A Guide to Treating and Avoiding Canker Sores
Roll your tongue around your mouth, and you might feel a sting from a new tender spot. A tiny, unwelcome crater of pain, a red circle of fire tucked against your cheek. It feels worse with every prodding poke.
Another canker sore. What did you do to deserve this?
Maybe nothing at all. âMost times, we donât know why they come,â says Dr. Alessandro Villa, chief of oral medicine and oral oncology at Miami Cancer Institute at Baptist Health South Florida. Humans have figured out the forces behind planetary motion and the Irish potato famine, yet most canker sores remain something of a mystery, even while affecting 25% of people worldwide.
Although a single cause hasnât been identified, we do know that these sores, also known as ulcers, can coincide with serious health problems. Hereâs a guide to distinguishing a trivial canker sore from one with deeper significance, along with strategies for treatment and prevention.
Meet the common canker sore
Usually a canker sore is nothing to write home about. In minor cases, they appear infrequently, maybe once every three months. Theyâre only slightly painful, just enough to be annoying, Villa says. âThe vast majority of canker sores are just canker sores,â agrees Dr. Herve Sroussi, associate professor of oral medicine at Harvard School of Dental Medicine.
Minor canker sores should go away in a few days to a couple of weeks. Kids and young adults are most likely to develop them, especially when theyâre under stress. This makes sense, Villa says, because canker sores seem related to immune system activity, and stress activates the immune system. âWe donât know if stress is the cause, but it could be a trigger,â he says.
The sores are also associated with sleep deprivation, another challenge to immunity. Or they could pop up with âany illness that causes your immune system to misbehave,â like COVID-19 or a stomach flu, Sroussi says.
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But the stressor doesnât always involve the immune system. People can get canker sores just from biting their cheeks. âTypically a little laceration will heal, but some people respond by getting an aphthous ulcer,â Sroussi says, using the scientific term for a canker sore. Simply try chewing more carefully. âThis kind of lifestyle modification is definitely part of the treatment,â Sroussi explains.
Foods that irritate the mouth could be another culprit, particularly crunchy, spicy, or acidic ones. Researchers havenât confirmed this effect, though these foods certainly make an existing canker feel worse.
A surprising factor in some cases is toothpaste. A foaming agent called sodium lauryl sulfate is a common ingredient that can disrupt the cheekâs protective barrier in people susceptible to mouth ulcers, some research shows. âIt might cause a tingly, burning mouth after brushing,â leading to canker sores, says Dr. Fazia Mir, a gastroenterologist in Albuquerque, who treats patients with these ulcers. Finding a brand without this ingredient could be your solution.
More than annoying
Other types of canker sores are more painful, turning eating into an act of self-torture. Compared to minor canker sores, so-called âmajorâ cankers are larger and occur more often.Â
âItâs to the point where the patient is never ulcer free, and it affects their quality of life,â Sroussi says. Major cankers call for a doctor visit, as theyâre linked to chronic underlying diseases in many cases.
In addition to major canker sores, another serious type is sometimes described as severe or complex. Itâs the one most associated with an underlying condition. Patients with these severe cankers, often women, have many tiny ulcers in their mouth at the same time. âItâs debilitating,â Villa says, interfering with eating, speaking, and swallowing.
Yet another subtype is herpetiform ulcers, which resemble but differ from herpes. The common denominator of these more problematic mouth ulcers is that they hurt more and last longer than the minor version, and they occur with other symptoms. âTheyâre red flags of a larger issue, where the mouth is just mirroring whatâs happening on a systemic level,â Villa says.Â
Upon visiting your primary doctor, youâll probably be referred to a dentist, especially if you didnât have cankers as a kid or young adult.Â
Rule out oral cancer
A dentist or oral medicine specialist will inspect the spot to make sure itâs not oral cancer. âWhat we really worry about with debilitating canker sores, especially if the patient uses tobacco or alcohol, is that itâs the first presentation of a malignancy,â Mir says.
In some instances, dentists can tell if itâs malignant or benign just by looking. Common cankers usually live inside the cheeks or lips; a sign of a more troubling issue is if the spot resides elsewhere, like on the gums, side of the tongue, or floor of the mouth. Most oral cancers are bumpier than ordinary cankers. However, âmajor cankers can resemble cancer of the mouth,â Villa says. When the eye test isnât definitive, a biopsy may confirm the diagnosis.
