Aphthae occur on the soft oral parts, such as the tongue, oral floor, and inside of the cheeks and lips . The lesions appear as white patches, surrounded by a red halo, and can also be multiple and recurrent.
The ” aphthous stomatitis”, or “oral aphthosis” , is an annoying disturbance of the mouth, characterized by small rounded ulcerations. Among the causes, not yet well defined, there are trauma, stress, allergies, immunodeficiencies and nutritional deficiencies .
However, ulcers can signal more serious illnesses, including Crohn’s disease, celiac disease, and Behçet’s syndrome. Very common, injuries affect 5 to 60% of people, especially in developed countries.
After a premonitory itch, the onset of aphthosis, the patient can feel from a simple discomfort to intense pain .
The sensation lasts for 4 to 7 days and may be accompanied by malaise and, in severe cases, fever and malnutrition. The pain is exacerbated by chafing, spicy foods, and hot foods and sometimes prevents you from speaking and swallowing.
Then the diagnosis is revealed by the symptoms and only rarely requires blood and allergy tests or biopsy of the part. Usually, canker sores heal spontaneously without surgery, within 1-2 weeks, but can recur.
For aphthosis, there are no targeted treatments, but it is possible to reduce inflammation, pain and duration. In fact, special gels, pastes and mouthwashes, based on disinfectants, antibiotics or cortisones, can give relief.
In addition, some herbs, such as Tea tree oil and Aloe vera , and anti-stress techniques are effective .
Aphthae /Mouth sores : what are they
Aphthae are small, rounded and painful lesions, which form inside the mouth by breaking the mucosa.
The term derives from the Greek “áphtha” which has the meaning of “pustule”, referring to the appearance of the wound.
The ulceration appears as a round white spot, with a red border, which develops in the soft parts.
Oral aphthosis, or aphthous stomatitis, affects the lining of the tongue, floor of the mouth, soft palate, and inner cheeks and lips.
The lesion is a cavity in the mucosa that appears as the surface layer is lost, making the underlying tissue visible. Its white part is due to fibrin, a blood clotting protein, and to dead cells and food debris that cover it.
This central patina can also be scratched off , but the fibrous membrane most often reforms. It is relevant that ulcers form on the thinnest, non-keratinized oral lining.
These inflammations vary in size , appearance, distribution and frequency of onset. Their manifestation tends to repeat itself over time so new canker sores grow in always different or recurring points.
Aphthae and types of injuries
The lesions are divided into three main forms of aphthous stomatitis :
- minor in which the canker sores are usually small, with a diameter of less than 1 centimeter
- major in which the lesions remain for at least 2 weeks, are larger than 1 cm in diameter, can be very painful and heal with scars
- herpetiformis , the most severe, involves numerous ulcerations, even a hundred, with a diameter of 1-2 millimeters, which disappear in 2 weeks.
In summary, the smallest canker sores often occur in groups of 2 or 3 and disappear in 10 days, without scars. On the other hand, larger , less frequent lesions are irregular, take many weeks to heal and leave scars.
But unlike herpes blisters, canker sores are not contagious and are not sexually transmitted.
Epidemiology: who it affects, sex, in which parts of the world
The most common form of aphthae is the “minor” one which affects over 80% of patients, while the “major” one concerns 15% of cases. Herpetiform aphthous stomatitis is less common than the others as it is diagnosed in a maximum of 5% of patients.
In many Aphthae sufferers, canker sores recur 3 to 6 times a year , with an average duration of 10 days. The disorder is so common that it affects 20% of people, with variations from 5 to 60% in different states.
Aphthae affects mainly the most developed countries, such as the United States, Canada, Australia and some European countries.
In the majority, it is the upper socioeconomic strata that blame the disorder, with men and women affected equally. The boys are more susceptible to ulcers that made their debut in childhood , only to fade over the years.
In fact, 80% of those affected developed the disease before the age of 30, peaking between 10 and 19 years of age.
