Homoeopathic perspective on aphthous ulcer: a review

Dr Pratiksha Prabhakar Kamath

ABSTRACT
Aphthous ulcer or Canker sores is a common and painful mucosal ailment that affects the oral cavity. In addition to being painful, it is frequently accompanied with redness, swelling, and sporadic bleeding from the affected region or areas. It is common in immunocompromised people, young children, and the elderly and presents as painful, white, ulcerative sores in the mouth. Culture tests are used in addition to the primary clinical diagnosis. Antifungal medications like fluconazole and nystatin are available as treatment alternatives. Keeping good oral hygiene and treating underlying medical issues are the major goals of prevention. Homoeopathy has great scope in the management of Aphthous Ulcer. This review article highlights the clinical manifestation, diagnostic standards, and current developments in the treatment of aphthous ulcers.

KEYWORDS: Aphthous ulcer, Canker sores, Oral cavity, Homoeopathy

INTRODUCTION
Aphthous ulcers, commonly known as canker sores, are small, painful lesions that develop on the soft tissues inside the mouth. These ulcers are characterized by their round or oval shape, with a white or yellowish center surrounded by a red inflamed border. These ulcers, most commonly appear on the non-keratinized oral mucosa, they can cause substantial pain, and may cause difficulty with chewing, eating, and speaking. Aphthous ulcers are found typically where the skin is not tightly bound to the underlying bone, such as on the inside of the lips and cheeks or underneath the tongue. Aphthous ulcers are mostly a minor nuisance, but they are associated with significant health problems in some people. Most ulcers are benign and self-resolving but a small percentage of them are malignant.

EPIDEMIOLOGY
Aphthous ulcers affect between 20-25% of the population and are one of the most common oral lesions in the overall population. It can reoccur any time in life with a frequency that varies up to 3 months and the recurrence rates are as high as 50%. Developed countries have the highest prevalence of aphthous ulceration, and women are at a slightly greater risk than men. Usually, men and women are equally affected but in a special type called herpetiform ulcers, women are at a slightly high incidence, etiology of this remains unknown.

TYPES OF ORAL APTHOUS ULCER AND CLINICAL ASPECTS
Oral aphthous most often begin after 10 years of life and may be caused by minor strain,

menstruation or stress, or contact with certain hot or spicy foods. During this initial phase, erythema develops, and it is localized to a specific part. Within hours, small white papules form which later ulcerates, and slowly enlarges over the next 48–72 hours. There are three morphological types of aphthous ulcers.

Minor Aphthous Ulcer
It affects about 70-80% of patients. Ulcers are tiny less than 4 mm in diameter, spherical, usually with a yellowish or grey-white false membrane and erythema is also present. It usually occurs on non-keratinized surfaces particularly the mucosa of lips and mucosa of the mouth, and floor of the mouth. If we talk about the sex ratio, we can safely say men and women are equally affected. The age of onset for minor aphthae is approximately between 10-19 years. The number of ulcers is usually 1-5 and the size is less than 10 mm. Scarring does not occur, and the ulcer heals within 10-14 days. If recurrence occurs, it will occur between 4-14 months.

Major Aphthous Ulcer
Major Recurrent Aphthous Stomatitis is a severe form of Recurrent Aphthous Stomatitis also known as peri adenitis mucosa necrotica recurrent in the USA. 10% of the affected patients present with this complaint. These ulcers usually occur on the lips, cheeks. tongue, palate, and pharynx. Just like a minor aphthous ulcer, the sex ratio in men and women is equal. The age of onset for major aphthae is approximately between 10-19 years. The number of ulcers is usually 1-10 and the size is greater than 10 mm. If recurrence occurs, it will occur in less than a month. They persist for up to 6 weeks and scarring may or may not occur. Large ulcers may take a longer time to resolve and mostly heal without scarring. The major ulcer will rarely leave a scar. They can be mistaken as malignant lesions due to their clinical appearance. The major aphthous ulcer usually appears after puberty, it is chronic and persists for up to 30 years.

Herpetiform Aphthous Ulcer
Herpetiform ulceration (HU), is a rare form of aphthous ulcer, only 1-10% of patients are affected. It is characterized by multiple recurrent picks of extensive, minor, painful ulcers. This ulcer usually occurs on the lips, cheeks, tongue. pharynx, palate. gingiva, the floor of the mouth. In herpetiform aphthous ulcers, females are more affected than males, cause and reason for this are maybe it is stress associated. During stress situations and menses, some women might develop these ulcerative lesions. The age of onset for herpetiform ulcers is almost mid-twenties.

