But there are other reasons which might also trigger canker sores such as a sharp tooth surfaces, braces, or ill-fitting dentures. In cases of these sores, a dentist should be consulted too.

The sores we are worried about are the ones who are caused by an underlying health problem, which might be  an impaired immune system, vitamin B-12, zinc, folic acid, or iron deficiency, or gastrointestinal tract disease, such as celiac disease or Crohn’s disease.

Sometimes canker sores are misunderstood as cold sores, which are also known as fever blisters or herpes simplex type 1, and are groups of painful, fluid-filled blisters. Unlike canker sores, cold sores are caused by a virus and are extremely contagious. Also, cold sores typically appear outside the mouth – usually, under the nose, around the lips, or under the chin while canker sores occur inside the mouth

Make sure that you let your physician know if you develop any sores, since the cold sores need immediate medical treatment, in some cases antiviral therapies.

Canker sores are often inside your mouth on the tongue or back portion of your roof of the mouth and on the inside of your cheeks. They can tingle or burn particularly if you eat something acidic. In severe cases you may have a fever and swollen lymph nodes. Make sure you let your physician know if you develop fever or swollen lymph nodes.

For the regular canker sores there are plenty of options for treatment.  On the People Pharmacy website there are some interesting alternative therapies discussed which include sauerkraut with patients testimonials.  One reader reported:

Sauerkraut juice has worked like a miracle for me! It starts clearing up a canker sore within hours, and the sore usually healed by the next day. One caveat, though: juice from canned sauerkraut doesn’t work nearly as well as the fresh stuff (in the refrigerated deli section).

Another wrote,

It’s such a weird remedy that I did some research on sauerkraut to see why it might work. Sauerkraut is fermented (like yogurt or sourdough) and is full of probiotics. I’ve discovered that if I sip a little sauerkraut juice every couple of days I don’t develop canker sores in the first place.

You can purchase sauerkraut juice. If you can’t find it in a store, purchase it online or buy  sauerkraut if you can’t find any sauerkraut juice or it’s too expensive. Drain the juice from the sauerkraut or just dip a tablespoon in it as you need it. Use about a tablespoon of sauerkraut juice. Swish it around your mouth for about 30 seconds and swallow it. Rinse your mouth with sauerkraut juice at least two or three times a day. Your sores should clear up in about a week.

Or even easier, you can eat foods with sauerkraut for added benefit. Some of these foods include Reuben sandwiches, hot dogs with sauerkraut, or sauerkraut and bratwurst. (That is the advantage of being German).

Other possible intervention is saltwater solution and sodium bicarbonate – Mix 1 teaspoon salt with one cup warm water. Swish the solution in your mouth for 30 seconds, then expectorate (spit) the solution out of your mouth. In addition to salt, 1/2 teaspoon baking soda (sodium bicarbonate) may be added to the saline solution as well.

Create a paste by mixing baking soda with small drops of water until a thick consistency has resulted. Use this paste to cover the canker sores, which will help relieve pain. These methods may be repeated as often as needed. Saline and sodium bicarbonate both help the mouth heal quickly by gently reducing the alkalinity and bacteria in the mouth.

You can also use  hydrogen peroxide solution – Mix one part hydrogen peroxide with one part water. Use a cotton swab to dab the solution directly onto the canker sores. Do not swallow the solution. Hydrogen peroxide is an antiseptic that will help reduce the amount of bacteria in the mouth.

You can use milk of magnesia. apply it directly onto the canker sores with a cotton swab, three to four times a day. This method is recommended after using the hydrogen peroxide solution. Milk of magnesia will help reduce the pain and help speed the healing process.

Many sleeping medications make you sleep but don’t allow you to really rest. They take away your dream/REM pattern which is necessary to get the feeling of rest. Those who fall asleep easily and sleep through the night are the lucky ones.

By definition, insomnia is “difficulty initiating or maintaining sleep, or both” and it may be due to inadequate quality or quantity of sleep. It is typically followed by functional impairment while awake. The pattern of insomnia often is related to the etiology.  Insomnia affects 1 in 3 people.

1. Onset insomnia: Difficulty falling asleep at the beginning of the night, often associated with anxiety disorders.
2. Middle-of-the-night insomnia:  Insomnia characterized by difficulty returning to sleep after awakening in the middle of the night or waking too early in the morning, also referred to as nocturnal awakenings, encompasses middle and terminal insomnia.
3. Middle insomnia: Waking during the middle of the night, difficulty maintaining sleep. Often associated with pain disorders or medical illness.
4. Terminal (or late) insomnia: Early morning waking. Often a characteristic of clinical depression.

