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| {{Aphthous ulcer}} | | {{Aphthous ulcer}} |
| {{CMG}} | | {{CMG}} |
| | ==[[Aphthous ulcer overview|Overview]]== |
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| ==Overview== | | ==[[Aphthous ulcer historical perspective|Historical Perspective]]== |
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| ==Presentations of aphthous stomatitis== | | ==[[Aphthous ulcer pathophysiology|Pathophysiology]]== |
| Aphthous ulcers are classified according to the diameter of the lesion.
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| ===Recurrent Aphthous Stomatitis=== | | ==[[Aphthous ulcer epidemiology and demographics|Epidemiology & Demographics]]== |
| Recurrent Aphthous Stomatitis is a [[T-cell]] [[Cell-mediated immunity|mediated]] localized destruction of oral mucosa associated with an increased relative ratio of CD8+ T-cells to CD4+ T-cells.
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| [[Image:Mouth sore.JPG|290px|thumb|left|Large aphthous ulcer on the inner side of the lower lip: 10 mm (1 cm) length and 5 mm width. <!-- Recurred for the third time in the same place, though, previous two times it was small. -->]] | | ==[[Aphthous ulcer risk factors|Risk Factors]]== |
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| ===Minor aphthous ulcerations=== | | ==[[Aphthous ulcer causes|Causes]]== |
| This is the most common and least severe form of the disease. Aphthous ulcers develop in childhood and [[adolescence]], and continue sporadically throughout life. Aphthous ulcers occur exclusively on non-[[keratinized]], moveable mucosa, such as buccal (cheeks) and [[lingual]] mucosa, the floor of the mouth, and the [[soft palate]]. It is characterized as a yellow-gray ulcer surrounded by an [[erythema]]tous halo less than 10 mm in diameter. They tend to heal without scarring in 7–10 days.
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| Typical '''treatment''' is with topical [[steroid]]s, although treatment is not necessary for healing to occur.
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| ===Major aphthous ulcerations=== | | ==[[Aphthous ulcer differential diagnosis|Differentiating Aphthous ulcer]]== |
| ''Major aphthous ulcers'' have the same appearance as minor ulcerations, but are greater than 10 mm 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-[[keratin]]izing oral surfaces, but the ulcer borders may extend onto keratinized surfaces. The lesions heal with scarring and cause severe pain and discomfort.
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| [[Image:Aphthous ulcer in the back of the mouth.jpg|thumb|200px|left|Major aphthous ulcer in the back of the mouth]] | | ==[[Aphthous ulcer natural history|Complications & Prognosis]]== |
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| ===Herpetiform aphthous ulcerations=== | | ==Diagnosis== |
| 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 care|Palliative]] treatment is almost always necessary.<!--
| | [[Aphthous ulcer history and symptoms|History and Symptoms]] | [[Aphthous ulcer physical examination|Physical Examination]] | [[Aphthous ulcer laboratory tests|Laboratory tests]] | [[Aphthous ulcer electrocardiogram|Electrocardiogram]] | [[Aphthous ulcer chest x ray|X Rays]] | [[Aphthous ulcer CT|CT]] | [[Aphthous ulcer MRI|MRI]] | [[Aphthous ulcer echocardiography or ultrasound|Echocardiography or Ultrasound]] | [[Aphthous ulcer other imaging findings|Other images]] | [[Aphthous ulcer other diagnostic studies|Alternative diagnostics]] |
| --><ref>{{cite journal | author = Bruce A, Rogers R | title = Acute oral ulcers. | journal = Dermatol Clin | volume = 21 | issue = 1 | pages = 1–15 | year = 2003 | id = PMID 12622264}}</ref> | |
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| == Symptoms == | | ==Treatment== |
| 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.
| | [[Aphthous ulcer medical therapy|Medical therapy]] | [[Aphthous ulcer surgery|Surgical options]] | [[Aphthous ulcer prevention|Prevention]] | [[Aphthous ulcer cost-effectiveness of therapy|Financial costs]] | [[Aphthous ulcer future or investigational therapies|Future therapies]] |
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| 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 [[clot]]ting of blood. The ulcer, which itself is often extremely painful, especially when agitated, may be accompanied by a painful swelling of the [[lymph node]]s below the jaw, which can be mistaken for [[toothache]].
