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                                                        DR. DAN PETERSON

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If they persist for more than a week, you need to see us.~

Causes of Mouth Sores Hairy Tongue
Canker Sores Geographic tongue
Cold Sores Oral Warts
Leukoplakia   Swollen Lips
Oral lichen planus Behcet's Syndrome
Candidiasis  Canker Sores Expanded 
Lupus Cold Sores Expanded
Thrush Medical Update for Dental Professionals

  Mouth sores can interfere with smiling, eating, and look unsightly.

     They can be caused by:


Ill fitting dentures




Sharp edge of a broken tooth




Fungal or viral infection




Symptom of a disease and/or disorder

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     Mouth sores are common and rarely cause complications.  The most common sores are:

1.  Canker sores are small white or gray based ulcer with a red border IN the mouth.  They are very common but not contagious. Fatigue, stress or allergies can increase the likelihood of getting canker sores.

Canker Sore Self Test  

 Canker Sores Expanded                                         

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2.  Cold sores are called fever blister or herpes simplex because they are usually caused by herpes virus type 1 which is very contagious and occur OUTSIDE the mouth. 


Cold Sores

Canker Sores


Herpes simplex virus I/



Most often found around the mouth but sometimes occur on the gums or roof of the mouth

Inside the mouth (soft tissue)


7-14 days

7-14 days


bullet  Topical creams
bullet  Oral anti-viral medications
bullet Valtrex for herpes outside the mouth
bullet Over-the-counter anesthetics
bullet  In severe cases, topical-based steroids

Is it contagious?




bullet  Stress
bullet  Trauma
bullet  Ultraviolet light
bullet  Weakened immune system
bullet  Stress
bullet  Ultraviolet light
bullet  Certain foods
bullet  Trauma

Cold Sores Expanded

Dec 12/03 Academy of General Dentistry                                                             

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3.  Leukoplakia It is defined as a whitish plaque that cannot be characterized  as any other disease and is not associated with any physical or chemical causative agent except the use of tobacco ***  A thick, whitish  or gray color patch that forms on the inside of cheeks, gums or tongue and is caused by excess cell growth.  It is the mouth's reaction to chronic irritation of the mucous membranes of the mouth.  It is found among tobacco users, or those wearing ill fitting dentures or have a habit of chewing on their check.  It is more common in men than in women, however women with leukoplakia have a higher risk of developing squamous cell cancer.***


The growth can occur at any time in life but it most common in the elderly.
"Hairy" leukoplakia of the mouth is an unusual form of leukoplakia that is seen only in people who are infected with HIV, have AIDS, or AIDS-related complex. It consists of corrugated, fuzzy, hence the name "hairy," white patches on the lateral borders of the tongue and less frequently elsewhere in the mouth. It may resemble thrush, an infection caused by the fungus Candida which, in adults, usually occurs if your immune system is not working properly, and may be one of the first signs of infection with the HIV virus.  Unlike thrush, it is not easily scrapped off. It is painless, but patients occasionally complain of its appearance and texture.

Causes :

bulletIrritation from rough teeth, fillings, crowns, or ill-fitting dentures that rub against your cheek or gum
bulletChronic smoking, pipe smoking, or other tobacco use
bullet body's reaction to the Epstein-Barr virus (responsible for mononucleosis)
bulletSun exposure to the lips
bulletOral cancer, although rare
bulletHIV or AIDS


bulletWhite or gray colored patches on your tongue, gums, roof of your mouth, or the inside of the cheeks of your mouth.
bulletThis patch may have developed slowly over weeks to months and be thick, slightly raised, and may eventually take on a hardened and rough texture.
bulletPainless but may be sensitive to touch, heat, spicy foods, or other irritation.


bullet Biopsy will likely be taken to rule out other causes.


