How To Tell If You Have A Canker Sores (aphthous Ulcers)

Canker sores (aphthous ulcers) are painful ulcers that occur in the lining of the mouth. Ulcers are not cancerous, but they may be contagious. The mouth and adjacent areas are involved. Canker sores can affect both sexes, all ages, but is more common in females. The typical appearance involves an erythematous periphery with a white or yellow depressed center. Healing within 10 to 14 days is the rule.

Causes: Viral (coxsackievirus, herpesvirus), systemic illness (Crohn's disease, lupus, Behcet's disease, erythema multiforme), toothpaste (sodium lauryl sulfate), stress, and smoking. Dental trauma, vitamin B12, folate, and iron deficiency have also been implicated in some cases.

Treatment: Symptomatic relief can be obtained by the use of diphenhydramine elixir as a mouth rinse that is then xpectorated. Alternatively, viscous lidocaine 2% can be used in the adult. This may suppress the gag reflex, however, and may result in systemic toxicity in children. The application of a topical steroid (triamcinalone as 0.1% in Orabase) or steroid mouth rinse (betamethasone syrup) may accelerate recovery. Herpetiform ulcerations may respond to tetracycline syrup, which is used as a mouth rinse and then swallowed. A burst of oral prednisone may be required in some cases. The use of multiple other drugs including cyclosporin A, colchicine, thalidomide, and dapsone attest to the stubborn nature of these lesions. A mixture of nystatin 12,500 units, diphenhydramine 1.25 mg, and hydrocortisone 0.25 mg/ml has been used as a "shotgun" solution. Some also include tetracycline syrup in the mixture.

Prevention: Using a toothpaste free of sodium lauryl sulfate or changing toothpastes has been shown to be helpful in some cases. Topical use of steroids, mouth rinses, may decrease recurrence. Recently, pentoxifylline has been used to prevent recurrent aphthous ulcers in an open label trial. However, blinded studies are lacking.

Herpes simplex virus infrequently causes recurrent intraoral herpes. The lesions occur as a cluster of vesicles that rupture leaving superficial ulcerations that remain for 3 to 10 days. Keratinized tissues, attached gingiva, and the hard palate are often involved, and such features distinguish herpes from aphthous ulcers. Treatment with acyclovir may decrease healing time.

Findings of a study show that 90% of HIV-positive patients with aphthous ulcers of the mouth and oropharynx have at least partial healing in response to treatment with thalidomide.

Dr. Jeffrey M. Jacobson of the Bronx Veterans Affairs Medicine Center in New York City and colleagues at 19 sites treated 29 HIV-positive patients with 200 mg thalidomide or placebo daily for 4 weeks. All subjects had biopsy-confirmed oral aphthous ulcers at least 2 weeks prior to treatment. The double-blind, randomized study was part of the AIDS Clinical Trials Group protocol 251 sponsored by the National Institute of Allergy and Infectious Diseases. In addition to weekly evaluations of the subjects` clinical status, quality of life and evidence of drug toxicity, the researchers also measured plasma tumor necrosis factor alpha (TNF-alpha), soluble TNF-alpha receptors and HIV RNA.

Dr. Jacobson reports that by 4 weeks, 55% of treated subjects experienced complete healing of their ulcers, compared with 7% in the placebo group. Some patients had complete healing as early as 1 week. The subjects also reported less pain and were better able to eat. Treatment side effects included somnolence and rash, and toxicity necessitated treatment discontinuation in six subjects.

According to Dr. Jack Y. Killen, director of the Division of AIDS at the National Institute of Allergy and Infectious Diseases in Bethesda, Maryland, "thalidomide is the first treatment shown in a scientific study to heal these ulcers." He also cautioned that thalidomide treatment should be carefully monitored and limited in its duration because of the drug's potential toxicity.

  • Mark A. Graber, M.D. and Laura Beaty, M.D. Otolaryngology: Tongue and Mouth. University of Iowa Family Practice Handbook, 3rd Edition, Chapter 19

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