Aphthous Ulcers| canker sores

Aphthous Ulcers| canker sores | causes and management

Aphthous Ulcers| canker sores

Updated 19/9/2021

Ulceration is a breach in the oral epithelium, which typically exposes nerve endings in the underlying lamina propria, resulting in pain or soreness, especially on eating spicy foods or citrus fruits. Patients vary enormously in the degree to which they suffer and complain of soreness in relation to oral ulceration.

It is always important to exclude serious disorders such as oral cancer or other serious disease, but not all patients who complain of soreness have discernible organic disease. Even in those with detectable lesions, the level of complaint can vary enormously – some patients with large ulcers complain little; others with minimal ulceration complain bitterly of discomfort. Sometimes there is a psychogenic or cultural influence.


Mucosal atrophy or desquamation – terms often used for thinning of the epithelium which assumes a red appearance since the underlying lamina propria containing blood vessels shows through. Most commonly seen in desquamative gingivitis (usually related to lichen planus, or less commonly to pemphigoid) and in geographic tongue (erythema migrans, benign migratory glossitis), a similar process may also be seen in systemic disorders such as deficiency states (of iron, folic acid or B vitamins)

Mucosal inflammation (mucositis, stomatitis) can cause soreness. Viral stomatitis, candidosis, radiation mucositis, chemotherapy-related mucositis and graft-versus-host-disease are examples. Erosion is the term used for superficial breaches of the epithelium. These often initially have a red appearance, since there is little damage to the underlying lamina propria, but it typically becomes covered by a fibrinous exudate and then has a yellowish appearance. Erosions are common in vesiculobullous disorders such as pemphigoid.


Ulcer is the term used usually where there is damage both to epithelium and lamina propria. An inflammatory halo, if present, also highlights the ulcer with a red halo, around the yellow or grey ulcer. Most ulcers are due to local causes such as trauma or burns but recurrent aphthous stomatitis must always be considered.

Aphthous Ulcers

Aphthous ulcers are very common and easy to recognize. Their cause remains uncertain, although an association with human herpesvirus 6 has been suggested. Found on freely moving, nonkeratinized mucosa (eg, buccal and labial mucosa and not attached gingiva or palate), they may be single or multiple, are usually recurrent, and appear as painful small round ulcerations with yellow-gray fibrinoid centers surrounded by red halos. Minor aphthous ulcers are less than 1 cm in diameter and generally heal in 10–14 days.

Major aphthous ulcers are greater than 1 cm in diameter and can be disabling due to the degree of associated oral pain. Stress seems to be a major predisposing factor to the eruptions of aphthous ulcers. A study found that the frequency of viral rhinitis and bedtime after 11 pm were independent predictors of aphthous ulcer frequency and severity in college students.

Twice as common in women than men, aphthous ulcers typically first appear between the ages of 10 and 40 in about 20 to 25 percent of the population. They may recur at any time. Aphthous ulcers do not occur on the skin outside of the mouth. Cold sores (fever blisters) on the lips are a different problem caused by the herpes virus.

Causes of Aphthous ulcers

We don’t know what causes an aphthous ulcer but we do know that they are not an infection (viral or bacterial). Aphthous ulcers are probably due to an attack of your mucous membrane by your own body’s immune system. The tendency to develop aphthous ulcers may be inherited. If your parents had aphthous ulcers, you have a 90% chance of developing them too. Since they are not caused by infection, you do not become immune to them. They are not contagious.

Frequently, aphthous ulcers first appear when a person is under physical or emotional stress, for example, during college exams. Trauma from dental procedures, aggressive tooth cleaning or accidentally biting your tongue or cheek, head colds, a deficiency in iron, folic acid, or vitamin B12, menstrual periods and other hormonal changes, food allergies and sodium lauryl sulfate found in toothpaste may be causes.


You will first feel a tingling or burning sensation followed by a red spot or bump that soon erodes into a painful ulcer. The pain may continue for seven to fourteen days, sometimes with worsening pain until the end. Any acid drinks or food (for example colas and orange juice) increase the pain.

Just before the ulcer heals, it may have a gray membrane. Occasionally, with a severe occurrence, you may have fever and tender swollen lymph nodes. You may also have malaise, a general, vague feeling that you are not well. Recurrence is common and may continue for years


Since we do not know the cause of aphthous ulcers, we don’t know the best treatment. There are no specific drugs for aphthous ulcers but the following may be helpful:

Over-the-counter mouthwashes and topical medications.

Topical corticosteroids (triamcinolone acetonide, 0.1%, or fluocinonide ointment, 0.05%) in an adhesive base (Orabase Plain) do appear to provide symptomatic relief in many patients.

For pain relief try benzocaine available as Anbesol®, Num-Zit® and Zilactin-B®.

For antisepsis try chlorhexidine gluconate (Peridex®, Periogard®) and carbamide peroxide (Gly-Oxide®, Orajel®) Rinse your mouth for 60 seconds twice a day at the first hint of a sore.

For inflammation try amlexanox (Aphthasol®) and hydrocortisone (Orabase-HCA®).

Other topical therapies shown to be effective in controlled studies include diclofenac 3% in hyaluronan 2.5%, doxymycine-cyanoacrylate, mouthwashes containing the enzymes amyloglucosidase and glucose oxidase, and amlexanox 5% oral paste. A 1-week tapering course of prednisone (40–60 mg/day) has also been used successfully. Cimetidine maintenance therapy may be useful in patients with recurrent aphthous ulcers. Thalidomide has been used selectively in recurrent aphthous ulcerations in HIV-positive patients.

Large or persistent areas of ulcerative stomatitis may be secondary to erythema multiforme or drug allergies, acute herpes simplex, pemphigus, pemphigoid, epidermolysis bullosa acquisita, bullous lichen planus, Behçet disease, or inflammatory bowel disease. Squamous cell carcinoma may occasionally present in this fashion. When the diagnosis is not clear, incisional biopsy is indicated.



Some nutritional supplements and lifestyle changes may be helpful in treating or preventing canker sores. There is no proven evidence for these but people have reported relief with the following:

Vitamins · B vitamins … B1, B2 and B6. Take a daily B complex. · Lactobacillus acidophilus: (Chew four Lactobacillus tablets three times per day to reduce soreness). Some people with recurrent canker sores have been reported to respond to Lactobacillus acidophilus and Lactobacillus bulgaricus.

Herbs · Aloe (Aloe vera): 1–3 tablespoons of aloe vera juice used as a mouthwash, then swallowed, three times daily.

Licorice (DGL) (from Glycyrrhiza glabra): Combine 200 mg of powdered DGL and 200 ml of warm water swished in the mouth and then spit out; continue each morning and evening for one week.

Chamomile (Matricaria recutita): A diluted tincture or strong tea made from chamomile flowers can be swished in the mouth three to four times per day.



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