NAPWA

Symptoms

An open sore, or lesion. Usually results in red inflammation around the ulcer, which may be sore to touch. Size varies from 1mm to 2cm in diameter.

Causes

Mouth ulcers are a common side effectAn unwanted effect caused by the administration of drugs. Onset may be sudden or develop over time. of HIV itself as a result of a declining immune system. Causes can be herpes simplex virusA small infective organism which is incapable of reproducing outside a host cell., cytomegalovirus (CMV) or coxsackie virus. Ulcers may be worse when there are other conditions in the mouth, such as when the gums are inflamed and become tender and bleed. If there are bacterial infections in the mouth, such as Candida albicans , which is a white growth, these can also make aphthous mouth ulcers worse. Candida in the mouth may also cause lesions and be tender to touch. The Epstein-Barr virus is thought to be the cause ofanother oral condition called Hairy leukoplakia which can form raised white patches and lesions on the tongue. When symptoms of any ulcer or lesion first occur they should be mentioned to your doctor for an early diagnosis, to determine whether the ulcer is drug related or due to some other cause or infection.

Complementary & Supportive Therapy

Dietary supplements: Vitamin C and the bioflavonoids hesperidin, rutin and quercetin, improve skin tissue and the fine blood capillaries in the mouth. Crushed or powered vitamin C applied directly to a mouth ulcer can assist in healing it, but consult your doctor about this first. Zinc supplements can assist healing, especially for moist areas of the mouth that are difficult to treat with topical applications because the wound does not get enough air to dry and heal. The amino acid L-Glutamine, vitamin A or Beta-carotene can benefit skin and wound healing in the mouth. Lysine supplements may assist in the healing of oral herpes ulcers. Acidophilus (taken as a supplement) can assist where ulcers are associated with inflammatory and bacterial gut problems. Garlic is believed to have antifungal properties which can assist when there is candida or thrush in the mouth. Bee propolis can help alleviate candida in the mouth and has been shown to be beneficial for oral herpes (cold sores around the mouth). Propolis is non-toxic, but allergic reactions have occurred from ingestion. Topical application to ulcers can cause allergic reactions, but may be safer than taking propolis internally. Propolis has exhibited antifungal, antiviralA medication or substance which is active against one or more viruses. May include anti-HIV drugs, but these are more accurately termed antiretrovirals., and anti-tumour properties.

Mouthwash: Golden seal ( Hydrastis canadensis ), and/or sage ( Salvia officianalis ) are useful as a mouthwash or gargle to combat infected gums, sore throats, and mouth ulcers associated with infections such as Candida albicans (thrush). Tea tree oil is a natural anti-fungal agent, which can be used as a mouthwash to help guard against fungal infections and protect against infections getting into ulcerated wounds in the mouth. Apple cider vinegar used as a mouthwash may also help. Salt-water gargle can assist to sterilise infections in the mouth and throat, and may heal small wounds and open cuts in the mouth (it may sting for a while when doing this).

Diet: Dietary strategies include limiting acidic and spicy foods (e.g. citrus fruits and juice, chillies and curries), choosing small frequent meals that are moist and soft in texture and cold foods such as canned fruits, ice-cream, ice-blocks, yoghurts and other dairy desserts. Using a straw when drinking may be useful. If food intake is hard to sustain, nutritional supplements can assist in increasing energy and nutrient intake, helping to prevent weight loss and promote the healing process.

Medical & Drug Treatment

Specific treatments for mouth ulcers include steroids or anaesthetics applied directly to the lesion/s for symptomatic relief of inflammation and pain. BiopsySurgical removal of a piece of tissue from a living subject for microscopic examination to make a diagnosis (e.g., to determine whether abnormal cells such as cancer cells are present). (removal by surgery) may be considered in people with large ulcers (1 to 2cm in diameter) if they continue to recur and look like malignant lesions (growths). Thalidomide is a drug used for severe types of mouth ulcers, but there are restrictions on its use. Your doctor can advise if this treatment is applicable. Mouth rinses with dexamethasone or viscous lidocaine are other treatments.

Your doctor will try to treat any infections such as candidiasis or symptoms such as leukoplakia, which may be sometimes due to an infection, in order to prevent infections getting into any mouth ulcers. Dry mouth conditions can be treated with sugarless gum to help stimulate saliva, or your doctor may recommend a saliva replacement if needed. Oral gels (e.g. Bonjela or SM33) are pain-relieving preparations that reduce inflammation, irritation and swelling. They do not heal mouth ulcers, but help fight infection and numb pain in toothache, denture sore spots and cold sore lesion areas (due to their anaesthetic action). Treatment for candida in the mouth varies according to your level of immune function. When the immune system is near normal, candida treatment may consist of nystatin (e.g. Mycostatin, Nilstat) solution swished and swallowed five times daily. When there is moderate immune damage or poor response to topical treatment, stronger (systemic) antifungal drugs areused such as fluconazole (Diflucan) for both prevention and treatment. Amphotericin B (Fungizone) may also be used in very severe cases.

Special Precautions & Considerations

• Some evidence exists for avoiding garlic supplements if taking saquinavir and other protease inhibitors.
• Vitamin A is toxic in large doses and causes vomiting and liverA large organ, located in the upper right abdomen, which assists in digestion by metabolising carbohydrates, fats and proteins, stores vitamins and minerals, produces amino acids, bile and cholesterol, and removes toxins from the blood. toxicity. Use only under prescription and supervision of your doctor.
• Bee propolis, and other bee products can cause allergic reactions which can be severe and life threatening, especially if taken internally, such as in the form of lozenges or tinctures. Talk to your doctor first before taking propolis or other bee products.
• Golden seal ( Hydrastis canadensis ) should not to be taken when pregnant as one of its ingredients (berberine) stimulates the uterus to contract.
• Any lesion, tumour, ulcer or growth in the mouth that does not show signs of healing within a week or two should be seen by your doctor for diagnosis and treatment. It is important not to treat mouth ulcers and oral lesions with home remedies until a doctor has assessed them, so that serious conditions are not worsened by the wrong treatment.
• Kaposi's sarcoma (KS) lesions occur in the mouth, but they are not a side effectAny undesired actions or effects of a drug or treatment. Negative or adverse effects may include headache, nausea, hair loss, skin irritation, or other physical problems. Experimental drugs must be evaluated for both immediate and long-term side effects. of HIV antiviral drugs.
• Oral Hairy Leukoplakia rarely requires treatment, as it often goes away by itself. It can be treated with high doses of acyclovir if painful.
• When there is gum diseaseDisease of the tissues that support the teeth, including the gums, the periodontal membrane and the underlying bone. Periodontal disease, which includes gingivitis and the more serious periodontitis, is the most common cause of loss of teeth in adults. People with HIV/AIDS are at increased risk of developing periodontal disease, even with good oral hygiene. and inflammation (called gingivitisInflammation of the gums (the gingiva) caused by poor oral hygiene. Chronic gingivitis can worsen to become periodontal disease.), a referral to a dental surgeon may be provided, so that any treatment for ulcers has the best chance of success and is not worsened by infection in the gums. Treatment by a dental surgeon may be followed by a short course of treatment with metronidazole (e.g. Flagyl), and sterilising mouth rinses such as povidone iodine and further daily mouth rinsing with chlorhexidine gluconate.
• If you have peripheral neuropathy, metronidazole may make it worse and therefore should not taken if you are on d4T (stavudine, Zerit), or ddI (didanosine, Videx). In this case, clindamycin or amoxicillin may be prescribed.

Managing side effects