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Canker Sores: An Overview

What You Need to Know About Canker Sores (Mouth Ulcers)

(canker sores = Recurrent Aphthous Stomatitis = RAS
= aphthous ulcers = oral ulcers = mouth ulcers)

Canker sores (mouth ulcers) plague the lives of millions. While for some these small oral ulcerations present only a minor nuisance, for others, canker sores (mouth ulcers) make life nearly unbearable. The situation is often made worse when a patient's doctor or dentist does not know how to treat or prevent these ulcers leaving the patient frustrated and in pain.

We see many people who suffer from canker sores (mouth ulcers). In fact, canker sores are very common affecting nearly 20% of the population.

The good news is that while much remains unknown about canker sores (mouth ulcers), inroads have been made into effectively preventing and treating these nuisances.

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The Difference Canker Sores (Mouth Ulcers) and Fever Blisters (Cold Sores)

Often, canker sores (mouth ulcers) are confused with fever blisters (cold sores). While fever blisters and canker sores share several features in common (such as the fact that both are very common, often recurrent, and can be very painful), there are important differences:

Canker Sores (Mouth Ulcers):

Are strictly intraoral meaning that canker sores occur only within the mouth.

  1. Are not contagious meaning they can not be spread from person to person.
  2. Are not caused by a virus.

Fever Blisters (Cold Sores), on the other hand:

  1. Are preceded by small blisters called vesicles.
  2. Usually occur on the outside of the mouth although they sometimes occur on the inside of the mouth. When they do occur on the inside of the mouth, fever blisters appear on bound (non-movable) sections of the mouth such as the mouth roof.
  3. Are contagious meaning they can be spread from person to person.
  4. Are caused by a virus.

It appears that what we eat may influence whether or not we come down with an episode of canker sores. Some people have allergies to certain foods. Consumption of these foods can lead to canker sores. Studies show that elimination of these offending foods can sometimes dramatically reduce the number of canker sore episodes a person experiences.

The Three Classes of Canker Sores (Mouth Ulcers)

The three classes of canker sores refer to the size and duration of the canker sores.

Minor Recurrent Stomatitis:
Small canker sores (mouth ulcers) usually less than one centimeter in diameter. This is the most prevalent form of canker sores accounting for nearly 70% of all cases. Usually these canker sores heal within 7-10 days with little or no scarring.

Major Recurrent Stomatitis:
Larger canker sores (mouth ulcers) often greater than 1 cm in size. These canker sores can take longer to heal (up to three weeks or longer) and may leave scarring after they heal.

Canker sores (mouth ulcers) are pinpoint 2-3 millimeter. Often these pinpoint canker sores merge into larger ulcerations. This is one of the rarer forms of canker sores.

The first canker sores usually occur between the ages of 10 and 20. During life, episodes usually, but not always, become less frequent and less severe. Interestingly, women often report increased susceptibility to canker sore formation during certain times of their menstrual cycle. Some women report complete relief from canker sores during pregnancy.

Interestingly, canker sores (mouth ulcers) affect people to varying degrees of severity. Some people may get an occasional outbreak of canker sores once or twice a year while others may suffer near continuous overlapping episodes of canker sores (mouth ulcers).

Systemic Conditions Associated with Canker Sores (Mouth Ulcers)

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Although the vast majority of canker sore cases are associated with no underlying illness, in a small percentage of cases, canker sores are indicative of a bodily (systemic) disorder. People with Behcet's Disease, for instance, will often have canker sores (mouth ulcers) in addition to genital lesions, eye lesions, and general skin afflictions.

Many people with digestive conditions such as celiac disease, Crohn's Disease, Ulcerative Colitis, and gluten hypersensitivity will also display canker sores as a manifestation of their underlying disorder. HIV infected patients may also develop canker sore like ulcers.

In the small percentage of cases where an underlying condition may be suspected, a careful medical history and examination by a physician will be able to indicate whether canker sores in a particular patient are associated with an underlying disorder.

What Causes Canker Sores (Mouth Ulcers)?

Current theories on the causes of canker sores have focused on the immune system. This research suggests that canker sores may be caused by the body's own immune system attacking the cells lining the inside of the mouth.

Research is being conducted to determine what makes a person susceptible to canker sores in the first place as well as what actions and mechanisms trigger canker sore outbreaks. Among those things that may trigger an attack or make a person more susceptible are ingredients in toothpastes, certain allergies to food products and preservatives, trauma from overzealous brushing or lip biting, and stress.

Treatment of Canker Sores (Mouth Ulcers)

Usually canker sores clear within 7-14 days without treatment. During this time, however, the canker sores can be painful especially when people eat or drink. Treatment helps ease the pain and may help reduce the amount of time it takes for the ulcers to go away.

