Dr. Elizabeth Boham:
One of the most common reasons, when we have people who have a lot of canker sores, whether they test positive for coeliac or just we think it’s gluten sensitivity, or we don’t have a full positive coeliac test, but when they take away gluten, they often will clear up.
Dr. Mark Hyman:
Welcome to The Doctor’s Farmacy. I’m Dr. Mark Hyman, that’s Farmacy with an F, F-A-R-M-A-C-Y. Welcome to this special episode called House Call, where we talk about some tough issues that affect so many people that are really not well dealt with with traditional medicine. And today we’re going to talk about the mouth. Cold sores and canker sores, which are annoying, but not life-threatening, but they can make you miserable. And they’re not too pretty either for people. So today we have with us, our physician from the UltraWellness Center, Dr. Liz Boham, who’s my friend and colleague for over two decades. She’s an incredible physician, family doctor, trained in nutritional medicine, and also a registered dietician and an exercise physiologist, what I’d love all doctors to be. And she is teaching all over the world, functional medicine. She’s now part of our GI course, which is great, at the Institute for Functional Medicine and has got her own wonderful CD called breast wellness. Because she went through breast cancer and has a lot to say about it and a lot to teach. So welcome Liz, back to House Call.
Dr. Elizabeth Boham:
Thank you Mark. It’s great to be with you.
Dr. Mark Hyman:
Fantastic. So let’s get right into it. Canker sores, what are canker sores? We’ve all probably had them one time or another. Why are they a problem? And what do they signify and how do we think about them differently in functional medicine than traditional medicine?
Dr. Elizabeth Boham:
Absolutely. So canker sores are those ulcers, those sores that you get in your mouth. They’re usually at the side of your mouth, by your cheek, inside of your cheek that is, underneath your tongue. Those are some typical places for them. And they are about three to five millimeters in size and they are a sore that comes. If you look at them, they’ll look like a round circle. They’re reddish. Sometimes they’ll have like a yellow…
Dr. Mark Hyman:
Coating.
Dr. Elizabeth Boham:
Coating on it, yeah.
Dr. Mark Hyman:
And they hurt like heck.
Dr. Elizabeth Boham:
They hurt like heck, yes. And like you said, most of us have had them at least once or twice. And having one once or twice is not a big deal. Or even more than that, but what we get concerned about or what we want to talk a little bit about are those people that are getting lots and lots of canker sores. And could that mean that there’s something we need to be looking into and thinking about?
Dr. Mark Hyman:
Yeah. I think that’s right. I think, in traditional medicine we go, “Oh well, a canker sore is not a big deal. Swish your mouth with tetracycline and Benadryl” was the cocktail we used to use, and that’ll help reduce the pain and inflammation. But there really wasn’t ever a conversation about, well what was the cause of these and how do we diagnose the root cause and make it so people don’t get then anymore?
Dr. Elizabeth Boham:
Absolutely. And you know-
Dr. Mark Hyman:
And what does a functional medicine doctor think when they see a canker sore?
Dr. Elizabeth Boham:
Again, if it’s an isolated incident, it might not be a big deal at all. But if people are getting them all the time or even a couple of times a month, or even five or six times a year, it makes you want to ask that question, why? What could be going on? And there could be many things from coeliac disease to an impact in the immune system not working properly, to eating a food that causes inflammation for your body.
Dr. Elizabeth Boham:
So coeliac disease it would be gluten, but there’s other foods that for people can be inflammatory for them. It’s like a food sensitivity or a food reaction. Definitely. We see it with some food additives. So some food coloring and some food additives, people will get canker sores. There are some more rare situations where people get lots and lots of canker sores, Behcet’s they’ll get sores in their mouth and other areas of their body. So that’s an auto-immune process. Another auto-immune process, lupus, can cause some recurrent sores in the mouth as well. And of course, nutritional deficiencies. It’s something I think about all the time. We know B12 deficiencies, B vitamin deficiencies. So I’m thinking when somebody is coming in with recurrent canker sores, those are things I’m thinking about.
Dr. Mark Hyman:
Yeah. So it could be some of the food that we’re eating or the chemicals in our food. The average American eats three to five pounds of food additives a year. And we go, “Oh it was a little additive here.” When you add it all up, with all the crap we eat, it’s three to five pounds. And a lot of these things are really immunoreactive. It can be very inflammatory, irritating, and can cause these canker sores. But we mentioned also Behcet’s and lupus. These are autoimmune diseases. But what’s really striking to me, after doing functional medicine for decades, is that so many people with canker sores really have gluten problems.
Dr. Elizabeth Boham:
Absolutely.