Itâs unlikely to be cancer, particularly in younger people. âIf youâre under 20, Iâll think itâs either a nutritional deficiency or gastrointestinal health,â Mir says.
The canker is trying to warn you
Assuming itâs not cancer, a very painful and frequent canker sore may indicate another chronic problem to be explored and addressed. Several underlying conditions are associated with canker sores.
Poor nutrition is sometimes involved. âThereâs pretty strong data to support that nutritional deficiencies could be a causative factor for canker sores,â Villa says. Mir tells some patients to take a zinc supplement. Other nutrients that may play a role include ferritin, folate, and B12.Â
A preliminary study last year found a connection between canker sores and vitamin D deficiency. Not enough antioxidants in your diet is another potential factor, research shows. âIf youâre eating a lot of ultra-processed food, or youâre in a nutritional desert, then by all means, itâs important to look at diet,â Mir says.
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The sore will likely go awayâand reoccurâbefore oneâs diet or supplements can fix the deficiency. The corrective process can take months. âItâs probably going to come back until the deficiency is addressed,â Mir explains.Â
Aside from nutrition, cankers are also linked to a range of autoimmune disorders like Crohnâs and celiac disease. A rarer autoimmune condition, Behcetâs disease, features painful cankers. Because these diseases may affect the intestines as well, they can present with digestive issuesâsuch as ulcerative colitis, irritable bowel syndrome, and colon ulcersâin addition to the mouth ulcers.Â
Inflammation throughout the body could also contribute to canker sores. âInflammatory markers are overexpressed in patients with aphthous ulcers,â Villa says.
Yet another condition linked to cankers is a syndrome called periodic fever, adenopathy, pharyngitis (PFAPA) syndrome. In addition to cankers and fevers, patients may get swollen lymph nodes.
Not everyone develops canker sores due to these conditions. Some are more susceptible; researchers have found certain genes associated with mouth ulcers. âItâs clear that genetic background puts people at higher risk,â Sroussi says.Â
How to treat and prevent canker sores
Several treatments can help, and theyâre especially effective when started as early as possible.
For a minor canker, you probably donât need a prescribed medication. Before all else, try home remedies: swab a mix of water and hydrogen peroxide onto the sore several times per day, or rinse with warm water and salt. This should ease some discomfort. âI get my little canker sore here and there,â Villa says. âItâs annoying, but Iâm not taking a steroid for it.â
Major or complex ulcers are another story. In these more painful situations, a topical corticosteroid can be rubbed onto the canker to soothe the area. A physician may prescribe stronger steroids in pill form. The most common example is prednisone.Â
Other steroids like triamcinolone can be injected directly into the lesion. âThis works well for ulcers that are really deep and painful,â Sroussi notes. For all steroid types, Sroussi recommends against prolonging their use, due to potential side effects.
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A drug typically given for psoriasis, called apremilast, provides an anti-inflammatory effect without the immune suppression of steroids, Sroussi says. In a recent pilot study, apremilast caused ârapid and sustainedâ improvements. Especially bad cankers may be treated with a medication called CellCept, which does suppress the immune system to bring down inflammationâbut only if all else fails.Â
Over-the-counter gels provide temporary pain relief for both minor and moderate cankers. They feature an anesthetic called benzocaine that numbs the affected area. They also shield the canker from irritating food. However, these gels wonât necessarily make the sore go away.
Prescription mouthwashes can help. Mir recommends Magic Mouthwash to her patients. Itâs a cocktail of canker remedies like lidocaine, which is a local anesthetic, and antihistamines. Other mouthwashes for cankers are single-ingredient antimicrobial rinses.
More therapies are in the works. A Swedish startup called Mucocort is developing a biodegradable patch that goes over the canker sore with the goals of protection, pain relief, and healing. A clinical trial is set to begin soon. Other research supports such patches, as well as laser and freezing therapies.
Of course, if a patient is found to have an underlying condition, the priority is treating the condition, which may address the cankers, too.
Donât forget nutrition. Sroussi recommends keeping a diary to track which foods seem to incite cankers. As always, regular brushing and flossing are important. Canker sores are associated with certain mouth bacteria.
If they really torment you, consider keeping a broader diary to identify other activities that reliably coincide with cankers, and try to avoid them. If the behavior is necessary, like stressful work or lost sleep during an international flight, Sroussi sometimes prescribes swish-and-spit steroids to stop cankers in their tracks, before people even get them. âPrevention is a possibility,â he says.Â
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