Treatment may involve:

bulletremoving the source of irritation i.e. rough tooth or an irregular surface on a denture or filling the tooth will be smoothed and dental appliances repaired
bulletcaused by smoking, you will be asked stop smoking or using other tobacco products.
bullethairy leukoplakia requires treatment with an antiviral medication

Leukoplakia is usually harmless, and lesions usually clear in a few weeks or months after the source of irritation is removed. If eliminating the source of irritation is ineffective in reducing leukoplakia, the lesion may need to be surgically removed. The lesion can be removed either by your general dentist or by an oral surgeon in their office under local anesthesia.ADA 7/04

         New Discovery-Sanguinarine, a natural anti-bacterial agent, was once a key ingredient in the Viadent line of toothpastes and mouth rinses.Researchers suspect that sanguinarine causes the formation of white lesions, called oral leukoplakia. The current study suggests that users of the former Viadent formulation were eight to 11 times more likely to develop leukoplakia than were those who had never used the product. Patients who used the old formulation of Viadent develop lesions two, three, four, even five years after they stopped using the product".  Patients with leukoplakia should be alert for oral cancer.* 

Oral lycopene - An efficacious treatment for oral leukoplakia?

A total of 58 patients received either 8 mg oral lycopene in two doses daily (n=20), 4 mg oral lycopene in two doses daily or placebo capsules  for a 3-month period. Progress of patients was followed for a further 2 months.

There was no significant difference in the clinical response of people who took 8 mg lycopene compared with those taking 4 mg lycopene. The clinical responses measured in both these groups were significantly greater, however, than those in the control group. The response, assessed histologically, after the 8-mg
lycopene treatment was significantly better than that from 4 mg lycopene and than the response seen in the control group, Patients taking 4 mg lycopene also responded significantly better than those in the control group .

Oral lycopene appears, from this small RCT conducted over 5 months, to be effective in the treatment and management of oral leukoplakia.

Oral lycopene an efficacious treatment for oral leukoplakia? Joanna M Zakrzewska1
Singh M, Krishanappa R, Bagewadi A, Keluskar V. Efficacy of oral lycopene in the treatment of oral leukoplakia. Oral Oncol 2004; 40:591−596.

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4.  Oral lichen planus:


is a mouth rash of unknown cause. 


is not contagious and not inherited. 


may be painless or cause pain. 


may be more severe at times of  stress. 


may eventually disappear.


skin, nails and scalp may be affected .


may be caused or aggravated by medicines, tooth filling materials, or toothpastes. 


biopsy is usually necessary to confirm the diagnosis.+


Oral lesions-classifications and appearances 


white area wipes off and leaves a bleeding submucosa.    

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Lichen Planus of the Mouth

Lichen planus of the mouth and tongue most commonly affects 1-2% of the population, most of whom are middle aged women. The condition is less common in the very young and the very old.  It appears on the inside of the cheeks, gums and tongue. Oral lichen planus is more difficult to treat and typically lasts longer than skin lichen planus. Fortunately, many cases of lichen planus of the mouth cause minimal problems. About one in five people who have oral lichen planus also have skin lichen planus.

Oral lichen planus typically appears as patches of fine white lines and dots. These changes usually do not cause problems. Dentists during routine checkups often find them. More severe forms of oral lichen planus can cause painful sores and ulcers in the mouth. Often a biopsy of affected tissue is needed to confirm a diagnosis of lichen planus. Your doctor may have to make sure that the sores are not caused by a yeast or an infection and are not canker sores.  Sometimes, several biopsies are needed at various times, along with blood tests.

No one knows what causes lichen planus, although some experts suspect that it is an abnormal immune reaction following a viral infection, probably aggravated by stress. Occasionally, lichen planus in the mouth appears to be an allergic reaction to medications, filling material, dental hygiene products, chewing gum, or candy. The cases of lichen planus-type allergic reactions to dental materials are very rare. When an allergy by dental material has been proven, removing dental material is recommended.

Lichen planus in the mouth occurs in six different forms with a variety of symptoms:

lacy-white streaks


white plaques, or eroded ulcers


gums are affected, so that the surface of the gum peels off, leaving the gums red and raw.

There is no known cure for oral lichen planus although there are many treatments that eliminate the pain of sores. When the disease causes no pain or burning, treatment may not be needed. More severe forms of lichen planus - those with pain, burning, redness, blisters, sores and ulcers - can be treated with a variety of medications, both applied to the sores (topical) and taken by mouth (oral). As with any disease of the lining of the mouth, lichen planus can lead to poor dental hygiene and gum disease.     


