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Chronic mouth ulcers

MagazineApril 2009 (Vol. 20 Issue 1)Chronic mouth ulcers

Recurrent aphthous stoma-titis (RAS)-better known as 'mouth ulcers' or 'canker sores'-is an un-pleasant affliction that is charac-terized by the appearance of single

Recurrent aphthous stoma-titis (RAS)-better known as 'mouth ulcers' or 'canker sores'-is an un-pleasant affliction that is charac-terized by the appearance of singleor clustered shallow, painful red-ringed lesions-ranging from 1-12 mm in diameter-in the soft tissues of the mouth and cheeks.

Indeed, these ulcers can arise anywhere in the mouth and are frequently covered by a thin 'pseudo-membrane'. It is thought that around 20 per cent of the EU population is affected at one time or another by these lesions.

Mouth ulcers generally resolve in one to three weeks but, in many sufferers, they are recurrent.

Causes and treatment

Precisely what causes RAS is often unknown, although an autoimmune mechanism was long suspected (J Pathol, 1969; 97: 481-3). Recently, however, the initiating factors have been confirmed to involve nutrient deficiency, stress, certain thera-peutic interventions and/or food sensitivity (J Oral Pathol, 1978; 7: 418-23; Am J Med, 1962; 32: 32-43; Oral Surg Oral Med Oral Pathol, 1982; 54: 388-95).

- Nutrient deficiency has been linked, in my experience, to RAS

in about 15 per cent of cases. In general, the deficiencies involved are iron, zinc, folic acid and vitamin B12. Clinical experience has shown that when these ulcer sufferers' nutritional deficiencies are corrected, complete remission follows in the majority of cases.

- Ginkgo biloba preparations that contain ginkgolic acids and ginkgols are known to trigger aphthous stomatitis (Woerdenbag HJ, de Smet PAGM. Adverse effects and toxicity of Ginkgo extracts, in van Beek TA, ed. Ginkgo biloba. Amsterdam: Harwood Academic Publishers, 2000: 443-51). However, the German Federal Health Agency's Commission E has determined that Ginkgo products in which the amount of ginkgolic acids is limited to <= 5 ppm (parts per million) do not trigger the condition (Blumenthal M et al., eds. The Complete German Commis-sion E Monographs. Austin, TX: American Botanical Council, 1998: 136-8).

- Stress is frequently a contributing factor in RAS, which points to a breakdown of the normal host-protective mechanisms.

- Food and the environment are known to play an important role

in the development of RAS. The mucosa in the mouth is the first site of contact for allergens that are either ingested or inhaled. Indeed, the increase in serum antibodies to food antigens found in patients with RAS indicates that an allergic reaction has taken place (Ann Allergy, 1980; 44: 303-7).

In addition, the numbers of IgE-bearing lymphocytes-associated with food allergy responses and believed to be the cause of the gastrointestinal symptoms seen in such patients-are greatly increas-ed in RAS (Arch Oral Biol, 1977; 22: 147-53). An elimination diet has been shown to have beneficial results (Oral Surg Oral Med Oral Pathol, 1984; 57: 504-7).

Furthermore, in my practice, sending patients for a blood test-specifically, the FACTest (Food Allergen Cellular Test)-has also yielded useful information.

- Coeliac disease significantly increases the incidence of RAS. It has been known for nearly 30 years that withdrawing gluten from the diet results in complete remission of RAS in patients with coeliac disease (Gut, 1980; 21: 223-6).

- Chemotherapy and radiation therapy (of the head and neck area) can also cause stomatitis and mucositis. These cutaneous and mucosal lesions in the mouth were treated in a double-blind clinical trial with Matricaria recutita (German chamomile) used vigorously as an oral rinse or mouthwash (15 drops/100 mL warm water, six times a day).

The researchers found that, compared with patients who had received the same amount of radiation with conventional oral care-a 3-per-cent hydrogen peroxide rinse, plus saline and 5-per-cent sodium bicarbonate-the results with chamomile were considerably better (J Prosthet Dent, 1991; 66: 361-9).

- Quercetin is known to inhibit basophil histamine release and mast cell degranulation-frequently seen in hypersensi-tivity reactions-and, in my experience, can often help in particularly resistant cases.

- Deglycyrrhizinated Glycyrrhiza glabra, or liquorice, administered as a mouthwash or chewable lozenge, may be beneficial (J Assoc Physicians India, 1989; 37: 647).

- Dietary factors can contribute to RAS and, in my experience, the patient's diet should be low in animal products, high in complex carbohydrates and free of any known allergens as well as gluten.

Harald Gaier

Harald Gaier, a registered naturopath, osteopath, homeopath and herbalist, practises at The Allergy and Nutrition Clinic, 22 Harley Street, London, and the Irish Centre of Integrated Medicine, Co. Kildare (www.drgaier.com).


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