Conventional treatments usually fall into three categories:

  • Corticosteroid Rinses and Gels: Often prescribed by a dentist or physician for severe or painful cases, these medications have proven extremely effective. A topical prescription steroid (non-alcoholic) gel of lidex applied lightly to the ulcer 2-4 times daily is commonly prescribed. The biggest downside to the medication is that it hurts upon application.
  • Analgesic (Pain Relieving) and Protective Ointments and Gels: These are pain relieving medications which can be purchased at your local drug store. These include compounds such as Zilactin or Oragel. Many of these compounds, after being applied, dry forming a protective cover over the sensitive ulcerations.
  • Anti-microbial Mouthwashes: Surprisingly the use of anti-microbial mouthwashes has provided effective relief for many. Canker Sores are not caused by a bacteria or virus so the mechanisms by which these anti-microbial mouthwashes work remains unclear. Commonly prescribed are anti-microbial mouthwashes containing the active ingredient chlorhexidine gluconate.

On the Subject of Preventing Canker Sores (Mouth Ulcers)

Trauma to the inside of the mouth can trigger an outbreak of canker sores. This trauma includes overzealous tooth brushing, biting your cheek or tongue, and scraping the inside of your mouth with hard or sharp foods (like hard pretzels). Because of this:

  • We encourage our patients to cut down on eating foods like potato chips, hard pretzels, cut apples, and hard candies which might nick, abrade, or otherwise traumatize the oral tissue.
  • We encourage our patients to stop brushing so hard. This causes your toothbrush to injure your teeth, gums and oral mucosa. Studies indicate that two out of three people brush too hard. Unfortunately, most people can not consciously stop brushing so hard because tooth brushing is such an ingrained habit.

    Consequently, we encourage them to use the Alert toothbrush whose red light lights up when you begin to traumatize your oral tissue. It teaches you to brush with the force that will clean teeth and remove plaque but not damage gums and oral tissue.

  • We encourage our patients not to bite the insides of their mouth or the sides of their lips. Many people do this as a nervous habit. Others tend to bite the insides of their mouth while sleeping. For these people, we often suggest that a mouth guard be worn during sleep. This is often very effective at preventing further oral trauma.

Stress is another factor capable of triggering canker sores. We advise those patients susceptible to canker sores to try to reduce the stress in their lives. In today's society this is often easier said than done. Its well worth the effort, however, since reducing stress has other health benefits as well.

Research suggests that reactions to certain food products may be responsible for many cases of canker sores. Among the foods that may cause canker sores in certain people are: nuts, peanut butter, sea food, wheat products, chocolate, and milk.

Also implicated as a factor for canker sore occurrence are deficiencies in certain vitamins and minerals - principally B12, iron, and folic acid. Several British studies have shown deficiencies in these levels of vitamins / minerals in a significant number of canker sore sufferers. U.S. studies, however, do not show the same correlation between levels of these vitamins / minerals and canker sore occurrences.

One of the most exciting advances has been the establishment of the link between canker sores and an ingredient common to almost all toothpastes. The additive SLS or sodium lauryl sulfate may be a culprit in canker sore formation.

SLS (sodium lauryl sulfate) acts just like a detergent. It is used in the laboratory as a membrane destabilizer and solubilizer of proteins and lipids. SLS is used in toothpaste to emulsify (mix) oil and water based ingredients together. In your toothpaste it creates the foam you get when brushing.

The thought is that SLS may, in susceptible individuals, cause microscopic trauma or membrane disruption to the skin cells in the mouth. This along with trauma or actions of the immune system may lead to canker sore formation.

Although these are only preliminary studies and more research needs to be done, it does offer hope.

Many of my patients and my wife have benefited greatly from using toothpastes which don't contain SLS. We recommend Enamel Saver toothpaste which does not contain SLS.

Incredibly, many of the visitors to this website have e-mailed thanking us for the tip about SLS free toothpaste which had immediately made an impact by dramatically reducing the number of canker sores they experienced!

To learn more about the relationship between SLS and canker sores see our SLS article.

Keeping a Canker Sore (Mouth Ulcer) Diary

What can you do if you suspect one of the above factors may be causing your canker sores? We suggest keeping a Canker Sore Diary. This is a simple notebook in which you keep track of the toothpaste you use, the foods you eat, stressful events, and any trauma that may occur to the inside of your mouth. In the same notebook keep a record of the number of canker sore occurrences.

By keeping this notebook you may be able to correlate a specific factor to the cause of your canker sores.