The number of ulcers is usually 10-100 and the size is greater than 10 mm. Scarring can occur following the fusion of ulcers. If recurrence occurs, it will occur in less than a month. Despite the name, there is no association with herpes viruses.

CAUSES:

They are divided into four categories –

I Local causes

II Malignant causes

III Systemic causes

IV Other causes

Local causes

• Most common causes of oral ulceration is local trauma. It is most frequently caused by tooth procedures, braces, or sharp/broken teeth
• It can also be due to accidental tongue or cheek biting, scratching of the tongue with fingernails.
• Eating rough/hot foods

Malignant causes

• oral squamous cell carcinoma (most common)
• lymphoma
• minor salivary gland tumors
• tumor extension from the maxillary sinus
• Odontogenic tumors
• metastatic neoplasms
• neoplasms of bone
• neoplasms of connective tissue
• neoplasms of melanocytes
• vascular neoplasms

III. Systemic causes

• Oral ulceration is the most common indicator of Behcet’s disease and can occur in up to 99% to 100%
• Crohn’s disease
• coeliac disease
• HIV infection

Other causes

• Genetic predisposition – HLA-DR2, HLA-R12, HLA-A2
• Stress or anxiety is said to trigger aphthous mouth ulcers in some people
• Changes in hormone levels. Some women get mouth ulcers just before their menses.
• A lack of iron, or a lack of certain vitamins (such as vitamin B12 and folic acid) may be a factor.

PATHO- PHYSIOLOGY-

Cellular and Humoral Immunity –

Cellular immunological etiology has been identified by numerous studies that have shown autoantibodies directed against the cellular spinal layer from the structure of the epithelium. In these situations, the cellular spinous layer would have a modified antigenic structure due to multiple factors. Research has shown blastic transformation of autologous T lymphocytes that were incubated with mucosal homogenates of the same patients. Autologous T lymphocytes were cytotoxic for their own epithelial cells. Helper T4 cells were observed in epithelial chorion when keratinous cells were activated with HLA-DR antigens. Changes in the ratio of different subset of T lymphocytes in patients with this condition compared to a control group were also observed. The ratio of T4 (CD4) helper / T8 (CD8) suppressor has been changed.

The humoral immunity occurs by the attaching of circulating immune complexes to the blood vessels’ endothelium. This results in the activation of some complement fractions, which causes the activation of endothelial cells and the migration of neutrophilic polymorphonuclear PMN cells to the lesion. The inflammatory infiltrate that forms at the site of the lesion therefore contains neutrophilic polymorphonuclear cells, red blood cells, macrophages attracted by complement fractions and mast cells. Histamine released by macrophage cells becomes the conductor of the whole inflammatory process in which occurs vasodilation and the consequent increase of the vascular permeability, with the extravasation of macrophages and neutrophils.

Vascular Pathology
Vascular alterations are also accompanied by micro thrombosis. After this initial inflammatory phase, ischemia occurs at the level of the damaged blood capillaries with consequent epithelial necrosis. The epithelium is thus broken, the epithelial necrosis leads to the formation of ulcers which are the characteristic clinical sign of the oral aphthae.

SIGN AND SYMPTOMS OF APTHOUS ULCER –

The clinical appearance is typical: after a short onset of up to 24 hours

accompanied by erythema, pruritus or burning sensation, an ulceration of 2-7 mm round or oval appears, with a clear outline, unrelieved edges, covered with a deposit of white or yellowish fibrin.

There is a congestive halo around the ulceration and the surrounding mucosa is edematous.

Ulcers are located on the labial, lingual mucosa, buccal floor, tonsillar pillars, soft palate. The consistency of the aphthae is supple, elastic.

• Problems with chewing or tooth brushing because of the tenderness.
• Irritation of the sores by salty, spicy or sour foods.
• Irritation of the sores by dentures, orthodontic aligners or mouth splints.

PREVENTION OF APHTHOUS ULCER –

Vitamins

• Vitamins B1, B2 and B6. Take a daily B complex.
• Lactobacillus acidophilus: (Chew four Lactobacillus tablets three times per day to reduce soreness) Some people with recurrent canker sores have been reported to respond to Lactobacillus acidophilus and Lactobacillus bulgaricus.