Dr. Mark Hyman:
And I remember, one of my friends was a Harvard trained doctor who started having really severe, recurrent canker sores. We call it aphthous stomatitis, but it’s like a really nasty case of this. And I said, “Have you checked yourself for coeliac disease?” He’s like, “No.” And I’m like, “Well check.” And he had it and he stopped eating gluten and everything went away.
Dr. Elizabeth Boham:
I see that all the time. That’s probably one of the most common reasons, when we have people who have a lot of canker sores. Whether they test positive for coeliac or just, we think it’s gluten sensitivity, or we don’t have a full positive coeliac test. But when they take away gluten, they often will clear up, which is phenomenal and a wonderful response. The other thing, I was thinking when you were talking about the food additives and food coloring. Halloween is a time where kids will get canker sores all the time, right after Halloween. All of that, the candies they have, they’re eating so much of it with a lot of additives and coloring and stuff. And so, people will notice that that’s a time where they get a lot of them.
Dr. Mark Hyman:
It’s true. That’s true. And I remember when I was really sick with chronic fatigue and my immune system wasn’t working right. And my gut was a mess. I used to get tons of canker sores, and it was terrible. I’d get them on my tongue, I’d get on my cheeks and it was like, it’s horrible. Once you start to get things back in balance and fix your gut and your nutritional status, really, really makes a huge difference. Tell us about this patient you had, it was a young woman who had really bad canker sores.
Dr. Elizabeth Boham:
Yeah. I just want to mention one thing about that. And then we’ll delve into this case. When things are out of balance in the digestive system, there’s a lot of inflammation in there. And so the ability for the body to digest and absorb your nutrients is much less. And the oral mucosa, the cells in your mouth and the digestive system, need a lot of regular nutrition. So many times we see nutritional deficiencies show up first in the mouth and the gut area, because they’re just getting turned over so quickly. And so, you think a lot about those B vitamins that are necessary for healing and zinc that’s necessary for healing. So when you mentioned, when your body was depleted, there may have been some just decreased absorption of some nutrients that are so necessary.
Dr. Mark Hyman:
Yeah. I think you’re right. And you get those cracking at the corners of your mouth. That’s called Cheilitis, that can be also from B vitamin-
Dr. Elizabeth Boham:
B vitamins, yep.
Dr. Mark Hyman:
Deficiencies. So, yeah, I had that. It’s interesting to see what happens when you start looking at this stuff. You go, wow, because you teach a whole course on the nutrition, physical examination, or through looking at various signs on your body, you can pick up nutritional deficiencies. They may be related to some of these things.
Dr. Elizabeth Boham:
So with Dr. Michael Stone, so that’s fun. Yeah, so this woman was a 25 year old woman who had regular canker sores, her whole life. She had them as a kid. She had them in her teenage years. She was getting them probably once a month and sometimes she’d have multiple canker sores. And they were kind of… They were painful and no fun. Like you mentioned. And she was always thin. So she was always on the thin side. She had some digestive issues, some diarrhea, some bloating, but otherwise, she was healthy. She was told she had iron deficiency. So she was low in iron, but otherwise not really anything that would make you think she was ill or sick in any way. But she just wasn’t… She wanted to deal with these canker sores and came in. And so we decided to test her for coeliac disease, because as we are mentioning, gluten and wheat can be a common cause of these canker sores for some people and-
Dr. Mark Hyman:
And also cause irritable bowel and prevent you from absorbing iron and make you not be able to gain weight, all the things she was exhibiting.
Dr. Elizabeth Boham:
Exactly. And she tested positive conventionally with regular coeliac testing. She was positive. Her tissue transglutaminase was elevated. So we were like, “Oh my goodness, you have coeliac disease.” And, and so she stopped eating gluten-
Dr. Mark Hyman:
It’s like a miracle.
Dr. Elizabeth Boham:
It was kind of, she stopped eating gluten and the canker sores went away.
Dr. Mark Hyman:
And so did her irritable bowel and her iron deficiency.
Dr. Elizabeth Boham:
Exactly.
Dr. Mark Hyman:
She started gaining weight, I’m sure.
Dr. Elizabeth Boham:
She did. I mean the iron and the weight took a little bit more time, but the canker sores and the irritable bowel went away right away.
