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Canker sores are shallow, painful sores in your mouth that are usually red and may sometimes have a
white coating over them. Canker sores often appear on the inside of your lips and cheeks, the base of
your gums or under your tongue. Canker sores are different from fever blisters, which are usually on the
outside of your lips or the corners of your mouth.
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Doctors do not know what causes canker sores, but they may be triggered by physical or psychological
stress, poor nutrition, food allergies, viral or bacterial infection, chemical irritations, menstrual periods and
trauma. Also orthodontic appliances, for example braces, cause canker sores.
No one knows what causes canker sores. The vast majority of people who develop canker sores do not
have another problem as the cause.
` Both hereditary and environmental causes of the disease have been suggested, but the exact
cause is not clear.
` A number of factors have been suggested to precipitate outbreaks in susceptible individuals;
however, none has been proven to be the cause in all people.
oral trauma
hormonal changes related to the menstrual cycle
anxiety or stress
smoking cessation
heredity
drugs (including anti-inflammatory drugs, such as ibuprofen [Motrin], and beta-blockers,
such as atenolol [Tenormin])
food allergies or sensitivities (chocolate, tomatoes, nuts, and acidic foods such as
pineapple, and preservatives such as benzoic acid and cinnamaldehyde)
toothpastes containing sodium lauryl sulfate
deficiencies of iron, folic acid, or vitamin B12 (although supplementation with iron or
vitamins has not been shown to decrease the likelihood of ulcer resolution)
` Some studies have suggested an association with u
, the same bacteria that
cause peptic ulcers. Recent studies have suggested that treatment of the u
infection may improve symptoms or completely stop recurrent disease in some patients.
` Recurrent canker sores have been associated with inflammatory bowel diseases, such as Crohn
disease and ulcerative colitis. In these cases, the development of canker sores may signal a
flare-up of the bowel disease.
` Celiac, or abdominal, sprue, a disease of the intestines caused by sensitivity to gluten, causes
malabsorption and is associated with development of canker sores. Gluten refers to a group of
proteins found in wheat, barley, and rye.
` Behèet's disease is a condition characterized by canker sores, genital sores that resemble
canker sores, and inflammation of the eye.
` Infection with the AIDS virus also has been associated with canker sores.
` It is a common misconception that canker sores are a form of herpes infection. This is not the
case.
The etiology of recurrent aphthous stomatitis (RAS) is not entirely clear, and aphthae are therefore
termed idiopathic. RAS may be the manifestation of a group of disorders of quite different etiology, rather
than a single entity.
Despite many studies trying to identify a causal microorganism, RAS does not appear to be infectious,
contagious, or sexually transmitted. Immune mechanisms appear at play in persons with a genetic
predisposition to oral ulceration.
A genetic basis exists for some RAS. This is shown by a positive family history in about one third of
patients with RAS, an increased frequency of HLA types A2, A11, B12, and DR2, and susceptibility to
RAS which segregates in families in association with HLA haplotypes. RAS probably involves cell-
mediated mechanisms, but the precise immunopathogenesis remains unclear. Phagocytic and cytotoxic T
cells probably aid in destruction of oral epithelium that is directed and sustained by local cytokine release.
Patients with active RAS have an increased proportion of gamma-delta T cells compared with control
subjects and patients with inactive RAS. Gamma-delta T cells may be involved in antibody-dependent
cell-mediated cytotoxicity (ADCC). Compared with control subjects, individuals with RAS have raised
serum levels of cytokines such as interleukin (IL)±6 and IL-2R, soluble intercellular adhesion modules
(ICAM), vascular cell adhesion modules (VCAM), and E-selectin; however, some of these do not correlate
with disease activity.
Cross-reactivity between a streptococcal 60- to 65-kd heat shock protein (hsp) and the oral mucosa has
been demonstrated, and significantly elevated levels of serum antibodies to hsp are found in patients with
RAS. Lymphocytes of patients with RAS have reactivity to a peptide of ½
Some cross-reactivity exists between the 65-kd hsp and the 60-kd human mitochondrial hsp. Monoclonal
antibodies to part of the 65-kd hsp of ½ react with
RAS thus may be
a T cell±mediated response to antigens of , which cross-react with the mitochondrial hsp and
induce oral mucosal damage. RAS patients have an anomalous activity of the toll-like receptor TLR2
pathway that probably influences the stimulation of an abnormal Th1 immune response.
` Hematinic deficiency: Up to 20% of patients are deficient of iron, folic acid (folate), or vitamin B.
` Malabsorption in gastrointestinal disorders: About 3% of patients experience these disorders,
particularly celiac disease (gluten-sensitive enteropathy) but, occasionally, Crohn disease,
pernicious anemia, and dermatitis herpetiformis. HLA DRW10 and DQW1 may predispose
patients with celiac disease to RAS.