Insomnia can be caused by many medications such as  psychoactive drugs or stimulants, including certain medications, herbs, caffeine, cocaine, ephedrine, amphetamines, methylphenidate, MDMA (also known as ecstasy), methamphetamine and modafinil. Some antibiotics can also cause chronic insomnia such as Levaquin® (levofloxin).

It is easy to understand that anxiety, stress (emotional, financial or sexual) and fear can cause you difficulty sleeping. We also know that jet lag or working night shifts can impact your sleep at some times of the day and cause excessive sleepiness at other times of the day.

If chronic insomnia exists specific medical conditions should be ruled out such as  hyperthyroidism or rheumatoid arthritis. Insomnia may be a symptom of magnesium deficiency, or low magnesium levels, but this has not yet been proven. A healthy diet containing magnesium may help to improve sleep in individuals without an adequate intake of magnesium.

Insomnia in women seems to be linked at least partly to lower estrogen levels, which is a potential reason why women often tend to develop insomnia at menopause. Estrogen helps with the uptake of magnesium into the soft tissues. If estrogen levels are low, magnesium deficiencies and conditions they can cause such as insomnia, heart palpitations, anxiety and fibromyalgia may become more problematic. Make sure you have seen your gynecologist to discuss estrogen replacement strategies.

As mentioned, insomnia can be caused by many other diseases, side effects from medications, or psychological problems. To be able to treat insomnia effectively, it is critical to find out all medical and psychological conditions before starting any medications. Obviously it is necessary to assure that there is an appropriate sleep hygiene which basically means no noise or other environmental factors leading to sleep disruptions.

Please discuss medication therapies with your oncologists.

However you might consider to explore some alternative options which you need to share with your treating physician. For example, when I am traveling I usually take 3 mg of melatonin to avoid jet lag, which seems to work for me. Melatonin is available over the counter but also in prescription form known as Rozerem® (ramelteon). These drugs seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation. While these drugs show good effects for the treatment of insomnia due to jet lag, the results for other forms of insomnia are less promising.

There are a number of herbal mixtures which have been suggested to have some modest effects including valerian, chamomille, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.

There is more you can try by changing the way you arrange your lifestyle. These include changing your sleep area or schedule, watching what and when you eat and drink, and being more active. It’s also important to keep regular bedtimes and wake times seven days a week and to try to avoid taking naps during the day.

A Harvard Medical School study found that yoga improved the study participants overall quality of sleep, including helping people to fall asleep easier and stay sleeping for longer periods. A study published in the Journal of the American Geriatrics Society found that elderly adults with moderate sleep complaints improved self-rated sleep quality through a low to moderate intensity Tai chi program conducted for six months.

Studies report that ginger can reduce blood pressure and reduce cholesterol which all help to decrease risk of coronary artery disease. One study showed that ginger is as effective as prescription drugs such as Reglan to treat nausea and vomiting associated with cancer chemotherapy.

Last week there was a big write-up in the Los Angeles Times, so most of my patients cut out the article and asked me if it is okay to take ginger.

We have known for quite a while that ginger ale can help some patients with nausea and vomiting.  A study in the British journal Lancet in 1982 showed it was actually more effective than Dramamine® in preventing motion sickness in seasick Danish sailors.  In another test conducted at Brigham Young University, 36 students were asked to take either 100 mg. of Dramamine (dimenhydrinate), two capsules of Ginger or a placebo. They had to sit in a special rotating chair. None of the students who took Dramamine or the placebo could do the whole six minutes, but half of the students with ginger could finish.  We usually recommend two capsules before your travel and every four hours.

Ginger has also some other interesting effects such as an anti-inflammatory and can help to fight a flu, bronchitis and sore throat because it contains antiviral compounds such as gingerols, shogaolsm and sesquiterpenes which can reduce fevers, pains and cough. Ginger also contains a proteolytic enzyme called zingipain which can help in patients with bunions and arthritis pains. Ginger can be also applied  externally as a compress and can reduce pain particular for  fibromyalgia, joint stiffness, abdominal cramps and skin inflammations.

We usually recommend preparing a warm ginger tea to help break a high fever and rid mucus buildup in the sinuses by drinking a cup every 2-3 hours.

There is one issue you need to check with your physician:  if you have a history of  blood-clotting problems, you need to discuss whether you can take ginger. We know that ginger can prevents blood clots, therefore discuss with your oncologists that you are taking ginger because it can influence blood clotting.

It turned out that these patients had iron deficiency coming from blood loss from colon cancer. These iron deficiencies can lead to a craving to chew or eat ice chips. Iron deficiencies can affect the mucosa in the gut and mouth, and ice chips may relief some of the discomfort caused by iron deficiencies.

My patients diagnosed with anemia underwent colonoscopies and were found to have colon cancer, which in both cases resulted in a curative removal by surgery and successful adjuvant chemotherapy.