Table 2. Compounds with potential to cause contact stomatitis include1,2
Antibiotics Iodine
Antiseptic lozenges Mouthwashes
Chewing gum Toothpastes (especially those containing cinnamonaldehyde, formalin and herbal components)
Cosmetics Topical anesthetics
Dental materials (amalgam, steel wires, beryllium, palladium, platinium, acrylic components) Topical steroids
Food additives  

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Table 4. Drugs that have potential to cause glossitis
Atrovastatin Etidronate Penicillamine
Benzodiazepines Fluoxetine Penicillins
Bleomycin Fluvoxamine Rivastigmine
Captopril Gabapentin Serteraline
Carbamazepine Gold compounds Sildenafil
Cephalosporines Imipenem/cilastatin Sulfonamides
Chloramphenicol Lansoprazole Tacrine
Chlorhexidine Mefenamic acid Tetracyclines
Clarithromycin Mercaptopurine Triamterene
Clomipramine Methotrexate Tricyclic antidepressants
Cyclosporine Metronidazole Trihexyphenidyl
Doxepin NSAIDs Venlafaxine
Enalapril Olanzapine  

The danger is that it can progress to cancer.  

This condition often needs a biospy.     Leukplakia on tongue.


      Treatment involves identifying the factors that may cause the lesions. An examination and a biopsy are done in order to determine how to individually manage your care.  The cause of this condition must be removedThe lesion must be examined at three to six month intervals depending on its type, location and size. Fluocinonide (Lidex) - 60g
apply to affected areas four times a day.
Also try using milder toothpastes instead of tartar control products also seems to lessen the number of ulcers and makes them less sensitive.


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  5.    Candidiasis often know as oral thrush is a fungal infection that occurs when they yeast Candida albicans reproduce in large numbers. It can also be called angularchelitis.  It results in red and cream  or while colored, slightly raised patches on the mucous membrane of the tongue, mouth and throat that form on the mouth's moist surfaces. The mucous membrane beneath the patches is usually raw and bleeding. The overgrowth of  this fungus results when the balance in the normal oral microbe population is disturbed by antibiotic therapy or disease.  Tissues under the patch can be painful  It can cause difficult in swallowing and diminish the sense of taste. It occurs most frequently in infants, in adults suffering from chronic illnesses, in the debilitated, in the immunosuppressed.

  Cracks at corner aof the mouth can be very painful and can be due to over closing.

     This is a common condition in very young, elderly or debilitated by disease or with improperly functioning immune system, denture wears who are over closed , babies, or  after antibiotic treatment and in individuals on long-term antibiotic, corticosteroid, or antineoplastic therapy.  It is often an early symptom of HIV infection.  People with dry mouths also have a higher occurrence of Candidiasis.  

     Treatment consists of controlling the conditions that caused the outbreak. Because candidiasis is common among denture-wearers, a thorough daily cleaning of dentures is important.  Removing dentures at night also allows the denture-bearing tissues to regenerate.  Saliva substitutes or prescription medication can help.  Good oral hygiene is essential. It can also be treated with antifungal/anti-inflammatory ointment. Also try hard not to lick your lips especially when the corners are cracked. Fluconazole is very helpful along with rigorous daily oral care   



Nystain 200 mg oral


Ketoconazole 200 tabs


Itraconazole 100 mg


Fluconazole 100 mg tabs


Chlorhexidine glucoate 0.12%


Amphotericin B 100 mg/ml suspension


Clotrimazole 10 mg troches

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Treatment for these conditions are provided through your dentist on an individual basis depending on your condition. Any ulcer which becomes increasingly painful or is persistent should be seen by a specialist.^Be sure to get new toothbrush, floss holder, anything else you would put in your put in your mouth.....bathroom cup? If a denture or your mouth can carry the fungus (which would be soaked in a nystatin mixture) than other items you use in your mouth can carry the fungus and you can reinfect your mouth by not cleaning these items or using new mouth care items.

     Dentists are recommending patients to consume aloe vera juice to treat various internal ulcerations of the mouth, including aphthous ulcer, a common condition usually caused by stress and/or may be precipitated by trauma; and lichen planus a disease of unknown origins affecting the skin and oral mucus membranes. Recent findings will show that aloe vera cleared up oral lesions associated with lichen planus better than any other traditional treatments.** 

    Thrush is a common side effect of Advair.  Nystatin suspension coats the mucosa and works well.  You can also use the Mycelex troches. Mycostatin oint (15gm)applied to inside of denture after cleaning and to corners of mouth and misolex troches (disp 70) 1 tab in mouth until gone 4-5Xday for 14 days. (CHX) will kill the planktonic bugs, but
wont do much for the biofilm. Even if you can kill all the bugs in the biofilm, unless you remove  the remnants of the polysaccharide matrix new bugs can re-populate  and re-form the biofilm very rapidly.
IDF 11/05

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Treatment for severe mouth ulcers .  

