Canker Sores: Supplements, Botanicals, and More

One must consider oral hygiene, local trauma, nutritional deficiencies, genetics, medications, as well as immune factors when creating a treatment plan to both prevent ulcers and hasten the healing process.^1, 2 Unfortunately, the painful nature of canker sores can also impact dietary intake and well as speech production and interfere with oral hygiene practices if left untreated.[i]

Three types of recurrent aphthous ulcers exist: minor, major, and herpetiform ulcers.[ii] The most common type is minor ulcers, which cause the least discomfort and are smaller in size.⁵ This is in contrast to major ulcers which are more severe, larger in size, increasingly painful, and slower to heal.^1, 5 Conversely, herpetiform ulcers range in diameter and form multiple shallow pinpoint lesions throughout the oral cavity—in fact, there can be up to 100 lesions active at a time.^1, 5 These recurrent lesions can be managed through conventional means or naturally through the use of oral supplementation and topical botanical preparations. Below are some of the best-researched naturopathic interventions to support the healing of recurrent aphthous stomatitis.

Aloe vera

Aloe vera is a cactus-like tropical plant with anti-inflammatory, antibacterial, antiviral, antifungal, antioxidant, and wound-healing properties.[iii] The probiotic fermentation products of Aloe vera, when applied topically, were found to shorten healing time and restore microbial diversity within the oral cavity.⁶ In a clinical trial, 35 adult patients with aphthous stomatitis applied Aloe vera fermentation gel or a chitosan gel on the surface of each ulcer every day after each meal until it resolved.⁶ For reference, chitosan is a natural polysaccharide prepared from chitin, which is a compound found in the shells of crustaceans like crab and shrimp.[iv] The study found that the use of Aloe was associated with a higher proportion of participants experiencing faster healing times (4–6 days) and a lower proportion experiencing longer healing times (7–10 days) compared to the chitosan group.⁶ Furthermore, the aloe group demonstrated a reduction in harmful oral bacteria like Actinomyces, Granulicatella, and Peptostreptococcus.⁶

In a separate, double-blind, case-control study, 40 adult subjects with minor oral aphthous lesions were randomized to receive treatment with a 2% Aloe vera gel or a 2% saline gel, for 2 weeks.[v] Though both groups were considered healed by day 10, the Aloe group had a lower pain severity compared to the control group after 4 days. The lesion diameter and circumscribed inflammation zone were also significantly smaller in the Aloe group after day 3 and day 7, respectively.⁷

Acemannan, a polysaccharide extracted from Aloe vera, has also been studied as a potential treatment for oral aphthous ulcerations.[vi] One-hundred-and-eighty (180) subjects with recurrent oral ulcers were randomized to receive 0.1% triamcinolone acetonide, 0.5% acemannan in a Carbopol^® polymer thickener, or the Carbopol^® thickener alone.⁸ Study participants were instructed to apply the treatments topically to their ulcers 3 times a day for 7 days.⁸ Although the Aloe group was not superior to the 0.1% triamcinolone acetonide group in reducing ulcer size and pain, it was superior to the control group.⁸

Vitamin B₁₂

One study found that 28% of patients with recurrent aphthous stomatitis had a deficiency in one or more of the B vitamins.⁴ Vitamin B₁₂, in particular, has a role in regenerating oral mucosal tissue given its effect on the formation of stem cells.[vii] For this reason, supplementing with vitamin B₁₂ orally, topically, and through injections has been proposed as a potential treatment, though studies show conflicting evidence of its efficacy.⁹

In one double-blind, placebo-controlled trial, 58 subjects suffering from recurrent aphthous stomatitis were randomized to receive a once-daily 1,000 mcg sublingual dose of vitamin B₁₂ for 6 months, regardless of their B₁₂ serum levels.² By the end of the trial, more than 74.1% of patients receiving B₁₂ were free from ulcers, compared to only 32% in the control group.² Furthermore, treated participants had a statistically significant decrease in the average duration of recurrent aphthous stomatitis episodes (p < 0.0001), the average number of ulcers per month (p < 0.0001), and the average subjective pain levels (p < 0.0001) at 5 and 6 months of treatment.² No significant decrease was found in the control group.²

Curcumin

Curcumin is the primary bioactive substance extracted from the plant Curcuma longa, better known as turmeric.[viii] It has potential anti-inflammatory, antioxidant, analgesic, and wound-healing effects when applied topically and taken orally.[ix] Curcumin inhibits the release of proinflammatory cytokines by modulating enzymes such as phospholipase, lipidase, and cyclooxygenase‑2.¹⁰ When used in the treatment of recurrent aphthous stomatitis, curcumin can be applied via a 1 to 2% curcumin gel, a powder, or a 10 to 50% oral curcumin solution.¹⁰ In fact, four studies have found curcumin to be as effective as 1% triamcinolone acetonide when applied topically for the reduction in ulcer size and pain.¹⁰ The three remaining studies found curcumin to be superior to control groups in reducing the signs and symptoms of oral ulcers as well.¹⁰

