted by all reports: * cite journal |author=Barrons RW |title=Treatment strategies for recurrent oral aphthous ulcers |journal=Am J Health Syst Pharm |volume=58 |issue=1 |pages=41–50; quiz 51–3 |year=2001 |pmid=11194135 |doi=]

* In some cases, switching toothpastes can prevent mouth ulcers from occurring with research looking at the role of sodium dodecyl sulfate (sometimes called sodium lauryl sulfate, or with the acronymes SDS or SLS), a detergent found in most toothpastes. Using toothpaste free of this compound has been found in several studies to help reduce the amount, size and recurrence of ulcers. cite journal |author=Herlofson BB, Barkvoll P |title=The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers |journal=Acta Odontol. Scand. |volume=54 |issue=3 |pages=150–3 |year=1996 |pmid=8811135 |doi=10.3109/00016359609003515] cite journal |author=Chahine L, Sempson N, Wagoner C |title=The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study |journal=Compend Contin Educ Dent |volume=18 |issue=12 |pages=1238–40 |year=1997 |pmid=9656847 |doi=] cite journal |author=Healy CM, Paterson M, Joyston-Bechal S, Williams DM, Thornhill MH |title=The effect of a sodium lauryl sulfate-free dentifrice on patients with recurrent oral ulceration |journal=Oral Dis |volume=5 |issue=1 |pages=39–43 |year=1999 |pmid=10218040 |doi=]

* Dental braces are a common physical trauma that can lead to mouth ulcers and the dental bracket can be covered with wax to reduce abrasion of the mucosa. Avoidance of other types of physical and chemical trauma will prevent some ulcers, but since such trauma is usually accidental, this type of prevention is not usually practical.

Nutritional therapy

* Avoiding citrus (sour) in your diet (lemons, oranges, acidic drinks, citric foods, and citric candies).
* Zinc deficiency has been reported in people with recurrent mouth ulcers. cite journal |author=Wang SW, Li HK, He JS, Yin TA |title= [The trace element zinc and aphthosis. The determination of plasma zinc and the treatment of aphthosis with zinc] |language=French |journal=Rev Stomatol Chir Maxillofac |volume=87 |issue=5 |pages=339–43 |year=1986 |pmid=3467416 |doi=] The few small studies looking into the role of zinc supplementation have mostly reported positive results particularly for those people with deficiency, cite journal |author=Orbak R, Cicek Y, Tezel A, Dogru Y |title=Effects of zinc treatment in patients with recurrent aphthous stomatitis |journal=Dent Mater J |volume=22 |issue=1 |pages=21–9 |year=2003 |pmid=12790293 |doi=] although some research has found no therapeutic effect. cite journal |author=Wray D |title=A double-blind trial of systemic zinc sulfate in recurrent aphthous stomatitis |journal=Oral Surg. Oral Med. Oral Pathol. |volume=53 |issue=5 |pages=469–72 |year=1982 |pmid=7048184 |doi=10.1016/0030-4220(82)90459-5]

ee also

* Oral ulcer


External links

* [http://www.mayoclinic.com/invoke.cfm?id=DS00354 MayoClinic.com: Canker sore]
* [http://www.aafp.org/afp/20000701/149.html Management of Aphthous Ulcers, American Family Physician]

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