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| == Causes ==
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| The exact cause of aphthous ulcers is unknown. Factors that provoke them include [[stress (psychology)|stress]], [[fatigue (physical)|fatigue]], [[illness]], injury from accidental biting, [[hormone|hormonal]] changes, [[menstruation]], sudden [[weight loss]], [[food allergy|food allergies]], the foaming agent in toothpaste ([[Sodium lauryl sulfate|SLS]]), and deficiencies in [[vitamin B12]], [[iron]], and [[folic acid]].<ref>{{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}}</ref> Some drugs, such as [[nicorandil]], also have been linked with mouth ulcers. In some cases they are thought to be caused by an overreaction by the body's own [[autoimmunity|immune system]].
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| 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 foods 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. contain [[Sodium dodecyl sulfate|Sodium lauryl sulfate]] (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.<!--
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| --><ref>{{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}}</ref><!--
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| --><ref>{{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}}</ref><!--
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| --><ref>{{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}}</ref>
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| However, some studies find no connection between SLS in toothpaste and mouth ulcers.<!--
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| --><ref>{{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}}</ref>
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| Artificial sugars, such as those found in diet cola and sugarless gum, have been reported as causes of aphthous ulcers as well. They can also be linked to an increased intake of acids such as [[ascorbic acid]] (one form of [[Vitamin C]]) or [[citric acid]]. In this case the sores disappear after intake decreases (for example, by substituting [[ascorbate]] [[salt]]s for ascorbic acid).
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| According to small-scale experiments by one [[patent]] applicant Hau, ({{US patent|6248718|6,248,718}}), topical preparations of high doses of [[penicillin]] resulted in accelerated healing of mouth ulcers.
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| There is a commonly held belief that another cause of aphthous ulcers is gluten intolerance ([[Celiac disease]]), whereby consumption of [[wheat]], rye, barley and sometimes oats can result in chronic mouth ulcers. However, two small studies of patients with Celiac disease have demonstrated no link between the disease and aphthous ulcers.<ref name="bucci">{{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}}</ref><ref>{{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}}</ref> If patients with aphthous ulcers do happen to have gluten intolerance, they may experience benefit in eliminating breads, pastas, cakes, pies, scones, biscuits, beers and so on from their diet and substituting gluten-free varieties where available.<ref name="bucci"/>
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| 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.<ref name="Lewkowicz">{{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}}</ref> The presence of the unrecognized [[molecule]]s garners a reaction by the [[T-cell]]s, which trigger a reaction that causes the damage of a mouth ulcer. People who get these ulcers have lower numbers of regulatory [[T-cell]]s.<ref name="Lewkowicz">{{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}}</ref>
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| Repeat episodes of aphthous ulcers can be indicative of an [[immunodeficiency]], signalling low levels of [[immunoglobulin]] in the mucous membrane of the mouth. Certain types of [[chemotherapy]] cause mouth ulcers as a side effect.<!--
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| --><ref name="nonhodgkinsAdvice">{{cite web | title=Non Hodgkin's Lymphoma Cyberfamily — Side effects | url=http://www.nhlcyberfamily.org/effects.htm | publisher=NHL Cyberfamily | accessdate=2006-08-10}}</ref>
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| Mouth ulcers may also be symptoms or complications of several diseases listed in the following section. The treatment depends on the believed cause.
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| ==Pain relief and healing==
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| '''Any mouth sore that does not heal after two weeks should be looked at by a dentist or an oral surgeon as it could be a sign of a more serious condition such as [[oral cancer]].'''
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| Aphthous ulcers normally heal without treatment within 1 to 2 weeks. Good oral [[hygiene]] should be maintained, and spicy, acidic, and salty foods and drinks are best avoided, as they may irritate existing ulcers. Strong mouthwash such as [[Listerine]] has also been known to cause irritation because of its strong ingredients, and many oral care professionals discourage the use of it while having a mouth ulcer. | |
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| Pain can be mitigated by an [[Over-the-counter_drug|OTC]] pain-relieving gel, such as [[Anbesol]], [[Bonjela]], Campho-Phenique, Orabase B, Zilactin, or Kanka, available in drugstores.
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| [[Triamcinolone]] Acetonide dental paste can be very effective; the [[steroid]] reduces the immune system's response in the area of the ulcer. It is available by prescription only for bigger pack size - 10g or over the counter for smaller pack size - 5g in pharmacies in the UK.
