Introduction:
Apthous ulcers are painful red eruptions with a central white area which occurs in the mucosal lining of the mouth. They have known to occur in areas where excoriation of the inside of the mouth occurs after brushing or biting the cheek. They may be associated with immune deficiency, viral infection, menstrual cycle, food allergies, stress, hormonal changes, and deficiency of folate, iron, or B12. These take a few days to heal but if they last over 10 days, if there are multiple which occur simultaneously with increasing pain, redness, drainage or fever a physician evaluation is required.
Milk consumption and apthous ulcers:
In a study by Calderón PE et al, a strong associated between cow’s milk proteins and recurrent aphthous ulcerations (RAU) (“canker sores”) was established. The authors tested the level of IgA, IgG, and IgE antibodies by enzyme-linked immunosorbent assay (ELISA) test, in 50 subjects with RAU and 50 healthy individuals. Compared to the control group, the levels of IgA, IgG, and IgE antibodies to cow’s milk proteins were significantly higher in subjects with RAU (P < 0.005). This study suggests a link between cow’s milk proteins and the development of RAU. Besu et al concluded similar results and found an association of recurrent aphthous ulcerations (RAU) in 50 subjects which had an increase in levels of IgG, IgA and IgE antibodies to cow’s milk proteins in comparison to 50 healthy people without RAU. Levels of antibodies were measured by enzyme-linked immunosorbent assay (ELISA) test. The results indicated RAU patients had significantly higher levels of anti–specific cow’s milk proteins (SCMP) IgA, IgG, and IgE antibodies in comparison to healthy people without RAU (p<0.005). The study showed a strong relationship between high levels of anti-SCMP IgA, IgG, and IgE antibodies from cow’s milk and occurrence of RAU.
Gluten related disease may cause recurrent apthous stomatitis.
A high rate of patients with recurrent apthous stomatitis and celiac disease respond well to treatment with a gluten-free diet. Patients with recurrent apthous stomatitis were found to have a higher rate of gluten sensitive bowel disease than the general population which supports screening these patients for celiac disease.
Assessment and Plan: Apthous Ulcers (Canker Sores)
- The primary care physician should evaluate patients with recurrent apthous ulcers, multiple lesions, drainage, fever, or ulcers lasting over a prolonged period of time. Further evaluation may be needed for Herpes Simplex Virus or immune deficiency.
- Avoid all dairy products.
- Correct nutritional deficiencies of folic acid, B12 and iron.
- Prevent viral infections with frequent hand washing and sanitizing surfaces.
- Patients with recurrent apthous stomatitis were found to have a higher rate of gluten sensitive bowel disease than the general population which supports screening these patients for celiac disease. Consider eliminating gluten in the diet.
References:
1.Calderón PE, Valenzuela FA, Carreño LE, Madrid AM. A possible link between cow milk and recurrent aphtous stomatitis. J Eur Acad Dermatol Venereol. 2008 Jul;22(7):898-9. Epub 2007 Jan 10. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0714.2012.01204.x/abstract
2.Besu I, Jankovic L, Konic-Ristic A, Raskovic S, Besu V, Djuric M, Cakic S, Magdu IU, Juranic Z. The role of specific cow’s milk proteins in the etiology of recurrent aphthous ulcers. J Oral Pathol Med. 2012 Aug 24. http://www.ncbi.nlm.nih.gov/pubmed/22924810
3.Shakeri R, Zamani F, Sotoudehmanesh R, Amiri A, Mohamadnejad M, Davatchi F, Karakani AM, Malekzadeh R, Shahram F.Gluten sensitivity enteropathy in patients with recurrent aphthous stomatitis. BMC Gastroenterol. 2009 Jun 17;9:44. http://www.ncbi.nlm.nih.gov/pubmed/19534771