Recurrent Mouth Sores and Burning Mouth Syndrome
Frederick R. Jelovsek MD, MS
"Why do we get mouth sores? I get them on my tongue and under as well as on the inside of my mouth."
"I am 40, normal menstrual history. Meds I'm on are Orthocept® for birth control, Celexa®, an antidepressant, and Zyrtec® for allergies."
Mouth sores are sometimes called apthous ulcers or apthous stomatitis when the cause is not known but thought to be allergic or immune in origin. About 15-20% of the population complains of recurrent mouth sores at various times (1).
I am glad you included your medications because many times these sores are caused by prescribed or over-the-counter medications. Of the medicines you list, none are known for a high incidence of mouth ulcers except anti-depressants which can have a drying effect on the mouth. All of your mediciations have had a very small incidence of this problem reported. The Zyrtec® can produce a pharyngitis and both Zyrtec® and Celexa® have about a 20% incidence of dry mouth. It is possible that a lack of saliva makes you more susceptible to the mouth sores from some other ingested food or drink.
The list of causes of mouth sores is quite long (2). In general, however, you should look for direct contact irritants or allergens, immune skin conditions and infectious agents.
Contact irritants/allergens can include:
- tooth paste
- acidic foods like colas, juices, coffee
- spicy foods, eg., cinnamon
Therefore look at foods or beverages that you are using on a daily basis and go through a trial period of eliminating them either all at once and add them back one at a time about every two weeks, or eliminate one at a time for two weeks. If you have any suspected food allergies such as wheat, eggs etc, be sure to include them in the elimination process.
Immune skin conditions can manifest in the mouth without being a problem elsewhere on the skin. A dermatologist can sometimes help with this and even do a biopsy to get a precise diagnosis (3). Some of those skin conditions include:
- lichen planus
- pemphigus vulgaris
- benign mucous membrane pemphigoid
- discoid lupus erythematosus
- erythema multiforme
The treatment may include systemic or topical steroids but you need a firm diagnosis by a dermatologist. If you tend to have skin problems otherwise, check with a dermatologist about the oral sores. They can also perform cultures for some infectious agents.
Infectious causes can include:
- oral herpes simplex
- Behcets disease (often causes vulvar ulcers also)
- periadenitis mucosa necrotica recurrens
Your dentist may be helpful with these (4). Be sure to have your teeth cleaned as dental plaque can make the recurrences more often. If you find that any toothpastes or mouthwashes seem to make the recurrences worse, discuss that with the dentist to get alternative brand suggestions.
Finally, recurrent mouth sores can be a manifestation of a systemic disease such as hepatitis, HIV, lupus or other conditions that affect the immune system. Ask your doctor to screen for any of these that might be appropriate.
Burning Mouth Syndrome
Burning mouth syndrome is different from having mouth ulcers that are sore. With burning mouth syndrome there is a generalized burning pain that may include the tongue, the roof of the mouth, the gums, the inside of the cheeks and/or the back of the mouth or throat. There are usually no visible ulcers or sores that can be seen although ocassionally the tissues look slightly reddened. Dry mouth and a bitter metallic tase sometimes go along with this condition. The pain is often not present in the morning but intensifies throughout the day and into the evening.
It is more common in women after menopause and after 60 but it can occur at younger ages and in males also. Often the cause is related to ingested substances that are irritants or toxic to the nerves of the mouth just as they may be for causing mouth ulcers. Sometimes there are other causes but many times no one can find a cause for it. Other terms used to describe this condition syndrome include glossodynia (tongue pain) and stomatodynia (mouth pain).
Other causes can be similar to those that cause ulcers and may include:
- dry mouth due to Sjogren's syndrome, anti-hypertensive medications (especially ACE inhibitors) and anti-depressants
- nutritional deficiencies such as iron, zinc, folate and vitamins B-1, B-2, B-6, B-9 and B-12
- irritating dentures, tooth pastes, chewing gums, mouth washes, tongue brushing
- food allergies
- gastric reflux
- medical conditions such as thrush infections, diabetes, hypothyroidism
Since there are so many different causes for both recurrent mouth ulcers and burning mouth syndrome, it is important to individualize diagnosis and treatment for each individual. Start with the simple and sequentially eliminate various possibilities.
- Look up the side effects of any medications you are taking and if any are reported to cause mouth burning, ask your doctor to consider a substitute medication.
- Eliminate for 2 weeks regular tooth pastes, mouth wash, chewing gums, tobacco and very acid liquids (certain fruit juices, colas and coffee). Baking soda toothpaste may be ok to use during this time.
- If these above steps do not resolve the problem, see your doctor or dentist to make sure you do not have diabetes, Sjogren's syndrome, thrush (yeast infection of the mouth), nighttime teeth grinding, denture irritation or other conditions they can detect.
- You may also want to consider testing for low thyroid (TSH), mineral deficiencies (MineralCheck) and food allergies (foodScan IgE).
Treatment is to eliminate the cause. If that cannot be done, switching to basic baking soda based toothpaste and mouth wash. You might also consider an anesthetic mouth rinse (UlcerEase).
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