Dr. Mark Hyman:
It’s pretty amazing when you think about how common this is. Because we’ve talked a lot about gluten on this podcast, but even people who don’t have coeliac, they can have non-coeliac gluten sensitivity. So they’re not on the full blown coeliac numbers on the lab test, but they’re in that continuum. And they can still have all the same problems. And the thing people don’t realize is that, doctors don’t realize is that they think, “Oh, the problem you have is canker sores. That’s the diagnosis.” That’s not the diagnosis. That’s just a symptom. What’s the cause? And that’s what’s so different about functional medicine is what we do here at the UltraWellness Center that’s so unique is we are really medical detectives that look at the cause and it may be different for different people. Some people’s canker sores might be caused by a food additive or maybe it’s because of a food sensitivity or maybe it’s gluten or maybe something else. So I think that’s really the beautiful thing about functional medicine, is we can kind of drill down.
Dr. Elizabeth Boham:
Yeah. You want to look for that underlying root cause. And then, if it is more of an auto-immune, if for somebody it’s more of an autoimmune condition, then you have to ask that question, why, right? Why do they have this autoimmune condition? What is out of balance in their body? What’s triggering it? And we can’t always answer those questions, but they’re really important questions to ask because that really influences how we treat them. So we’re not just treating the outward symptom of the canker sore, but looking for that underlying root cause.
Dr. Mark Hyman:
Yeah amazing. And people don’t have to suffer from it because it’s so annoying. They’re terrible.
Dr. Mark Hyman:
Hey everybody, it’s Dr. Hyman, thanks for tuning into The Doctor’s Farmacy. I hope you’re loving this podcast. It’s one of my favorite things to do and introducing you to all the experts that I know and I love, and that I’ve learned so much from. And I want to tell you about something else I’m doing, which is called Mark’s Picks. It’s my weekly newsletter. And in it, I share my favorite stuff. From foods to supplements, to gadgets, to tools to enhance your health. It’s all the cool stuff that I use and that my team uses to optimize and enhance our health. And I’d love you to sign up for the weekly newsletter. I’ll only send it to you once a week on Fridays. Nothing else, I promise.
Dr. Mark Hyman:
And all you do is go to drhyman.com/picks to sign up. That’s drhyman.com/picks P-I-C-K-S. And sign up for the newsletter. And I’ll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger, longer. Now, back to this week’s episode.
Dr. Mark Hyman:
Let’s talk about something else that’s very common in the mouth, cold sores.
Dr. Elizabeth Boham:
Yeah.
Dr. Mark Hyman:
Which are way more common even than canker sores. Affect so many people and it’s an embarrassing thing to get, people worry about kissing. It’s just unsightly and in functional medicine, there’s a lot you can do to actually prevent you from getting these cold sores. So tell us about why we get them, how they come and what the story is a little bit about cold sores?
Dr. Elizabeth Boham:
I mean, one good thing to recognize, because sometimes cold sores and canker sores can get confusing for people. So canker sores that we started with are not infectious. So you’re not going to transmit anything to somebody else if you have canker sores inside your mouth, inside the inside of your cheek. And canker sores won’t come out on your lips. Okay, so cold sores, which typically when you get a recurrence of cold sores, they can happen inside your mouth, near your teeth and in certain areas of your mouth, but they often will come out on the lips. Right on that border.
Dr. Mark Hyman:
Even in your nose.
Dr. Elizabeth Boham:
Yes. They can yes. And they can come out on your skin too, as well. And cold sores are because of the HSV virus. So the herpes simplex virus. And so typically, herpes virus that affects the head and neck, like the mouth area is herpes simplex virus one. And this is infectious. We can pass it to one another. In fact, I was reading about 66% of the world population has had exposure to HSV one infection. And so it’s very common and we can transmit it through kissing, sharing cups or straws. We can of course transmit it through sexual contact with other people. But, but even the oral herpes HSV one, just close contact with people.
Dr. Mark Hyman:
Yeah. And it’s really common and usually what happens is you get an initial infection where you get kind of sick. So if you’re a kid, you basically get maybe a cold or something, you’ll get a sore throat, you’ll get maybe sores, and then it goes away. But it doesn’t really go away. So with certain viruses, they just sort of linger on. If you get a cold, you get a cold, it goes away. Herpes stays around for your whole life. And it ends up living in the nerves. And then there are certain triggers. So what are the kinds of triggers that we see for these cold sores to come?
Dr. Elizabeth Boham:
Yeah. So, people will notice when they’re stressed. So when they’re exhausted or stressed or they have another infection, sometimes they will come out. So if the body’s depleted in any way. Sunshine for some people, getting dental work for some people will also trigger them. And definitely nutritional depletion. We can talk a little bit more about that. So when people are getting lots of these cold sores and they keep… So you mentioned, you had the initial infection and then it lays dormant in the nerves, and then you can get a reactivation. It can get reactivated and come out. You can see the cold sore on the mouth, right on the lips.