After all, Aphthae over the years instead of getting worse tends to resolve itself without any intervention. In particular, dark-skinned individuals are at risk of aphthosis, with a probability 3 times higher than those of light-skinned individuals.
Furthermore, the lesions appear more easily in celiacs, in immunosuppressed people, in subjects with AIDS or other diseases, such as intolerances.
About 40% of patients have relatives with aphthosis, and many of them develop the severe form of the disease at an early age.
Most common causes of Aphthae / mouth ulcers
To this day the causes that cause Aphthae / canker sores remain unknown, but there are theories about it. A certain genetic predisposition, therefore with a hereditary matrix, was also taken into consideration.
In fact, twins separated at birth both presented aphthous stomatitis, despite living in different conditions. Particularly relevant is the fact that a combination of several factors may be at the basis of ulcer formation.
Their origin could be due to hormonal imbalances , which alter the barrier of the oral mucosa, favoring ulcers.
In women, the formation of Aphthae / canker sores has been hypothesized especially during the menstrual cycle or behind the use of contraceptives . The process would be related to the decrease in progesterone , resulting in less growth of the mucosa.
Therefore, according to some researchers, remission of aphthous stomatitis may occur during pregnancy .
Aphthae and nutritional deficiencies
The thinning of the mucosa could be due to nutritional deficiencies, in particular of:
- vitamin B12
- folic acid
Malfunctioning of the immune system appears to be one of the most important underlying causes of Aphthae / ulcers.
In this case, the white blood cells would be stimulated to attack the cells of the mucous membrane of the oral cavity. Systemic immuno-dysregulation, which distinguishes pathologies such as AIDS, could generate recurrent and related aphthous stomatitis.
Moreover, a decrease in the defensive barriers at the level of the mouth can make aggressive pathogens, normally present.
Additionally, oral aphthosis has been linked to local trauma, such as excessive tooth brushing and accidental bites .
Aphthae and allergy
The onset of Aphthae / canker sores may also depend on allergic reactions, due to certain foods, toothpastes or mouthwashes.
In addition, the subject may be hypersensitive to certain foods, such as:
- citrus fruits
Among the chemicals that induce ulcers in the intolerant, there are benzoates, food preservatives , and the sodium lauryl sulfate of toothpastes.
Bacteria and Viruses
But the patient’s allergic response could be linked to some bacteria in the mouth, such as Helicobacter pylori.
Some scholars have proposed some viruses as antigenic triggers, including:
- herpes simplex.
But other researchers say there isn’t enough evidence to prove a viral etiology of Aphthae / canker sores. Injuries can be the warning sign of more serious conditions, such as Crohn’s disease and ulcerative colitis.
At aphthous stomatitis they have been associated with celiac disease, systemic lupus erythematosus and lichen planus.
In Behçet’s syndrome, canker sores also appear on genital and semimucosal mucous membranes, with ocular manifestations, such as uveitis.
Therefore it is important to communicate the disorder to your doctor , especially if the canker sores are associated with other symptoms:
- abdominal pain
- pain in the eyes
- skin rashes
- other ulcerations in various parts of the body.
Stress also appears to play a role in the onset of injuries due to its damaging effects on the immune system.
For example, a student may suffer from canker sores during the last week of the exams, due to the psycho-physical load endured. In addition, during demanding periods, the stressed person tends to violently clench the jaws and, in general, to increase the movements of the mouth.
This oral hyperactivity can be damaging to the mucosa, subjected to frequent and more intense trauma. In fact, in times of stress, an autoimmune reaction of the organism against components of the oral epithelium would also occur .
In fact, in convalescence, after too much exposure to the cold or to the sun and during antibiotic therapies, canker sores appear more easily.
Smoking and Aphthae / canker sores
Those who quit smoking may become prone to ulcerations they did not have when they smoked. The phenomenon occurs because tobacco stimulates keratinization of the oral mucosa, which strengthens and is thicker.
On the contrary, when you quit smoking, the lining of the mouth is reduced as it is affected by the lack of action of nicotine.
However, you should not smoke to avoid canker sores, since tobacco can cause consequences, such as leukoplakia, precancerous keratization.
