Kiss Canker Sores Goodbye!

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Kiss Canker Sores Goodbye!
April 2006
Roland Barach, PhD
Contemporary Dental Assisting

Recurrent Aphthous UlcersÛNew Understandings and Treatments

Abstract
Unlike cold sores, canker sores are not viral, occur inside the mouth, are not contagious, and if untreated, usually last 1 to 2 weeks. Presently aphthous ulcers are of unknown etiology, but there is a strong genetic component that makes people susceptible to developing the condition. The primary triggers for an episode are physical trauma, like a small cut or bite on the cheek or lip and stress. Hormonal changes can make one more susceptible to canker sores. Some nutritional deficiencies and food allergies can lead to developing sores, but rarely do so. Prevention can occur by minimizing stress and trauma to the mouth. Treatment for serious cases is possible by a number of prescription medications. This article will discuss a number of over-the-counter and natural remedies to speed up healing and reduce pain.

Learning Objectives
After reading this article, the reader should be able to:
- distinguish between canker and cold sores.
- explain the triggers for canker sores.
- explain what can be done to help prevent an outbreak.
- explain the treatment options available for canker sores.

Nearly 20% of the population (more than 55 million Americans) suffers from recurrent aphthous ulcers, or as they are commonly calledÛcanker sores.1-3 These painful sores interfere with eating, swallowing, and speaking. The physical symptoms themselves are sufficiently unpleasant and irritating, but additionally the condition is made more difficult for many sufferers because of a lack of knowledge about canker sores. For example, the general public often confuses canker sores with cold sores.

Canker and cold sores are two very different afflictions. Cold sores are viral (Herpes Simplex 1 virus), contagious, and typically occur on the outside/corner of the mouth or on the outer lip. Canker sores are not viral, cannot be passed from one person to another, and occur inside the mouth.

It is important for sufferersand health care providers to fully understand the causes of canker sores and the different products and methods available for treatment. This information can help sufferers act to decrease the frequency of occurrence and appropriately treat episodes when they do happen.

While undergoing a dental examination or procedure, questions about canker sores are frequently asked. A summary of important information for canker sore sufferers was recently developed by the author and Dr. Peter VanDerVen for the makers of a new canker sore treatment, Cankermelts (Orahealth Corporation). The title is ÏThe Can?ker Sore Survival GuideÓ and its purpose is to provide sufferers with factual information about the condition, steps to help prevent canker sores, and ways to treat the ulcer when it has occurred. Areas of the summary are discussed in this article.

General Information
What Are Canker Sores?
Canker sores are little ulcers inside the mouth that cause discomfort. If one has a sore on the outside of their lip, it is likely a cold sore, which is very different. Cold sores are caused by the Herpes Simplex 1 virus and can be spread to others. Canker sores are not contagious, just unpleasant and uncomfortable. Most canker sores are less than 10 mm, heal without scarring, and are defined as minor aphthae. Major aphthae account for 10% to 15% of canker sores and are larger, deeper, and more painful. Both canker and cold sores usually last 1 to 2 weeks; however, major aphthae last significantly longer.4

What Causes Canker Sores?
If a person was to ask their doctor or dentist this question, the answer would be, ÏThey are of an unknown etiology,Ó which when translated means, ÏDespite a lot of research, we still donÌt know.Ó What is known about canker sores is that they run in families, so there is a strong genetic component making people susceptible to developing aphthous ulcers. There is a 20% chance of developing canker sores when neither parent has a history of them.2 The probability climbs to more than 42% if one parent gets canker sores and reaches 90% when both parents are afflicted with them.2 Medical and dental fields are now leaning to an immunogenetic explanation for aphthous ulcers where there is an inherited susceptibility to an autoimmune reaction causing the condition.4

What Triggers Getting a Canker Sore?
The two primary triggers of canker sores are stress and Ïphysical trauma.Ó Physical trauma can be either a small cut or a bite on the cheek or lip. Hormonal changes can also make one more susceptible to getting a canker sore. So, women during the premenstrual phase are more vulnerable to contracting a canker sore. This may be why more women than men develop canker sores.4 Some nutritional problems (iron, folate or vitamins B1, B2, B6, and B12) and food allergies (eg, coffee, chocolate, cheeses, tomatoes, and gluten) can lead to developing canker sores, but rarely do so.4

Prevention
What Can You Do to Prevent Canker Sores?
Try to Minimize Stress
As stated before, stress is one of the primary triggers for developing a canker sore. One way to prevent getting a canker sore is minimizing stress. Get enough sleep, eat right, and take some time for yourselfÛrelax and have some fun. Stop worrying about things you cannot do anything about. As Mark Twain pointed out, 99% of the things we worry about never happen. Wait until a problem has happened, or is about to happen, and then come up with a plan to handle it. A plan is what you can do about a problem, while worrying is thinking how bad it is going to be. Develop a list of steps to take to deal with a problem if it does occur. When you have developed a strategy, write it down and then you can stop thinking about the problem. If the problem does occur then pull out the list and follow the steps outlined.