Dr. Elizabeth Boham:
And so when that is happening a lot, then you’ve got to say, “Well, why is this person’s body depleted? Why is their immune system not able to keep this at bay? Why is it that the immune system is not able to keep this virus in the nerves? It’s letting it, it’s coming back out and getting reactivated on that person.” And we transmit it typically when you have the cold sore. But you can transmit it when you’re asymptomatic, especially like it could be right before a cold sore comes on. There is possibility to transmit it at that time as well.
Dr. Mark Hyman:
So you really brought up something super important, which is that our risk of getting recurrent cold sores is directly tied to the state of our immune system.
Dr. Elizabeth Boham:
Yes.
Dr. Mark Hyman:
And in functional medicine, it’s very different our approach than traditional medicine, where you go to your doctor and say, “Well, how can I boost my immune system?” I’m like, I don’t know, sleep and eat good, and maybe exercise, and I don’t know take a vitamin. There really isn’t a whole strategy for how do we create immuno resilience or as our mentor, Jeffrey Bland calls, immuno rejuvenation. And particularly now in the time of COVID and the increased risk for those whose immune systems aren’t working well, it’s really important to understand how do you maximize the function of your immune system? Because we’re going to get into the specifics of actually how to treat the cold sores when they come, or to prevent them. But what the foundation of it really is, this whole idea of immuno resilience, immuno rejuvenation, and supporting our immune system. So what are the strategies from a functional medicine perspective that we use to help rejuvenate someone’s immune system and make them more resilient?
Dr. Elizabeth Boham:
It’s so critical for this, for prevention of these cold sores. But for, as you mentioned, all sorts of viral viruses that you want to prevent, or all sorts of infections that we want to prevent. And how can we support our immune system in the best way possible. I mean, we always start with food first because it’s so powerful. Making sure people are getting adequate nutrition, making sure they’re getting adequate protein, making sure they’re getting adequate minerals, making sure they’re able to digest and absorb those things properly, making sure that they’re getting adequate zinc, which is so important for the immune system. And is in a lot of our foods, but sometimes people get a little deficient-
Dr. Mark Hyman:
More vitamin D.
Dr. Elizabeth Boham:
Vitamin D is important, vitamin C is important. But really it comes down to that good, healthy diet. So when people are wasting their calories on foods that are highly processed and refined and low in nutrients, then they’re not going to get what the body needs for the immune system to work properly. So, it really all comes down to nutritional density-
Dr. Mark Hyman:
And sugar is a huge suppression factor for the immune system. Sugar and starch. So wheat, flour, or sugar. You’re literally shutting down your immune system, right?
Dr. Elizabeth Boham:
Yeah. We know that when our blood sugar is high, our immune system doesn’t work as well. Our natural killer cells don’t go out and find those things that they need to get rid of. All aspects of both the innate and adaptive immune system don’t work well when our blood sugar is high. So balancing, the simple act of balancing your blood sugar is critical.
Dr. Mark Hyman:
Yeah that’s why diabetics have so many infections, and that are hard to treat infections. And of course the usual things like exercise, sleep-
Dr. Elizabeth Boham:
Rest.
Dr. Mark Hyman:
Learning, stress, reduction, techniques, all of that, being in nature, all those things are critical. But there are some really powerful things we can do in addition to that, to help people prevent cold sores. Which I found very, very effective in my practice. You talk about a woman you saw, was a 25 year old who had these recurrent cold sores and some of the things you did for her. So tell us about her, and what you did and how we can start to think about approaching these patients.
Dr. Elizabeth Boham:
Yeah. So this 25 year old was trying to stay thin. So she was working, she’d always worked very hard in terms of her diet to stay thin. And so she restricted her diet. She wasn’t to the point of full blown anorexia, but she was very restrictive. She was very careful with what she ate. And so her calorie intake was a little on the lower end. And she always got colds and flus. She was sick all the time and she regularly were getting these cold sores. And she was run down and worn out, but really frustrated with these cold sores. And she also had some digestive issues. She had some diarrhea and bloating. And so when we got her history, these recurrent cold sores, it made me really go, “Okay, what is going on with her immune system? And what can we do to properly support it?”
Dr. Elizabeth Boham:
And as I mentioned, because of her digestion and the restriction of her calories, I was really concerned about her nutritional status. I was worried that she was having some nutritional insufficiencies that were weakening her immune system function. And so, we added in some zinc, we added in a bunch of vitamin C, we got her vitamin D levels up. We got her on a good multivitamin, some good essential fats. We worked to help her body digest and absorb her food better. But we also added in some Lysine. And Lysine is a really interesting amino acid that is very helpful for cold sores. Many people have tried this who’ve had cold sores, they’ve read about it on the internet or tried it. And they notice also when they come in to see me, they’re like, “It does really help.”