What are the symptoms of Aphthae / canker sores
On the implantation area, the aphthae anticipates with burning or itching that precedes its appearance by a few hours.
The first visible manifestation is an erythematous macula followed by the ulcer with the white patina and the red halo. Aphthosis can involve mild tingling, spontaneous or from contact, but in some individuals it causes difficulty in eating and drinking.
The most usual sign of injury is pain that is much more severe than might be expected from such a small ulcer. The pain is usually most acute at the onset of release of the ulcer and then subsides as healing approaches.
The painful sensation lasts about 4-7 days and increases with the rubbing of the tongue or food in the area.
In particular, taking hot , spicy, hard or hot foods and hot drinks can aggravate pain. People with tongue lesions usually experience fatigue and discomfort both speaking and chewing food. On the other hand, a person with Aphthae / canker sores on the palate or throat has trouble swallowing and feels pain, due to “odynophagia”.
The pain becomes chronic when the disease is severe , constant development of new ulcers replacing those healed. However, sometimes aphthosis is confused with toothache if the lymph nodes under the jaw are swollen.
On the other hand, if the cause of the canker sores is a food allergy , the ulcerations appear after about 12 hours from the ingestion of the triggering food. Aphthous stomatitis can usually also give a sense of general malaise and weakness.
Fever and swollen lymph nodes in the neck
The most severe Aphthae / ulcers may be accompanied by fever and swollen neck lymph nodes. If he fails to swallow, the patient becomes debilitated, due to malnutrition and weight loss.
Typically, oral Aphthae takes 1 to 2 weeks to disappear , but it can sometimes leave pinkish marks for many weeks. Between one episode and another, the subject does not feel any symptoms as the canker sores heal completely, until they return.
People with AIDS frequently have large canker sores that persist for a long time.
The point at which Aphthae / canker sores occur can be indicative to understand which form they belong to. To identify them, one can turn to the dentist or doctor who recognizes the canker sores by the appearance and pain they trigger.
Distinctive are the times, regularities and ways of appearance of the lesions, whether recurrent or not and whether they heal on their own. Recurrent ulcerations are usually attributed to oral stomatitis and, more rarely, to other, as erythema multiforme.
Allergy tests: the patch test
In some Aphthae cases, specialists may request blood tests or allergy tests.
In fact, blood tests must exclude:
- celiac disease
- nutrient deficiency, especially vitamin B12.
When it is assumed that the lesions are related to certain foods, the patient is subjected to a “patch test”.
This allergy test is carried out through patches with the substances to be evaluated, applied to the skin of the person concerned. After 2 or 3 days, the stickers are removed to check if there is an allergic response, causing the canker sores. On the other hand, drug-induced ulcerations can be discovered indirectly by replacing the suspect product, which stops damaging the mucosa.
The tissue biopsy is performed in rare and special circumstances, just to rule out more serious injuries, such as oral cancer.
Cures and treatments of Aphthae / canker sores
There is no specific cure for Aphthae / canker sores, but in most sufferers the lesions heal spontaneously. Some therapies can help reduce pain and speed up the disappearance of ulcerations.
First of all, it is useful to keep a diary in which to record how many times, when and how canker sores form . Thus it is possible to understand if the disorder is related to a food or to the use of a toothpaste or mouthwash.
Sharing this information with your doctor makes it easier for you to identify the most suitable strategies and treatment .
When Aphthae / canker sores are numerous, relief can be sought with mouthwashes or pastes containing disinfectants, such as chlorhexidine.
To relieve pain, an anesthetic , including diclonine and lidocaine, used as a mouthwash may be effective . However, the mouthwashes numb the mouth and throat, making swallowing difficult.
Therefore, children using mouthwash should be supervised to avoid choking on food.
The lidocaine in less liquid form , or viscose, brushstroke can be directly on the lesion. A layer of gels, such as carboxymethylcellulose-based, can often reduce inflammation.
In fact, the gel, especially associated with a corticosteroid, such as triamcinolone or betametazone, is protective, applied on the aphta.