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 Systemic Lupus (SLE) can and does manifest itself intraorally in the form of ulcerations, erythema (red lesions), and keratosis (thickened dermal layer, whitish in color). The vermilion border of the lip, the inner cheek, gums, and roof of the mouth are areas which are often affected.                                       

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Hairy tongue A hairy tongue is due to a profuse overgrowth of a particular type of taste bud the filiform papillae which gives the appearance of thick fur on the tongue. This can result from: 
Antibiotic treatment
Excessive use of mouthwashes, which liberate oxygen from the mouth environment
Reduction in salivary flow due to problems with the salivary glands 

Brown papillae are usually due to tobacco staining or overgrowth of a particular type of chromogenic bacteria. 

There are no symptoms associated with a hairy tongue. Treatment is of the underlying cause, such as stopping antibiotics or mouthwashes or dealing with the salivary gland problems.

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Geographic tongue Geographic tongue (benign migratory glossitis) is a benign condition that occurs in up to 3 percent of the general population. Most often, it is asymptomatic; however, some patients report increased sensitivity to hot and spicy foods. The cause and the pathogenesis are still poorly understood. The condition affects males and females and is noted to be more prominent in adults than in children. 

Classically, it appears as an area of erythema, with atrophy of the filiform papillae of the tongue, surrounded by a white, hyperkeratotic border. The patient often reports spontaneous resolution of the lesion in one area, with the return of normal tongue architecture, only to have another lesion appear in a different location of the tongue. Lesion activity may wax and wane over time, and patients are occasionally free of lesions. If lesions occur at other mucosal sites, the condition is termed erythema migrans.

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 Human papillomavirus Oral warts can occur anywhere in the mouth, including the tongue. The causative agent is the human papillomavirus (HPV). These growths generally are not painful and can be ignored unless they interfere with appearance or function. It is estimated that 40 million Americans are infected with one or more of the 80 strains of HPV. HPV has been implicated in some oral cancers and is contagious. 

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This literature review article examines the increase in incidence of Acute Necrotizing Ulcerative Gingitivitis (ANUG) as a result of the increasing incidence of severe immunodeficiency states such as  Acquired Immunodeficiency Syndrome (AIDS) in the presence of poor nutrition. This review provides an understanding of the etiology, pathophysiology, and management of ANUG with malnutrition.
The Epidemiology, Etiology, and Pathophysiology of Acute Necrotizing
Ulcerative Gingivitis Associated with MalnutritionFolayan MO

Swollen Lips

Angioneurotic edema  (Allergy related).  Find allergen causing the lip to swell.

Behcet's Syndrome

Behcet's syndrome .
Although rare, it presents with oral ulcers - a summary follows:

Sores in the Mouth are painful canker sores that can overlap  and take days or weeks to heal.  Look for white or yellow centers, with a red edge. They are especially painful on the tongue, but can be found anywhere inside the mouth. Gum lesions are not very common, but do occur. If they predominate, then consider another diagnosis. These sort of ulcers are quite common amongst perfectly healthy people and they have to be linked with some other symptoms to be part of Behcet's Syndrome. 
Thalidamide may be given for this condition. IDF 10/05

Pain relief for generally sore mouths: Rincinol by Butler

Medical Update for Dental Professionals on Mouthsores


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***Pennsylvania Dental Journal, September/October 2002; Dentistry Today February 2003 pg 46.
**Academy Of General Dentistry, Plant Aloe Vera: Relieve a Cold Sore 9/01.
~Common Mouth Sores, JADA, Vol. 132, November 2001
*Legacy of discontinued ingredients in patients' mouths, 27 Dec 2001 20:15:04 -0000, the research was supported by a grant from the American Cancer Society.
^VOLUME 192, NO. 3, PAGES 139-140, Oral ulceration: a new and unusual complication
#Picture courtesy of Dentalcare.
Mouth Ulcers Homepage

February 06, 2008

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