` Cessation of smoking: This may precipitate or exacerbate RAS in some cases.
` Stress: This underlies RAS in some cases; ulcers appear to exacerbate during school or
university examination times.
` Trauma: Biting of the mucosa and wearing of dental appliances may lead to some ulcers; RAS is
uncommon on keratinized mucosae.
` Endocrine factors in some women: RAS is clearly related to the progestogen level fall in the luteal
phase of the menstrual cycle, and ulcers may then temporarily regress in pregnancy.
` Allergies to food: Food allergies occasionally underlie RAS; the prevalence of atopy is high.
Patients with aphthae may occasionally have a reaction to cow's milk, and may have been
weaned at an early age.
` Sodium lauryl sulphate (SLS): This is a detergent in some oral healthcare products that may
aggravate or produce oral ulceration.
` Immune deficiencies: Ulcers similar to RAS may be seen in patients with HIV, neutropenias and
some other immune defects.
` Drugs, especially NSAIDs, alendronate, and nicorandil: These may produce lesions clinically
similar to RAS.
RAS affects 5-66% of the population in US. Approximately 1% of children from higher socioeconomic
groups in developed countries have RAS; however, 40% of selected groups of children can have a history
of RAS, with ulceration beginning before age 5 years and with the frequency of affected patients
increasing with age.
The 3 main clinical types of recurrent aphthous stomatitis (RAS) are as follows:
However, any significance of these distinctions is unclear (ie, they could just be 3 distinct disorders).
Diagnosis is based on history and clinical features.
Characteristics of MjAUs (ie, Sutton ulcers, periadenitis mucosa necrotica recurrens [PMNR]) include the
following:
` They are larger, of longer duration, of more frequent recurrence, and often more painful than
MjAUs.
` They are round or ovoid like MjAUs but are larger and associated with surrounding edema.
` They reach a large size, usually about 1 cm in diameter or even larger.
` They are found on any area of the oral mucosa, including the keratinized dorsum of the tongue or
palate.
` They occur in groups of only a few ulcers (ie, 1-6) at one time.
` They heal slowly over 10-40 days.
` They recur extremely frequently.
` They may heal with scarring.
` They occasionally are found with a raised erythrocyte sedimentation rate or plasma viscosity.
` They are found in a slightly older age group than the other RAS.
` They are mainly found in females.
` They begins with vesiculation that passes rapidly into multiple, minute, pinhead-sized, discrete
ulcers.
` They involve any oral site, including the keratinized mucosa, increase in size, and coalesce to
leave large round ragged ulcers.
` They heal in 10 days or longer.
` They are often extremely painful.
` They recur so frequently that ulceration may be virtually continuous.
Most patients appear to be otherwise well, but a minority have etiologic factors that can be identified by
the history. These factors may include the following:
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` Aspirin
` Barbiturates (used for insomnia)
` Chemotherapy drugs for cancer
` Gold (used for rheumatoid arthritis)
` Penicillin
` Phenytoin (used for seizures)
` Streptomycin
` Sulfonamides
RAS ulcers are recurrent small, round, or ovoid ulcers with circumscribed margins, erythematous haloes,
and yellow or gray floors. No specific investigations exist for RAS.
Some RAS cases involve a familial and genetic basis; approximately 40% of patients with RAS have a
familial history, but inheritance may be polygenic with penetrance dependent on other factors.
` Most relevant studies have found hematinic (eg, iron, folic acid, vitamin B-12) deficiencies in as
many as 20% of patients with recurrent ulcers. In addition, deficiencies of vitamins B-1, B-2, and
B-6 have been noted in some patient cohorts.
` The previously proposed association between recurrent ulcers and celiac disease (gluten-
sensitive enteropathy [GSE]) is tenuous, despite some evidence that the haplotype of HLA-DRW
10 and DQW1 may predispose patients with GSE to RAS.
` Hypersensitivity reactions to exogenous antigens other than gluten do not have a significant
etiologic role in RAS, and associations with atopy are inconsistent.
` Local physical trauma may initiate ulcers in susceptible people, and RAS is uncommon where
mucosal keratinization is present or in patients who smoke tobacco.
` A consistent association between aphthouslike ulceration and psychological illness, zinc
deficiency, or sex hormone levels is unlikely.
` Various microorganisms have been examined for a causal association. Latterly, u
has been detected in lesional tissue of ill-defined oral ulcers, but the frequency of serum
immunoglobin G (IgG) antibodies to u
is not increased in RAS. Little evidence suggests an
etiologic association between viruses and RAS. Human herpesviruses (HHV)±6 and HHV-7 DNA
have not been demonstrated in RAS, but HHV-8 DNA is present in HIV-related oral ulcers.