Usually iron deficiencies develop over a long period of time. When diagnosed it takes months to replace iron in the storage in the body. Iron is critical for red blood cell production. We usually use Slow Fe because it is better tolerated than other preparations which can cause stomach upset.

You need to know if you take iron supplements your stool may look black, similar to patients who have bleeding from their stomach. When there is bleeding in the stomach the stool is black because of its interaction with stomach acid. When bleeding  is in the colon, the stool is red.

If you are abnormally craving ice chips, make sure you are checked for iron deficiency.

Fennel

There are interesting remedies available for gas and bloating.

In Europe most babies get fennel tea in their bottles to reduce the risk of bloating and gas. There have been many reports showing that when you use one teaspoon of fennel seeds, brew a tea, and sweeten it with honey two to three times a day you can reduce your symptoms. It is no accident that many digestive drinks contain fennel.

Another helpful remedy is caraway seeds. If you combine caraway seeds and fennel seeds you may have additional benefit. We usually recommend one teaspoon each to make a cup of tea and use honey to sweeten it up. Caraway seeds are often used when sauerkraut is prepared, not only for the taste but also to reduce the gas associated with sauerkraut consumption.

Patients who have had a pancreas surgery may also consider using digestive enzymes. Foully smelly stools which float, associated with a lot of gas and cramping, can be a sign of pancreas insufficiency. The pancreas does not produce enough enzymes to help to digest food which leads to incomplete digested fat which makes stools stinky and able to float in the toilet bowl. Pancreas enzymes taken together with food can completely correct this very fast.

Patients who undergo chemotherapy know that every time they receive chemotherapy, oncologists take blood to test for blood counts and also for liver and kidney function.

There are many drugs which need their doses reduced or treatment held held if the kidney function changes. One of the common mistakes is that Xeloda, the oral 5-FU drug used for colon cancer, does need to have its dose reduced for kidney dysfunctions. However 5-FU and oxaliplatin don’t have to be dose reduced, which is astonishing since cisplatin has tremendous kidney toxicities which oxaliplatin does not.

Avastin needs to closely monitored for kidney toxicities. Rarely patients can develop proteinuria, which means the kidney loses too much protein. In this situation Avastin needs to be stopped. This is usually reversible within weeks. Proteinuria has been well described, particularly in patients with renal cancer. We have seen proteinuria in patients with colorectal cancer treated with Avastin, which is the reason we check a urinanalysis every 4 weeks to make sure there is no significant protein in the urine.

Patients can monitor proteinuria at home. Whenever there is a lot of protein in the urine, urine foams and makes a lot of bubbles in the toilet. Let your doctor know if this is happening.

Erbitux has also some toxicity to the kidney. It is very rare but needs to be monitored too. It can make the kidney loose magnesium. Your oncologist should test magnesium levels in the blood at every visit. Clinically patients can experience cramping in their legs and hands or can feel lethargic. Make sure magnesium levels are within normal range. This is particular important for patients who have diarrhea who may lose additional magnesium in the stool. If any of these symptoms occur you need to contact your oncologist to work you up.

In my own practice we have a number of patients who are on dialysis and treated effectively with chemotherapy. This is possible depending on the amount of the drugs being eliminated by the dialysis. Usually we treat these patients after their dialysis to allow optimal exposure of drugs to the tumor. Please discuss this with your oncologist if you have a chronic renal failure.

One of the problems for patients who have some increased creatinine levels is using contrast agents when they undergo CT scans. With any decreased kidney function you need to be very careful using IV contrast which can be harmful to your kidney. Discuss this with your oncologist.

Again for patients with kidney dysfunction, we offer very specific clinical trials which should consider if you do not qualify for other clinical trials.

The liver can compensate for a long time despite having large tumors.  This is reason that our blood tests of liver function remain normal despite the liver having multiple lesions.  However, if the tumors grow to a certain size or interfere with the bile ducts, they can cause the liver enzymes. including the bilirubin, to increase. When bilirubin increases patients develop jaundice, indicating that the liver is not functioning well.

This may have significant implications for treatment recommendations. Since most of the chemotherapeutic drugs are detoxified in the liver, many of them can not be safely be given in patients with increased bilirubin or liver enzymes. Irinotecan can not be given safely if the bilirubin is increased. Also Xeloda doses needs to be modified. However, 5-FU, oxaliplatin and both antibodies Erbitux and Avastin can be given despite high liver enzymes or bilirubin since they are not metabolized in the liver.

However liver enzyme levels are always criteria for clinical trials. Treatment with new agents is limited for patients who have had tumor progression after receiving all standard of care therapies. The National Institutes of Health has created an organ dysfunction working group, which USC is part of, which offers new drugs to patients with different degrees of liver dysfunction. Some of these drugs have shown some benefit for these patients.