Lifestyle changes

• Dental work: Irritation from poor-fitting dentures, rough fillings, or braces can aggravate canker sores and should be treated by a dentist.
• Good oral hygiene: Flossing teeth daily and brushing teeth and gums for at least two minutes two to three times daily may help prevent canker sores.
• Dietary changes Food sensitivities or allergies may aggravate canker sores. In a 1990 study, oranges, tomatoes, nuts, eggplant, tea and cola were the dietary allergens found to trigger ulcer formation. Other foods anecdotally associated with aphthous ulcers are pineapple and cinnamon oil or flavouring.
• Avoid Irritants: Refrain from consuming spicy, acidic, or very hot foods that can aggravate lesions.
• Balanced Diet: Eat a nutritious diet rich in vitamins and minerals to boost immune function.
• Hydration: Drink plenty of water to keep the mouth moist and prevent dryness.
• Limit Sugar Intake: Reduce consumption of sugary foods and drinks that can promote Candida overgrowth.
• Stress Management: Practice stress-relief techniques like yoga or meditation to avoid triggering outbreaks.

DIAGNOSIS OF APHTHOUS ULCER –

• The diagnosis of oral aphthous is pretty critical because there is no specific diagnostic test currently available.
• In this situation diagnosis is based on history and clinical findings.
• There is a need to exclude other possible causes of recurrent oral ulceration, such as Behcet’s disease, and possible infection by HIV.
• Medical specialists should ask about dental procedures before the emergence of the ulcer, and any recent local or chemical injury. Also, ask about the current use of drugs and the history of tobacco and alcohol use. As it is discussed above the causes of oral aphthous so, there is a need to prevent all those causes. Information about any other systemic illnesses or the use of drugs like NSAIDS or bisphosphonates should also be questioned.
• Examination of the oral cavity. A complete intraoral examination should be performed to examine the mucosa of the oral cavity. This process requires a good light source and preferably two dental mirrors. Tissues of the oral cavity can be held back with tongue depressors, and it will help with a clear visualization of the whole cavity. There are seven regions in the oral cavity, these must be examined thoroughly to avoid missing a lesion, these sites include lips, cheek mucosa, the floor of the mouth (mainly the posterior floor of the mouth between the tongue and the mandible), teeth and gums, hard palate, oral tongue, and the retro-molar trigone. If an ulcer is present assess whether it is localized or inflamed. The shape and margins of the ulcer should be noted. Induration of the ulcer should be felt along with the surrounding tissue and ensure that there is no fixation of moveable tissues such as the tongue. Note the relation of any prosthesis, sharp or broken teeth, or dental repairs to an ulcer if present. An extra-oral examination to look for swelling or lymphadenopathy should always be performed.
• Patients with Recurrent Aphthous Stomatitis show signs of immune dysregulation. Oral aphthous ulcers are mucosal ulcerations with a varied inflammatory infiltrate and large granular lymphocytes. These cells and inflammatory infiltrate predominate in the pre ulcerative and healing phases, keeping this in mind histology can be performed to make a diagnosis.
• Normal CBC (complete blood count) and hematinic can be done along with another serological testing .

PROGNOSIS OF APHTHOUS ULCER
The prognosis for a Aphthous ulcer is often favorable. In order to prevent more harm or the possibility of infection spreading, the best results are obtained when aphthous ulcer are treated as soon as feasible.

MANAGEMENT

HOME REMEDIES
Saltwater Solution and Sodium Bicarbonate- Mix 1 teaspoon salt with one cup water. Swish the solution in your mouth for 30 seconds, then spit the solution out. In addition to salt, 1/2 teaspoon baking soda (sodium bicarbonate) may be added to the saline solution. Create a paste by mixing baking soda with small drops of water until a thick consistency results. Use this paste to cover the ulcer, which will help relieve pain. These methods may be repeated as often as needed.

Milk of Magnesia- Used frequently as an aide to relieve constipation and as an antacid, milk of magnesia is a liquid suspension of magnesium hydroxide. Dab milk of magnesia directly onto the ulcer with a cotton swab, three to four times a day. This method is recommended after using the hydrogen peroxide solution. Milk of magnesia will help reduce the pain and help speed the healing process.

Over the counter oral care products and mouth rinse- Products such as gels, paste, a rinses that are specifically marketed for sores may provide pain relief and help speed the healing process.