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| A recent study of the Oral-B product Amosan suggests that it may reduce [[anaerobic bacteria]], such as those found in oral wounds. The study did not, however, demonstrate the efficacy of the product in treating mouth ulcers.<!--
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| --><ref>{{cite journal | author = Wennström J, Lindhe J | title = Effect of hydrogen peroxide on developing plaque and gingivitis in man. | journal = J Clin Periodontol | volume = 6 | issue = 2 | pages = 115–30 | year = 1979 | id = PMID 379049}}</ref>
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| [[Tincture of benzoin]] can be used as a protectant for recurring aphthous ulcers, by forming a layer over the sore and protecting it from further irritation.
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| ===Home remedies===
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| <!--
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| PLEASE ONLY INCLUDE REMEDIES SUGGESTED BY RELIABLE SOURCES - E.G. UNIVERSITIES, MEDICAL ORGANISATIONS, HOSPITALS, ETC - OTHERWISE THIS COULD EASILY GET OUT OF HAND
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| [[Aspirin]] is an excellent home remedy. Applied directly to the ulcer, it both alleviates pain and reduces inflamation from the T-cells. Care should be taken to avoid leaving an aspirin poltice on the ulcer for more than a few minutes, as burning of surrounding tissues may ensue. Those who find the taste of aspirin objectionable may prefer to use children's aspirin.
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| -->Some home remedies that have been suggested include:
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| * Licorice Root (Glycyrrhiza) in the form of over-the-counter medicated disk patches may help heal or reduce the growth of canker sores if applied early on.[http://www.webmd.com/oral-health/news/20070322/patch-may-help-heal-canker-sores]
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| * Sticking a small aspirin on the sore and applying pressure
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| * Apply three pinches of table [[salt]] on the sore. (Note this can be painful)
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| [[Antacid]] techniques suggested include the following:
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| * Gargling warm water and salt sometimes provides temporary relief from pain, and the salt may promote healing.
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| * Swab the ulcers with [[Milk of Magnesia]].<!--
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| -->[http://www.mayoclinic.com/health/canker-sore/DS00354/DSECTION=7]
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| * Make a paste of baking soda and water; apply directly to the ulcers.<!--
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| -->[http://www.pitt.edu/~cjm6/s98canker.html]
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| * Make a mix of half [[milk of magnesia]] and half [[Benadryl]], and hold in the mouth for up to 3 minutes.<ref>[http://familydoctor.org/613.xml Canker Sores: What Are They and What Can You Do About Them? (American Academy of Family Physicians)]</ref>
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| == Treatment for severe cases ==
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| In very severe cases, a doctor may prescribe a [[steroid]] treatment. One such steroid is [[methylprednisolone]] (usually in a dose-pack), taken orally for a period of 7 days. Alternatively, the doctor may inject a steroid directly into the site of the ulcer (this treatment is performed with kenalog. Between 0.2 and 0.4 ml of kenalog is injected into the site of the ulcer, which will usually be completely healed 72 to 96 hours after the injection).
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| Patients in whom ulcers do not respond to local treatment may benefit from a short course of pulsed [[prednisone]].
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| Some [[Dentistry|dentists]] recommend a [[sulfuric acid]] solution for treating mouth ulcers, such as debacterol.
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| [[Thalidomide]] has been effective in unresponsive aphthous stomatitis. Thalidomide has been used successfully generally to treat various inflammatory conditions characterized by tissue infiltration with [[polymorphonuclear leukocytes]] (PMNLs). Therapeutic benefit has been attributed to depression of PMNL [[chemotaxis]] and, possibly, PMNL [[phagocytosis]]. However, adverse effects can be both problematic and clinically significant.
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| Another chemical treatment option is the application of [[silver nitrate]] to cauterize the sore. In clinical trials it was found that this treatment reduced pain in patients by 70% with one application but had no effect on healing compared to placebo.<!--
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| --><ref>{{cite journal | author=Alidaee M, Taheri A, Mansoori P and Ghodsi S | title=Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial | journal=Br J Derm | year=2005 | month=September | volume=153 | issue=3 | pages=521 | id={{DOI|10.1111/j.1365-2133.2005.06490.x}}}}</ref>
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| Another choice doctors have is to prescribe Aphthasol, the only [[Food and Drug Administration]] (FDA) approved treatment specifically indicated for Aphthous ulcers.
