Aphthous Ulcer Treatment – Canker Sore Remedies – Recurrent Aphthous Stomatitis

February 7, 2012 6:04 pm Published by

Canker sores (Recurrent Aphthous Stomatitis, RAS or Recurrent Aphthous Ulcers, RAU) are idiopathic (canker sore causes are unknown) oral lesions that occur in approximately 10 -15% of the population. Most people who get canker sores find they recur several times a year. They typically appear as a white oval on the cheeks, lips, palate and tongue that lasts for about seven days. Ten percent of people who get canker sores will get major canker sores. Major canker sores (aka Sutton Ulcers or Periadenitis Mucosa Necrotica Recurrens) can reach up to a half inch in size and last for one or more months; they typically affect immunosuppressed people. Major canker sores can leave permanent scars. All canker sores can be extremely painful, highly disproportionate to their size. The pain from canker sores can prevent people from eating and/or drinking; this can lead to malnutrition and dehydration. Many people therefore seek help with canker sore relief. Unlike Herpes, canker sores are not contagious.

Physical trauma to the inner lining of the mouth (e.g. cheek biting, pizza burn), stress, diet or an allergic reaction to a food, toothpaste or mouthwash may cause a canker sore to occur. Vitamin B12 & folate deficiency, gluten sensitivity, allergy to sodium lauryl sulfate in toothpaste and smoking cessation are all liked to the development of canker sores. Men develop canker sores less frequently than women. Some medical conditions like Crohn’s disease, ulcerative colitis and celiac disease result in a higher incidence of canker sores. It also appears more frequently in people who have HIV/AIDS, neutropenia, reactive arthritis and those undergoing cancer chemotherapy who develop Oral Mucositis. Susceptibility to canker sores appears to be genetic.

Treatment for canker sores include: analgesics, anesthetics, antiseptics, anti-inflammatory agents, steroids, fumaric acid esters, sucralfate, tetracycline suspension and silver nitrate. The two most common anesthetic gels applied to canker sores are Benzocaine and Lidocaine. Another approach would be to use topical Benzydamine Hydrochloride (Amlexanox) which is an anti-inflammatory, anti-allergic medication. It was reformulated as a 5% topical oral paste that will adhere to oral mucosa and approved by the FDA for the treatment of canker sores. This will relieve pain and accelerate ulcer healing.

Other canker sore remedies use a protective barrier, such as topical Hyaluronic Acid or Cyanoacrylate adhesives. Topical Hyaluronic Acid is made up of 0.2 % Hyaluron Gel. It acts as a protective barrier that functions to help in local tissue hydration. It also serves as an anti-oxidant.

Antimicrobials that will reduce the duration of the ulcer. Some antimicrobials used are Chlorhexidine, Triclosan, Tetracycline, and Penicillin G. All of these are used to reduce ulcer pain and hasten healing time. Chlorhexidine comes in a 0.2% mouth rinse or 1% gel and is used to increase the number of ulcer- free days. Triclosan is an anti-inflammatory agent, as well as an antimicrobial and is used to reduce the number of canker sores, relieve pain, and shorten duration. There is some concern, however, about the use of Triclosan. Tetracycline has an anti-inflammatory effect that works in the ulcerative phase. Penicillin G can be used four times a day for 4 days and will reduce the healing time, pain and size of the ulcer.

Steroids and Immunomodulation can also be used in the canker sore healing process as well. Steroids come in mouth rinses (Betamethasone Valearate), ointment, and creams (Triamcinolone Acetonide). Immunomodulation treats canker sores by affecting the immune system. A few immunomodulators are Thalidomide, Colchicine, Pentoxifylline, Levamisole, Dapsone, and Cimetidine. The immunostimulant, Thalidomide, is especially useful in HIV positive patients with RAS. Some adverse drug reactions include teratogenic, rashes and peripheral neuropathy. Levamisole will reduce the pain and frequency of ulcers and also promotes healing.

Other medications used to treat canker sores are: Adalimumab, Alefacept, Cyclophosphamide, Cyclosporine, Dapsone, Efalizumab, Etanercept, Infliximab, Interferon, Methotrexate, and Penoxifylline. Herbal remedies include: Licorice Root, Sage, Echinacea, Chamomile and Myrrh. Magic Mouthwash provides a limited benefit. Hydrogen peroxide, salt water rinse, Milk of Magnesia and liquid antihistamines can be used as mouth rinses. Silver Nitrate Sticks cause a chemical burn when applied to the oral mucosa.

Physical therapy may be employed to manage the ulcer: surgical removal, laser ablation, chemical cautery, and low dense ultrasound. Laser therapy reduces canker sore pain and may reduce the frequency of recurrence. Cryotherapy (freezing the canker sore) does not work.

The canker sore treatment we use in our office involves a medication that induces a chemical burn (chemical cautery) on the canker sore. The exposed nerve endings of the canker sore are covered in a callus that forms in response to the burn. This burn will last about seven days but during that time nearly all of the pain associated with the canker sore will be gone.  This aphthous ulcer medication is currently available as an in-office treatment, or by prescription, only after diagnosis in our office.  The procedure itself takes a few minutes and is not painful.

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This post was written by Dr. Jeffrey Dorfman