HOMOEOPATHIC MANAGEMENT OF APHTHOUS ULCER:
Homoeopathy is based on the principle of “like cures like.” this means that a substance causes symptoms in a healthy person can, in a much diluted form, help treat similar symptoms in a sick person. Homeopathic treatment of the oral aphthae. Most simple mouth aphthae, with moderate or rare recurrences, will respond to the administration of the homeopathic medicines.

The list of homoeopathic remedies for aphthous ulcer is as follows:

1. Myrica cerifera: Tongue furred, with bad taste in mouth, and nausea. Tenacious, thick, nauseous secretion. Tender, spongy, and bleeding gums. [Merc.]
2. Kalium chloricum: Produces most acute ulcerative and follicular stomatitis. Profuse secretion of acid saliva. Whole mucous surface red, tumid, with grey-based ulcers. Tongue swollen. Stomatitis-aphthous gangrenous. Fetor. Mercurial stomatitis (as a mouth wash).

3. Eucalyptus globulus: Eucalyptus is a powerful antiseptic and destructive to low forms of life, a stimulating expectorant and an efficient diaphoretic. Throat.-Relaxed, aphthous condition mouth and throat. Excessive secretion of saliva. Burns, feels full. Constant sensation of phlegm in throat. Enlarged, ulcerated tonsils and inflamed throat. (Use tincture locally.)
4. Azadirachta Indica (Neem): A plant widely used in traditional medicine, has shown potential therapeutic effects in treating various oral conditions, particularly oral aphthae. Neem’s known properties include anti-inflammatory, antimicrobial, and wound-healing actions, which effectively promote healing and alleviate symptoms in oral ulcers. Previous studies have highlighted Neem’s significant antiulcer effects, with Nimbidin shown to prevent lesions induced by agents like acetylsalicylic acid and histamine [Liang et al., 2012]. According to Dr. K.M. Nadkarni in Indian Materia Medica (1954), heated Neem leaves or pastes are also effective antiseptics for skin diseases, ulcers, and pustules, and, when combined with Katuki and Chiretta, they treat fevers and soothe unhealthy ulcers. Treatment involved administering 10 drops of the mother tincture in a cup of water thrice daily, with follow-ups every two weeks for ten weeks for 6 months
5. Arsenicum album: A person who breaks out in burning, painful mouth sores, and also feels anxious and tired, is likely to benefit from this remedy. Hot drinks often ease the pain, and the person feels best when keeping warm. People who need this remedy often have unhealthy, easily bleeding gums.
6. Borax: This remedy is often helpful when canker sores feel hot and sensitive. Acidic foods-especially citrus fruits-may be irritating. Sores may break out on the inside of the cheeks, on the gums, and on the tongue. The person produces profuse saliva, yet still feels dry inside the mouth. People needing Borax are often very sensitive to noise and inclined toward motion sickness.
7. Calcarea carbonica: For infants and small children have recurring canker sores. A child who needs this remedy may also have head-sweats during sleep, and be slow to teethe or learn to walk. Calcarea carbonica may help with canker sores in adults who are chilly, stout, and easily fatigued
8. Hepar sulphuris : If a person develops painful mouth sores that become infected-with pus formation, extreme sensitivity, and aggravation from cold drinks-this remedy may be indicated. A person needing Hepar sulph often feels extremely chilly, vulnerable, and oversensitive.
9. Mercurius solubilis: Bleeding gums, a swollen coated tongue, and offensive breath are seen along with canker sores. The painful, burning sores feel worse at night, and salivation is profuse, with drooling during sleep. The person tends to sweat at night and is very sensitive to any change in temperature.
10. Natrum muriaticum: The mouth feels dry, and the tongue may have a tingling feeling. People who need this remedy often are troubled by cold sores around the corners of the mouth or chin, and have chapped or cracking lips. A craving for salt, strong thirst and a tendency to feel worse from being in the sun are other indications for Natrum muriaticum.