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| Controversial therapies include [[levamisole]], [[colchicine]], gamma-[[globulin]], [[dapsone]], [[estrogen]] replacement, [[MAOIs]], and [[tetracycline]]. [http://www.emedicine.com/ped/topic2672.htm]
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| Some evidence supports treatment with tetracycline. Tetracycline oral mouth rinse (ie, swish orally and swallow) decreases healing time and pain severity and duration. Whether this benefit is due to a direct antimicrobial effect, tetracycline's anti-inflammatory properties<!--
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| --><ref>{{ 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 }}</ref> or to an inhibitory effect on chemotaxis and chemotoxicity is not known.
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| The miracle cures that are advertised should be viewed with skepticism. However, [[aqueous]] sulphuric acid products as listed above can provide significant pain relief, if not treating the underlying causes.
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| == Prevention ==
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| ===Oral and dental measures===
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| * Regular use of [[mouthwash]] may help prevent or reduce the frequency of sores.<ref>Studies mostly agree that antiseptic mouthwashes can help prevent recurrences:<br>* {{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. | year=1991 | month=Oct | volume=72 | issue=4 | pages=425–9 | id=PMID 1923440}}<br>* {{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 | year=1996 | month=Aug | volume=23 | issue=8 | pages=778–81 | id=PMID 8877665}}<br>But this is not accepted by all reports:<br>* {{cite journal | author=Barrons RW. | title=Treatment strategies for recurrent oral aphthous ulcers. | journal=Am J Health Syst Pharm.| year=2001 | month=Jan 1 | volume=58 | issue=1 | pages=41–50 | id=PMID 11194135}}</ref>
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| * 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 simply 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.<!--
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| --><ref>{{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. | year=1996 | month=Jun | volume=54 | issue=3 | pages=150–3 | id=PMID 8811135}}</ref><!--
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| --><ref>{{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. | year=1997 | month=Dec | volume=18 | issue=12 | pages=1238–40 | id=PMID 9656847}}</ref><!--
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| --><!--
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| --><ref>{{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. | year=1999 | month=Jan | volume=5 | issue=1 | pages=39–43 | id=PMID 10218040}}</ref>
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| * [[Dental brace]]s are a common physical trauma that can lead to mouth ulcers and can be treated 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.
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| *Take caution when brushing or flossing teeth, and be extra careful when using a toothpick.
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| ===Nutritional therapy===
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| * [[Zinc]] deficiency has been reported in people with recurrent mouth ulcers.<!--
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| --><ref>{{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. | year=1986 | volume=87 | issue=5 | pages=339–43 | id=PMID 3467416}}</ref><!--
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| -->The few small studies looking into the role of zinc supplementation have mostly reported positive results particularly for those people with deficiency,<!--
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| --><ref>{{cite journal | author=Merchant HW, Gangarosa LP, Glassman AB, Sobel RE | title=Zinc sulfate supplementation for treatment of recurring oral ulcers | journal=South Med J. | year=1977 | month=May | volume=70 | issue=5 | pages=559–61 | id=PMID 870981}}</ref><!--
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| --><ref>{{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. | year=2003 | month=Mar | volume=22 | issue=1 | pages=21–9 | id=PMID 12790293 }}</ref><!--
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| -->although some research has found no therapeutic effect.<!--
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| --><ref>{{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 | year=1982 | month=May | volume=53 | issue=5 | pages=469–72 |id=PMID 7048184 }}</ref>
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| | ==Case Studies== |
| ==See also== | | ==See also== |
| * [[Mouth ulcer]] | | * [[Mouth ulcer]] |
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| ==References==
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| {{Reflist|2}}
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| == External links == | | == External links == |
| * [http://www.animated-teeth.com/canker_sores/t1_canker_sores.htm Animated-teeth.com canker sores] | | * [http://www.animated-teeth.com/canker_sores/t1_canker_sores.htm Animated-teeth.com canker sores] |
| * [http://www.mayoclinic.com/invoke.cfm?id=DS00354 MayoClinic.com: Canker sore]
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| * [http://www.aafp.org/afp/20000701/149.html Management of Aphthous Ulcers, American Family Physician] | | * [http://www.aafp.org/afp/20000701/149.html Management of Aphthous Ulcers, American Family Physician] |
| * [http://www.mothernature.com/Library/Bookshelf/Books/10/41.cfm MotherNature.com: Canker Sores] | | * [http://www.mothernature.com/Library/Bookshelf/Books/10/41.cfm MotherNature.com: Canker Sores] |
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| {{Oral pathology}}
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