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` Systemic disorders should particularly be suspected in the presence of features that may suggest
a systemic background.
` Diagnosis of recurrent aphthous stomatitis (RAS) is based on history and clinical features. No
specific tests are available; however, to exclude systemic disorders discussed above, the
following tests may be helpful:
Complete blood cell count
Hemoglobin test
White blood cell count with differential
Red blood cell indices
Iron studies (usually an assay of serum ferritin levels)
Red blood cell folate assay
Serum vitamin B-12 measurements
Serum antiendomysium antibody and transglutaminase assay (positive in celiac disease)
` Rarely, biopsy may be indicated in cases in which a different diagnosis is suspected.
The histology is nonspecific. The ulcer is depressed well below the surface, and the inflammation extends
deeply. The surface of the ulcer is covered by a fibrinous exudate infiltrated by polymorphs. Beneath is a
layer of granulation tissue with dilated capillaries and edema. Deeper still is a repair reaction, with
fibroblasts in the surrounding connective tissue laying down fibrous tissue.
Identify and correct predisposing factors for recurrent aphthous stomatitis (RAS). Ensure that patients
brush atraumatically (eg, with a small-headed, soft toothbrush) and avoid eating particularly hard or sharp
foods (eg, toast, potato crisps) and avoid other trauma to the oral mucosa.
SLS should be avoided if implicated as a predisposing factor. Any iron or vitamin deficiency should be
corrected once the cause of that deficiency has been established. If an obvious relationship to certain
foods is established, these should be excluded from the diet. Patch testing may be indicated to reveal
allergies. The occasional patient who relates ulcers to her menstrual cycle or to use of an oral
contraceptive may benefit from suppression of ovulation with a progestogen or a change in the oral
contraceptive. Causal drugs should be excluded.
In most cases, the natural history of RAS is one of eventual remission. However, for some patients,
remission occurs spontaneously several years later; thus, treatment is indicated in these patients if
discomfort is significant. Relief of pain and reduction of ulcer duration are the main goals of therapy.
Objective evidence shows the most efficacy from corticosteroids and antimicrobials used topically.
` Gastroenterologist
` Immunologist/allergologist
` Hematologist
` Rheumatologist
` TCs remain the mainstay of treatment for recurrent aphthous stomatitis (RAS). TCs reduce the
number of ulcer days compared with controls, but they have no consistent effect on the frequency
of ulceration. TCs may reduce the ulcer duration and pain. Amlexanox oral adhesive pellicles or
oral adhesive tablets appear to reduce ulcer pain and duration.
` Chlorhexidine gluconate mouth rinses reduce the severity and pain of ulceration but do not affect
the frequency.
` The range of systemic medications available is of variable or unproven efficacy or may have
serious adverse effects; such agents include systemic corticosteroids, colchicine, clofazimine,
and thalidomide (and many others).
A spectrum of different TCs can be used. All can reduce symptoms, and neither hydrocortisone
nor triamcinolone preparations cause adrenal suppression. Ulcers still recur.
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Decreases inflammation by suppressing migration of PMNs and reversing increased capillary
permeability.
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Decreases inflammation by suppressing migration of PMNs and reversing capillary permeability.
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` For inflammatory dermatoses responsive to steroids. Decreases inflammation by suppressing
migration of PMNs and reversing capillary permeability.
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High-potency topical corticosteroid that inhibits cell proliferation and is immunosuppressive,
antiproliferative, and anti-inflammatory.
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High-potency topical corticosteroid that inhibits cell proliferation and is immunosuppressive and
anti-inflammatory.
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Class I superpotent topical steroid; suppresses mitosis and increases synthesis of proteins that
decrease inflammation and cause vasoconstriction.
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Anyone can get canker sores, however, women, teens and people in their 20s suffer from canker sores
most frequently. Canker sores are not contagious.
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Aphthasol is the only FDA - approved medicament that helps you manage your canker sores. Early
treatment is the key to a fast healing.
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Unfortunately, doctors don't know of anything that prevents canker sores from forming. Using a
toothpaste that does not contain SLS (sodium lauryl sulfate) or other irritating ingredients, avoiding hard,
crunchy or spicy foods and chewing gum may help reduce mouth irritation. Brushing your teeth after
meals, using a soft toothbrush and flossing every day will also keep your mouth free of food that might
cause a canker sore.
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Clinical studies show that pain caused by a canker sore can be momentously reduced by applying
Aphthasol. Experience the efficacy of Aphthasol and get relief now!