11. Nux vomica: The patient may break out in canker sores after overindulging in sweets, strong spicy foods, stimulants, or alcoholic beverages. Irritability, impatience, and a general chilliness are often seen when this remedy is needed.
12. Sulphur: This remedy may be helpful for sores that are painful, red and inflamed, with burning pain that is worse from warm drinks and aggravated by heat of any kind. The mouth may have a bitter taste, and the gums can be swollen and throbbing. A person who needs this remedy often has reddish lips and mucous membranes, and a tendency toward itching and skin irritations.
13. Nitric Acid: Ulcers in soft palate, with sharp, splinter-like pains. Salivation and fetor oris. Bloody saliva. Dry. Pain into ears. Hawks mucus constantly. White patches and sharp points, as from splinters, on swallowing.
14. Mercurius Corrosivus: Red, swollen, painful, intensely inflamed. Uvula swollen. Swallowing painful. Most pain in post-nasal with sharp pains to ears. Burning pain, with great swelling; worse, slight external pressure. All glands about thorax swollen.

RUBRICS THAT CORRELATE TO APHTHOUS ULCER –

Synthesis Repertory

• MOUTH – APHTHAE – Tongue – ulcers; forming
• MOUTH – CRACKED – Tongue fissured – directions; in all – accompanied by – ulcer in the centre
• MOUTH – DISCOLORATION – Palate – spots, as if ulcers would form
• MOUTH – DISCOLORATION – Palate – spots, as if ulcers would form – Forepart; in
• MOUTH – DISCOLORATION – Tongue – brown – accompanied by – Throat – ulcers
• MOUTH – ERUPTIONS – vesicles – ulcers, becoming
• MOUTH – ERUPTIONS – vesicles – Tongue – ulcers, becoming MOUTH – ERUPTIONS – vesicles – Tongue – ulcers, becoming _painful
• MOUTH – ERUPTIONS – vesicles – Tongue – ulcers, becoming – small
• MOUTH – ERUPTIONS – vesicles – Tongue – Sides – ulcers; become
• MOUTH – INFLAMMATION – follicular, ulcerative
• MOUTH – INFLAMMATION – ulcerative
• MOUTH – INFLAMMATION – Gums – ulcerative
• MOUTH – MUCOUS MEMBRANE – swollen – red – accompanied by – gray based ulcers
• MOUTH – PAIN – ulcerative
• MOUTH – PAIN – Gums – pressure agg. – ulcerative
• MOUTH – PAIN – Gums – ulcerative
• MOUTH – PAIN – Gums – Lower – ulcerative
• MOUTH – PAIN – Gums – Skin; below – ulcerative
• MOUTH – PAIN – Gums – Upper – ulcerative
• MOUTH – PAIN – Lips – Inner side of – Lower – ulcerative
• MOUTH – PAIN – Palate – ulcerative
• MOUTH – PAIN – Tongue – ulcerative
• MOUTH – PAIN – Tongue – Below – Skin; below – ulcerative
• MOUTH – PAIN – Tongue – Tip – ulcerative
• MOUTH – STOMATITIS, ulcerative
• MOUTH – STOMATITIS, ulcerative – accompanied by.
• MOUTH – STOMATITIS, ulcerative – accompanied by – Tongue

Complete Repertory

• INFLAMMATION, sore throat; aphthous, tonsils:
• ULCERS; aphthous:
• ULCERS; aphthous; tonsils:
• ULCERS; aphthous; tonsils; right:
• FEMALE INFLAMMATION; aphthous:
• ULCERS; alternating sides:
• ULCERS; left:
• ULCERS; right:
• ULCERS; periodical:
• ULCERS; inflammation of tonsils, after:
• ULCERS; menses, before:
• ULCERS; painful; biting teeth together, while:
• ULCERS; painful; drinking agg.:
• ULCERS; painful; eating agg.:
• ULCERS; painful; menses, during:

Conclusion
Aphthae, often known as canker sore, causes substantial discomfort and interferes with daily tasks such as eating and speaking. Understanding its multiple causes, which include poor dental hygiene, systemic health concerns, and dietary habits, is critical for optimal care. Treatment options, such as antifungal drugs and homeopathic therapies, try to target both local lesions and underlying systemic issues. To reduce symptoms and avoid recurrence, an integrated approach to aphthae management is necessary. Additional research and clinical trials are needed to investigate novel therapeutic strategies and improve our understanding of this prevalent yet unpleasant oral illness.

References:

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Dr Pratiksha Prabhakar Kamath
PG Scholar, Department of Practice of Medicine.
Government Homoeopathic Medical College and Hospital. Benguluru – 560079
Under Guidance of: Dr. Praveen Kumar P. D ,HOD and PG guide
Email : drpratikshakamath12@gmail.com