Dr. Elizabeth Boham:
And it works very well to prevent these cold sore outbreaks for people. And typically people will take Lysine, which is an amino acid building block of protein, they’ll take about a thousand milligrams or 500 milligrams twice a day for prevention. And may take up to 3000 milligrams for treatment or when they feel an outbreak coming on. And at the beginning, we often have to give them more. And then over time we can lower the amount that they need. Because she was so restrictive we also gave her some general amino acids, just because she needed the baseline amino acids to build up her body. And we really worked with her. Our nutritionists worked really well with her to just help her increase her intake of her calories and her protein more.
Dr. Elizabeth Boham:
And what was phenomenal, she didn’t gain weight and we often see that. People kind of get that in their head that they can only eat a certain amount because they’ll gain weight if they don’t or whatever. And she didn’t gain weight at all. She was just healthier. Her immune system worked better. She got out of that pattern of getting all those recurrent cold sores. She wasn’t getting colds or flus as much anymore. She was just… Her immune system was more resilient.
Dr. Mark Hyman:
It’s amazing. And I think, you bring up this idea of Lysine and there are a number of foods that have very high Lysine. One of them is quinoa, which is a grain that’s from South America. And unfortunately we’re taking it all from the South Americans. So they’re all getting obese because they have to switch to rice because they can’t afford their quinoa anymore. But it’s a great source of Lysine. And what’s also interesting is that there’s a relationship between Arginine, which is another amino acid and Lysine. And so, one of the foods that has the highest levels of Arginine is almonds. So people, for example, are coming eating a lot of almonds, then keep getting cold sores. I tell them to cut out the almonds and choose other nuts which have less Arginine.
Dr. Elizabeth Boham:
Yeah, that’s a great point. And I also had somebody who was taking a protein supplement. Like they were getting it… It had a protein powder, but some amino acids in it and it had Arginine in it. And so she wasn’t getting cold sores for many, many years and then started this protein powder. And it shifted that balance that you were talking about. Her Arginine level went up and that impacts your Lysine. So in a sense her Lysine went down and then she started getting the cold sores again. And we realized, aha, it was that protein powder.
Dr. Mark Hyman:
Yeah. And you can bump up the Lysine by taking it as a supplement. So yeah, I think there’s some really simple things you can do. And some people do need, who really maybe can’t get their systems fully operational, may need an antiviral like Valtrex or others to help. I’m not opposed to that and they’re generally pretty safe medications. But often when you focus on the things you talked about, which is your underlying immune function, which is a whole foods, healthy diet, getting rid of the junk, sugar and processed foods, exercise, sleep, stress reduction, taking the basic things like zinc, Lysine, vitamin C and others, and even probiotics to help your gut immune system, can make a huge difference in people’s health. So this underscores the approach we take in functional medicine, which is not just to treat the symptom or the disease, but treat the soil.
Dr. Mark Hyman:
And I think in functional medicine, I think of it more like being a regenerative farmer than a industrial farmer where we’re trying to regenerate the health of the soil. So the plants just don’t need any chemicals and they don’t need any input. The soil itself is the source of all the nutrition and the healing that the plants need. And I think that’s something we could learn a lot from in medicine. And I think we need to move from basically an agricultural system that is destructive and uses all these agrochemicals to a regenerative one. I think we also need to move from a healthcare system that just focuses on immune suppressing or a suppressive medications, a block inhibitor, anti something in our body to regenerative medicine, which helps us to regenerate health and regenerate our immune systems. And I think we have a long way to go, but I think it’s really an interesting moment in healthcare right now where we really are seeing the need to actually do this.
Dr. Elizabeth Boham:
Absolutely. And what we do to help with preventing these issues can help our whole body feel better.
Dr. Mark Hyman:
Yeah. I mean, even with COVID-19, there’s a lot of research going on, vitamin D vitamin C and-
Dr. Elizabeth Boham:
Zinc.
Dr. Mark Hyman:
Zinc. And so these are just basic ideas that are not that hard to understand. These nutrients are not expensive. They’re easy to access. And I think we all could use a little boost right now, given the state of our world, the COVID pandemic and the increased stress round here. So Liz, thank you so much for being again on the House Call episode of The Doctor’s Farmacy. It’s been great to have you.
Dr. Mark Hyman:
If you love this podcast, we’d love to have you share with your friends and family on social media. Leave a comment, tell us, have you struggled with cold sores or canker sores, and how have you dealt with it? And of course, subscribe wherever you get your podcasts and we’ll see you next time on The Doctor’s Farmacy.
Dr. Elizabeth Boham:
Thank you Mark.
