Q) My boyfriend frequently suffers from mouth ulcers. Often, he'll get two or three at a time, and the pain makes eating difficult. He's tried a number of over-the-counter remedies, but they don't seem to work. Is there a more effective way to get rid of mouth ulcers and prevent them from coming back?-G.G., London
A) Mouth ulcers, also called 'aphthous ulcers', are shallow painful ulcerations in the soft tissues inside the mouth. Normally, they will heal within a week to 10 days but, for many people, they are recurring and persistent. In the UK, 20 per cent of people (one in five) suffer from recurrent mouth ulcers.
The best way to prevent or treat mouth ulcers is to find out if there's a correctable cause. One of the most common causes is trauma to the mouth, which could be the result of dental work, a jagged tooth or overzealous tooth-brushing. These problems are fairly simple to resolve, but there may be other factors to blame.
First of all, it's important to rule out an underlying condition. Coeliac and Crohn's disease sufferers are prone to mouth ulcers, and ulcers are also common in conditions such as Reiter's syndrome (inflammation of the urethra, eyes and joints), Behcet's disease (chronic inflammation of the small blood vessels), systemic lupus erythematosus, glandular fever, tuberculosis, syphilis, Wegener's granulomatosis (chronic inflammation of the small and medium-sized blood vessels) and agranulocytosis (loss of white blood cells).Certain drugs, such as sulphonamides, penicillamine, barbiturates, cytotoxics, carbimazole and sulphasalazine, can also predispose you to mouth ulcers.
When not caused by a specific condition or drugs, mouth ulcers could be related to food sensitivity/allergy. One study found evidence of food allergy in half of a group of people with recurrent mouth ulcers; avoidance of the offending foods led to improvement in nearly all cases (J Oral Pathol Med, 1991; 20: 473-5). Other research shows that switching to a gluten-free diet can result in complete remission or considerable improvement of recurrent mouth ulcers in coeliacs or in those (without the disease) who are sensitive to gluten (Gut, 1980; 21: 223-6; Dig Dis Sci, 1981; 26: 737-40; BMJ, 1976; 1: 11-3).
Nutritional deficiencies may also play a role. In 330 people with recurrent mouth ulcers, 14.2 per cent were deficient in iron, folic acid and/or vitamin B12. As soon as these deficiencies were covered by supplements, the majority were completely free of ulcers (J Oral Path, 1978; 7: 418-23). For ulcer sufferers deficient in zinc, taking extra zinc supplements can be effective (South Med J, 1977; 70: 559-61).
So, seeing a qualified nutritionist is a good way to determine whether allergies, sensitivities or deficiencies are at the root of your boyfriend's problem.
Another possible cause of mouth ulcers is stress, although the findings are mixed. One study concluded that "stress may play a role . . . particularly in patients who have an underlying anxiety trait" (J Oral Pathol Med, 1996; 25: 357-9). Moreover, patients undergoing relaxation/imagery treatment experienced a significant reduction in mouth ulcers in one trial (Psychosom Med, 1990; 52: 526-35).
Finally, yet another causal factor to consider is toothpaste as sodium lauryl sulphate (SLS), a detergent found in many toothpastes, may contribute to mouth ulcers. A Norwegian trial found a significantly higher frequency of mouth ulcers in people using an SLS-containing toothpaste compared with those using a detergent-free one (Acta Odontol Scand, 1996; 54: 150-3). Thus, an SLS-free toothpaste such as offered by Weleda or Green People is worth trying.
- Propolis. This sticky resin collected by bees from leaf buds and tree bark is used in some cultures as a natural mouth-ulcer remedy. In fact, it has proved effective in decreasing recurrences and improving the quality of life in those who suffer from recurrent mouth ulcers (Clin Oral Investig, 2007; 11: 143-7; Rev Cubana Estomatol, 1988; 25: 36-44).
- Probiotics. Topical and/or oral use of Lactobacillus acidophilus (with or without L. bulgaricus), the beneficial bacteria found in yoghurt, can speed the healing of mouth ulcers (Werbach MR. Nutritional Influences on Illness, 2nd edn. Tarzana, CA: Third Line Press, 1993: 56).
- Liquorice. A mouthwash of deglycyrrhizinated liquorice (DGL)-liquorice with the glycyrrhizic acid removed-and warm water healed mouth ulcers within three days for the majority of patients in one trial (J Assoc Physicians India, 1989; 37: 647). DGL is also available as a powder and as chewable tablets.
- Astringent herbs. Historically, astringent herbs have been used as mouth rinses to soothe the pain of mouth ulcers. These herbs include agrimony, cranesbill, tormentil, oak, periwinkle and witch hazel. The herbs chamomile, goldenseal and myrrh can also help.
- Lysine. Supplementing with 500 mg/day of this amino acid helped prevent mouth ulcers in one trial, and 1000 mg four times a day helped reduce the duration of an outbreak. However, excessive dietary lysine can contribute to the risk of atherosclerosis. Supplementing with a smaller dosage of arginine (with which lysine competes) can reduce the risk, but it's not known whether arginine interferes with lysine's therapeutic effects (Townsend Lett Doc Patients, 2005; 269: 144).