Mouth

Canker Sore

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Canker Sore, Aphthous Ulcer, Aphthous Stomatitis

  • Epidemiology
  1. Prevalence: 5-21% in United States
  • Pathophysiology
  1. Benign Autoimmune Condition
  2. Nutritional deficiency may contribute in some cases
    1. Iron Deficiency Anemia
    2. Vitamin B12 Deficiency or Folic Acid Deficiency
  • Symptoms
  1. Multiple painful Oral Ulcers
  • Signs
  1. Small round or oval white ulcer 1-5 mm in size
    1. White or yellow pseudomembrane covers center
    2. Surrounded by halo of reddened mucosa
    3. Typically less than 1 cm in size
  2. Distribution
    1. Single or multiple ulcers may coalesce
    2. Forms on nonkeratinizing oral mucus membranes
      1. Labial mucosa
      2. Buccal mucosa
      3. Ventral Tongue
  • Course
  1. Resolves spontaneously in 2 weeks
  • Management
  • General
  1. Good Oral Hygiene
  2. Avoid Toothpaste containing Sodium Lauryl Sulfate (SLS)
    1. Aphthous Ulcer recurrence associated with use
    2. Reference
      1. Herlofson (1994) Acta Odontol Scand 52:257-9 [PubMed]
  3. Chlorhexidine gluconate (Peridex) mouthwash
    1. Reduces severity of episode
  • Management
  • Controlling Pain
  1. Topical anesthetic
    1. Precautions
      1. Avoid extensive use over too wide an area
        1. May cause cotton-mouth feeling or taste loss
        2. May be worse than original problem
      2. Avoid in young children
        1. Risk of Seizures with Lidocaine
        2. Risk of Methemoglobinemia with benzocaine
    2. Dyclonine HCl Solution provides numbing for 1 hour
    3. Lidocaine (Xylocaine, ointment 5% or viscous)
    4. Diphenhydramine HCl (Benadryl elixir)
      1. Alone or with Kaopectate
    5. Anesthetic (Benzocaine) in Denture-like adhesive:
      1. Benzodent
      2. Orajel Denture
  2. Silver Nitrate Stick
    1. Destroys local nerve endings
    2. Provides pain relief for duration of eruption
    3. Ulcers may enlarge and heal more slowly
  3. Coat lesions
    1. Carafate (Sucralfate)
    2. Canker Cover
  4. Clean region after meals (may prevent irritation)
    1. Peroxide rinses (Peroxyl or Hydrogen peroxide 3% diluted 1:1 with water)
  5. Magic Mouthwash
    1. Example: Mix of viscous Lidocaine, Benadryl, maalox with or without a steroid
  • Management
  • Aborting Lesions and shortening course
  1. Suppress oral streptococci
    1. Saturate gauze pledget with antibiotic
    2. Dissolve in 30 cc water or elixir of Benadryl
      1. Tetracycline 250 to 100 mg or
      2. Keflex 250 mg
    3. Apply for 10-20 minutes 4-6 times/day for 5-7 days
  2. Topical Corticosteroids
    1. Kenalog 0.1% in Orabase applied qid
    2. Allow Corticosteroid tablet to dissolve at lesion qid
      1. HydrocortisoneSodium Succinate 2.5 mg
      2. Betamethasone 17-valeraet 0.1 mg
    3. Aphthasol (Amlexanox 5% oral paste)
      1. Applied to lesions after meals and at bedtime
    4. Oral Steroid rinse
      1. Dexamethasone elixir mouth rinses (swish and spit)
    5. Debacterol
      1. Cotton swab with hollow handle containing sulfuric acid and phenol.
      2. Applied for 5-10 seconds (stings)
      3. Rinse vigorously afterward
      4. (2018) David Johnson, MD, per correspondence received 6/10/2018
      5. Rhodus (1998) Quintessence Int 29(12):769-73 +PMID: 10196853 [PubMed]
  • Management
  • Severe, recurrent Aphthous Ulcers (medications used historically)
  1. Systemic Corticosteroids
    1. Taken for 4 days during prodromal period
  2. Colchicine 0.6-1.8 mg orally daily
    1. Response in 4-6 weeks
    2. Significant toxicity
  3. Phenelzine (MAO inhibitor)
    1. Strict dietary and concurrent medication limits
  4. Dapsone
  5. Thalidomide
    1. High risk medication (highly Teratogenic, category X in pregnancy)
    2. May be useful in severe cases in HIV patients