In the first study, 105 participants with recurrent minor aphthous ulcers were randomized to receive curcumin, honey, or an Orabase^® gel as a topical treatment.[x] They were instructed to apply the treatment 3 times daily to the ulcerated area for 7 days.¹³ Those receiving curcumin experienced a significant improvement in ulcer size (5.8 ±1.7 to 1.4 ±1.4), a reduction in VAS pain scores (6.2 ±1.5 to 0.8 ±0.2), and an improvement in erythema level (2.6 ±0.5 to 0.7 ±0.6).¹³ In a separate study, 28 participants were provided with a 2% curcumin gel or a placebo gel to be applied twice daily for 2 weeks.[xi] Pain was significantly relieved in the turmeric group at day 4 and ulcer size was reduced on day 4 and 7 compared to the placebo.¹⁴ Lastly, one study divided 83 patients into three treatment groups, with one receiving a 10% oral curcumin solution, another receiving a 50% oral curcumin solution, and the last group receiving a glycerin placebo solution.[xii] Over 70% of patients using either of the oral curcumin solutions saw complete recovery by day 5, whereas only 20% of the placebo group saw complete recovery at day 5.¹⁵

Honey

A variety of in vitro and clinical studies have demonstrated the antimicrobial effects of honey, and it has historically been used as a wound treatment for thousands of years.³ Honey is able to exert these effects due to its osmotic effect, its low pH, and its ability to modulate cytokines and inflammation.³ Honey also contains a variety of organic acids, amino acids, vitamins, enzymes, and carbohydrates, which contribute to its role as a medicinal agent.³

In one trial, 180 adult subjects with recurrent aphthous stomatitis were randomized to receive either a topical commercial-grade honey, 0.1% triamcinolone acetonide, or an oral protective paste, three times a day after meals, for eight days.³ Ulcers began to decrease in size and redness within 2.73 days of honey use, and 95.5% of participants using honey reported a dramatically reduced level of pain after the first day.³ In fact, pain relief was found to be more effective with honey use compared to the use of both triamcinolone and the oral protective paste.³

Saline rinses

The use of saline rinses for oral health first appeared as early as 2700 BCE in China.[xiii] Today, a large proportion of the general public uses sodium-chloride solutions to support healthy gums and improve the healing of oral ulcers like canker sores.[xiv] However, there is little understanding of how salt affects aphthous stomatitis and what concentrations are best to use for its prevention.¹² In one in vitro study, researchers isolated human gingival fibroblasts and human oral keratinocytes.¹² The cells were rinsed with 0 to 7.2% sodium chloride for 2 minutes 3 times a day.¹² The saline rinse was capable of promoting cell migration in human gingival fibroblasts and upregulated the expression of fibronectin and type I collagen.¹² Furthermore, the rinse upregulated factors such as F‑actin which are responsible for cytoskeleton reorganization and extracellular matrix protein formation.¹² Though preliminary, this study suggests some scientific basis to the use of saline rinses for oral ulcers.¹²

Licorice

Glycyrrhiza glabra contains a variety of bioactive ingredients like glycyrrhizin, licoricidin, and glabridin, which are both anti-inflammatory and immunomodulatory.[xv] When used as a paste, patch, or mouthwash, licorice has been shown to reduce recurrent aphthous stomatitis pain, ulcer size, and healing time.⁵ Although its effectiveness is dose-dependent, the use of licorice has shown some benefit when used in concentrations varying from 1 to 5%.[xvi] Licorice is able to elevate levels of epidermal growth factor (EGF), which participates in skin healing by stimulating the proliferation and migration of endothelial cells, keratinocytes, and fibroblasts.¹⁵ Furthermore, licorice exerts antimicrobial effects against certain strains of oral bacteria including Streptococci mutans and Porphyromonas gingivalis, which may be implicated in the pathogenesis of oral ulcers.¹⁵

In one double-blind trial, 23 subjects with aphthous ulcers were randomized to receive an oral dissolving patch with licorice extract or a placebo patch, for 8 days.[xvii] Those receiving licorice found an improvement in both ulcer size and pain compared to those receiving the placebo.¹⁶ A separate study using licorice bioadhesive hydrogel patches in 15 subjects found a significant reduction in VAS pain scores on days 2, 3, 4, and 5 of use compared to the no-treatment group (p < 0.001).[xviii] The patches also significantly reduced the size of both the lesion’s necrotic centre and the inflammatory halo surrounding the lesion (p = 0.03).¹⁷

Conclusion Managing recurrent aphthous stomatitis requires a multifactorial approach given its diverse etiology. Naturopathic interventions including treatment with Aloe vera, vitamin B₁₂, curcumin, honey, saline rinses, and licorice have shown promising evidence with respect to ulcer recovery and symptom control. Integrating these topical treatments and supplements with a balanced diet and good oral hygiene represents an optimal holistic approach to caring for patients with canker sores