Be Kind to Your Mouth
As stated before, another trigger is physical trauma. Any sharp object in the mouth can lead to a minor cut and painful sores. Braces are frequently the unavoidable culprit behind an episode because they lead to minor cuts inside the mouth. Even brushing your teeth too vigorously has caused canker sores. Eating very crunchy food has produced canker sores. Many people bite their lip or cheek, which can also trigger a canker sore. If someone is susceptible to canker sores, then it is wise to be careful not to engage in activities that might produce abrasions or minor cuts, which then lead to the development of a canker sore.

Excessive dryness can make one more susceptible to cuts and other irritants. Toothpastes that contain sodium lauryl sulphate can lead to excessive dryness for some people.3 If a toothpaste, mouthwash, or food leads to inordinate dryness, recommend use of another product and instruct your patients to pay attention to any foods that irritate their mouthÛthese may be acidic foods, nuts, or spicesÛand see if they start getting sores after eating any of these. Patients are also instructed to floss and brush regularly. Good oral hygiene may be preventive. If patients have canker sores that last more than 14 days, they should schedule an appointment with their doctor or dentist.

Treatment
What to Do When You Get a Canker Sore?
There are a number of prescription medications that can help sores heal and a variety of over-the-counter (OTC) products to relieve pain. The most serious of major aphthous ulcers require a physician or dentist for proper diagnosis and are treated by prescription medications such as thalidomide, topical and systemic steroids and, Apthasol (Discus Dental, Inc). The drawbacks of these medications for general usage are side effects, possible toxicity, and of course, cost. The first type uses film-forming gels made with polymerizing materials like cyanoacrylate (super glue) (Orabase Sooth-N-Seal, Colgate) or a cellulose compound that formsa film as a solvent evaporates (Zilactin [Blairex Laboratories, Inc] and Kanka [Blistex, Inc]). When properly applied and cured, the film seals the ulcer, preventing physical contact by irritants such as acids and salts.

The second type is topical local anesthetics such as benzocaine (Anbesol [Wyeth Consumer Healthcare] and Orajel [Del Pharmaceuticals], and many other brands), and some that combine benzocaine with film-forming gel (Zilactin-B and Kanka). Until recently, there has not been a product to do both. A new OTC medication, Cankermelts, is the only available treatment shown by scientific study to speed healing and reduce pain. Tests show that Cankermelts heals within 1 to 5 days when used as directed. It relieves pain within 5 minutes after being applied.5

Does Anything Else Help?
No other nonprescription treatment has been shown to speed healing, but there are the other options for pain relief that were identified in the previous paragraph. These include a topical anesthetic, like a teething medication, which numbs your mouth, or a product that covers and seals the sore. These are often messy and have an unpleasant chemical/ medicinal taste.

Why Use Cankermelts?
Cankermelts is a pleasant-tasting disc that adheres on or near a canker sore and slowly dissolves in 2 to 6 hours providing pain relief while healing. It does not interfere with eating or conflict with the taste of food. It is an all-natural remedy that uses a patented disc to allow a small, therapeutic amount of the age-old remedy licorice root (glycyrrhiza extract) to be concentrated on the canker sore. It has been known for more than 2,000 years that licorice promotes the healing of ulcers of the stomach and mouth and it continues to be a staple of Eastern medicine.5 The first scientific explanations for how this occurs began with studies in the 1950s showing licorice had anti-inflammatory effects and acted like a glucocorticoid and a mineralcorticoid promoting healing of ulcers by stimulating mucous secretion and cell proliferation.6

Summary
More help is available today for canker sore sufferers than ever before. As a more complete understanding of the etiology and various triggers for the condition has emerged, sufferers can now be told what steps to take to decrease the likelihood of getting a canker sore and of appropriate and helpful treatments if an episode occurs. For those susceptible to this condition, it is important to be ÏkindÓ to their mouths to minimize physical trauma, while for others it is also important to become aware of any specific triggers, such as types of food, and learning to avoid them. The recognition of the role that stress plays is important because this makes the occurrence of a canker sore less of a mystery to the sufferer and also serves as a reminder of the importance of better managing oneÌs stress. If a canker sore does occur, there are now OTC medications available to not only relieve the pain of a canker sore, but to help the healing process.

References
1. National Institutes of Health. National Institute of Dental and Craniofacial Research, NIH Publication No. 92-247. Revised, July 1992.

2. Ship II. Epidemiologic aspects of recurrent aphthous ulcerations. Oral Surg Oral Med Oral Pathol. 1972;33(3):400-406.

3. Ship JA, Chavez EM, Doerr PA, et al. Recurrent aphthous stomatitis. Quintessence Int. 2000;31(3):95-112.

4. Scully C, Gorsky M, Lozanda-Nur F. The diagnosis and management of recurrent aphthous stomatitis: a consensual approach. J Am Dent Assoc. 2003;134(2): 200-207.

5. Haley J, Martin M, Sherman J. Studies of licorice extract in an oral patch on minor aphthous ulcers. OOOOE. 2005;99:429.

6. Baker M. Licorice and enzymes other than 11 beta-hydroxysteriod dehydrogenase: an evolutionary perspective. Steroids. 1994;59(2):136-141.