Canker Sores
(Aphthous Ulcers)
What are canker sores?
Canker sores are small ulcer craters in the lining of the mouth that are frequently painful and sensitive. About 20% of the population (1 out of 5) people have canker sores at any one time. Canker sores are also medically known as aphthous ulcers. 
Women are more likely than men are to have recurrent canker sores. Genetic studies show that susceptibility to recurrent outbreaks of the sores is inherited in some patients. This partially explains why family members often share the condition.
What are symptoms of canker sores?
Canker sores are usually found on the movable parts of the mouth such as the tongue or the inside lining of the lips and cheeks. The ulcers begin as small oval or round reddish swellings that usually burst within a day. The ruptured sores are covered by a thin white or yellow membrane and edged by a red halo. Generally, the sores heal within 2 weeks without scarring. Canker sores range in size from an eighth of an inch wide in mild cases to more than an inch wide in severe cases. Severe canker sores may leave scars. Fever is rare, and the sores are rarely associated with other diseases. Usually, a person has only one or a few canker sores at a time.
Most people experience their first bout with canker sores between the ages of 10 and 20. Children as young as 2, however, can develop the condition. The frequency of canker sore recurrences varies considerably. Some people have only one or two episodes a year, while others may have a continuous series of canker sores.
What are the causes of canker sores?
The cause of canker sores is not well understood. More than one cause is likely, even for individual patients. Canker sores do not appear to be caused by viruses or bacteria, although an allergy to a type of bacterium commonly found in the mouth may trigger them in some people. The sores may be an allergic reaction to certain foods. In addition, there is research suggesting that canker sores may be caused by a faulty immune system that uses the body's defenses against disease to attack and destroy the normal cells of the mouth or tongue.
British studies show that in about 20 percent of patients, canker sores are due partly to nutritional deficiencies, especially lack of vitamin B 12, folic acid, and iron. Similar studies performed in the United States, however, have not confirmed this finding. In a small percentage of patients, canker sores occur along with gastrointestinal problems, such as an inability to digest certain cereals. In these patients, canker sores appear to be part of a generalized disorder of the digestive tract.
Other causes of canker sores are injury to the gums from brushing and illnesses in which the immune system causes swelling or inflammation of the body tissues (autoimmune disorders). Examples of autoimmune disorders are systemic lupus erythematosus , Crohn's disease , and Bechet's syndrome. Smoking and dentures can also contribute to the problem.
Female sex hormones also apparently play a role in causing canker sores. Many women experience bouts of the sores only during certain phases of their menstrual cycles. Additionally, most women experience improvement or remission of their canker sores during pregnancy. Researchers have used hormone therapy successfully in clinical studies to treat some women. Both emotional stress and injury to the mouth can trigger outbreaks of canker sores, but these factors probably do not cause the disorder.
What steps can be taken to help canker sores?
If you have canker sores, avoid abrasive foods such as potato chips that can stick in the cheek or gum and aggravate the sores. Take care when brushing your teeth not to stab the gums or cheek with a toothbrush bristle. Avoid acidic and spicy foods. Canker sores are not contagious, so patients do not have to worry about spreading them to other people.
What is the treatment for canker sores?
The treatment depends on the cause. If the cause is another illness, such as lupus, treating the underlying illness often results in healing the ulcers. In some cases, something as simple as changing toothpastes may get rid of recurrent canker sores. A "natural" toothpaste such as Tom's of Maine or another toothpaste that doesn't contain additives (especially sodium lauryl sulfate) is sometimes helpful.
There are several treatments for reducing the pain and duration of canker sores for patients whose outbreaks cannot be prevented. These include numbing ointments such as benzocaine, which are available in drug stores without a prescription. Anti-inflammatory steroid mouth rinses or gels can be prescribed for patients with severe sores. (See additional information below on steroid use.) A number of medications have been used for canker sores including diphenhydramine suspension (Benadryl and others). This liquid medication can be used as a mouth rinse in adults to provide temporary relief from the pain caused by canker sores. Patients should not swallow the diphenhydramine, but simply use it as a mouth rinse.
Mouth rinses containing the antibiotic tetracycline may reduce the unpleasant symptoms of canker sores and speed healing by preventing bacterial infections in the sores. Clinical studies at the National Institute of Dental Research have shown that rinsing the mouth with tetracycline several times a day usually relieves pain in 24 hours and allows complete healing in 5 to 7 days. The U.S. Food and Drug Administration warns, however, that tetracycline given to pregnant women and young children can permanently stain the children's teeth. Both steroid and tetracycline treatments require a prescription and care of a dentist or physician.
There are other topical medications that a healthcare practitioner can prescribe to ease the discomfort. Medications such as steroids (triamcinalone) or antibiotics (tetracycline) used topically on the ulcers sometimes promote healing. There is no evidence that antibiotics taken orally (swallowed) are helpful. If the canker sores are caused by a yeast infection, a topical anti-fungal medication can be used (nystatin). Some people with AIDS (HIV infection) who have canker sores respond well to thalidomide .
Patients with severe recurrent canker sores may need to take steroid or other immuno-suppressant drugs orally. Steroid mouth rinses have been shown to reduce the inflammation and number of recurrences and are reserved for more severe cases due to potential side effects. These potent drugs can cause many undesirable side effects, and should be used only under the close supervision of a dentist or physician.
What should I do if I get canker sores frequently?
Contact your healthcare professional. Most cases of canker sores do not reflect an underlying illness. However, if you are having canker sores frequently, your health care professional can check some very simple things to assure you there isn't a serious underlying cause. Most doctors recommend that patients who have frequent bouts of canker sores undergo blood and allergy tests to determine if their sores are caused by a nutritional deficiency, an allergy, or some other preventable cause. Vitamins and other nutritional supplements often prevent recurrences or reduce the severity of canker sores in patients with a nutritional deficiency. Patients with food allergies can reduce the frequency of canker sores by avoiding those foods.
What research is being done in the area of canker sores?
Researchers are trying to identify the malfunctions in patients' immune systems that make them susceptible to recurrent bouts of canker sores. By analyzing the blood of people with and without canker sores, scientists have found several differences in the immune function between the two groups. Whether these differences cause canker sores is not yet known.
Researchers also are developing and testing new drugs designed to treat canker sores. Most of these drugs alter the patient's immune function. Although some of the drugs appear to be effective in treating canker sores in some patients, the data are still inconclusive. Until these drugs are proven to be absolutely safe and effective, they will not be available for general use. - Canker sores are small ulcer craters in the lining of the mouth.
- The sores are usually found on the movable parts of the mouth.
- The ulcers can be caused by a number of conditions.
- The treatment of canker sores depends on the cause.
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