Furthermore, the medicamentous layer is able to decrease the pain , even if only temporarily. If the patient has numerous or large ulcers , the specialist may prescribe a tetracycline-based mouthwash.
The antibiotic compound can be used by people with recurrent canker sores as soon as they feel ulcers are forming.
A direct and localized application on the lesion , made by the specialist, is performed with the bactericidal silver nitrate . The chemical cauterizes, destroying the nerve endings beneath the ulcer and relieving pain.
The doctor can also obtain a cauterization of the ulcer with a specific instrument.
Laser healing is proposed both to reduce pain and to accelerate the healing of the Aphthae / ulcer . In fact, the diode laser, which offers immediate relief, removes the surface tissue, decontaminating the treated area.
After a couple of days, the injury should subside and relapses may also become less frequent.
In serious situations, a corticosteroid, such as dexamethasone mouthwash or, rarely, prednisone tablets may be used.
However, in the event, the doctor must make sure that the person concerned does not also have a herpes simplex infection.
In fact, this other oral infection can be greatly aggravated by taking corticosteroids. Furthermore, the corticosteroids in mouthwashes and tablets are absorbed by the body faster and better than those in gels.
Therefore, with such administrations, there is a risk of secondary effects , such as an increase in blood sugar and blood pressure.
A useful precaution is the use of supplements of vitamins, minerals and probiotics that improve the functioning of the immune system.
More natural therapies include herbal products which, however, in the opinion of some specialists, would have above all a placebo effect.
In fact, a massage on the lesion or mouth rinses with Tea tree oil would have soothing and antibacterial power. The same procedure and the same result are pursued with Aloe vera gel, a powerful anti-inflammatory.
To strengthen the immune system, Fenugreek is indicated , rich in vitamins and minerals, to be eaten or spread as a paste on the ulcer.
Also, echinacea and astragalus, immunostimulating herbs, can be taken in drops, tablets or as a mouthwash.
Even dried sage leaves can provide antioxidants and disinfect using it for rinsing, dissolved in water. To soothe ulcers, try coconut oil , an antiviral that forms a protective film on the ulcer.
Even traditional remedies can be effective, such as baking soda or coarse salt that burns, applied or for gargling.
The appearance of aphthous stomatitis can also be prevented thanks to correct and continuous oral hygiene.
In fact, specialists always recommend the use of a toothbrush and toothpaste after each meal.
Foods to avoid and lifestyles
As a precaution, those with a predisposition should avoid acidic and spicy foods, eat fruits and vegetables and drink plenty of water. Furthermore, for everyone, it is essential to reduce stress levels as this negative state can contribute to the recurrence of canker sores.
Among the anti-stress solutions, the change in lifestyle is crucial , with more exercise and hours of sleep. Furthermore, to increase the psychological and immune defenses, it is also advisable to allow oneself personal spaces and times of leisure.
It is necessary to slow down the pace of activities and improve one’s social relations, avoiding hostility.
Aphthae and relaxation techniques
But the most decisive strategy is the use of relaxation techniques, such as:
- Autogenic training
It is easier to breathe deeply and slowly at the level of the diaphragm, with low shoulders, an upright head and a firm chest. A relaxing exercise, to be practiced several times a day, should be done in your own corner, such as the car or the office bathroom.
Seated, in peace and with closed eyes, the subject must concentrate on the breath coming in and out. Placing a hand on the abdomen, one must let the breathing move back and forth, like the waves of the sea .
If the person visualizes the breath, inhaling for 4 seconds, it begins to penetrate inside. Then, holding their breath for 7 seconds , the individual feels that the air is spreading throughout the body.
With slow exhalation, in 8 seconds, the practitioner realizes that the air comes out, instilling inner tranquility. At the same time as breathing, the belly moves slowly with the same rhythm.
To prolong the state of relaxation, the subject must rest for a few minutes, without worrying about any thoughts.
At the end of the exercise, the subject can open his eyes and calmly resume his usual commitments, but without stress.