Please. if you have problems with your liver function which means you are not eligible for clinical trials, contact your cancer center or NIH for sites which offer these organ dysfunction trials.

In my practice we have seen patients not treated because of their liver enzymes. Treatment was delayed to wait until the enzymes decreased, but in many cases this will not happen because increased enzymes are due to the cancer. In these patients, chemotherapy can be safely given.

I had an interesting patients years ago, with bile duct cancer. His bilirubin was 20 (very jaundiced). Usually doctors give up on these patients and refer to hospice. I treated him with oxaliplatin and 5-Fu with the full doses. He recovered within months and was able to live for more than a year, saw his first grandchild be born, and passed away 13 months later.

Please discuss it with your oncologist if there are any issues of chemotherapy and liver dysfunction, particular if treatment is held for it.

He did very well with chemotherapy and he attributes his attitude and very few side effects to his regular tai chi. So I did some research on tai chi and found interesting information I wanted to share with you.

The following material is from the American Cancer Society:

Tai chi is an ancient Chinese martial art. It is a mind-body, self-healing system that uses movement, meditation, and breathing to improve health and well being.

It has been shown that tai chi may improve posture, balance, muscle mass and tone, flexibility, stamina, and strength in older adults. Tai chi is also recognized as a method to reduce stress that can provide the same cardiovascular benefits as moderate exercise, such as lowered heart rate and blood pressure.

People who practice the deep breathing and physical movements of tai chi report it makes them feel more relaxed. The slow movements of tai chi together with rhythmic breathing can relax the body as well as the mind. Research has found that tai chi can reduce stress, lower blood pressure, and reduce the risk of heart disease. There is also evidence that tai chi is particularly suited for older adults or for others who are not physically strong or healthy.

Tai chi students begin by learning a series of gentle, deliberate movements flowing into body positions called forms. Each form contains between 20 to 100 moves, and requires up to 20 minutes to complete. Each form derives its name from nature, for example, “Wave Hands Like Clouds,” or “Grasping the Bird’s Tail.” In order to balance the yin and yang, the movements are practiced in pairs of opposites. For example, a turn to the right follows one to the left.

While doing these exercises, the person is urged to pay close attention to his or her breathing, which is centered in the diaphragm. Tai chi emphasizes technique rather than strength or power, although the slow, precise movements require good muscle control. Tai chi is taught in many health clubs, schools, and recreational facilities.

Clinical trials suggest that tai chi improves posture, balance, flexibility, muscle mass and tone, stamina, and strength in older adults and may help prevent falls and fractures. A recent small study of breast cancer survivors compared tai chi 3 times a week with another group. The women who were in the tai chi group had improved flexibility, strength, and aerobic capacity, whereas the women in the other group had improvements in flexibility only. Another randomized clinical trial of people over age 69 compared tai chi to a stretching exercise class. After 6 months, the tai chi group had better balance and fewer falls than the stretching group. There is no evidence that tai chi can cure cancer or any other disease, although it does suggest it may be helpful when used along with conventional treatment.

It is not easy to navigate through the overwhelming information available on the web. It is even more important today that we evaluate these information sources to make a better decisions on treatment.

About two years ago, I joined revolutionhealth.com because I wanted to provide a voice to guide patients and help them understand and weigh the information available. Through that process, which has been very rewarding, I got to know many unselfish people who were going out of their way to help others. Unfortunately Revolution Health became too commercial, and I found in the C3 website a wonderful new home among people who are experts in colon cancer and have made it their mission to fight for patients and families and the community.

Many of my patients have become proactive in the fight against this disease and provide help and advocacy groups to push legislatures to fund more research, screening programs, and access to health care.

Two of my patients have had a significant impact. One is Mike Stennis, who was my patient and was, in fact, a famous college football player for the University of Hawaii. He was diagnosed with metastatic colon cancer, and we fought the best we could.  His wife was a big supporter, and after his passing she founded the Stennis Foundation, one of the few foundations focusing on colon screening and prevention in the African American community. She is heavily involved in pushing for screening programs in California and providing health insurance coverage.

Another of my patients, a firefighter, founded the Firefighter Cancer Support Network, which got him invited to speak in the United States Senate and with many high-ranking politicians to increase awareness of colon cancer. Because of his involvement and preliminary data on colon cancer risk in firefighters, USC has launched a research project to determine the risk for firefighters getting colon cancer.

Our local Wellness Communities play a critical role. They offer unique resources, particularly support groups where you can meet others in similar situations. They are very helpful resources for general information as well as information about new clinical trials. My colleagues and I visit most of these Wellness Communities at least once a year to meet with the colon cancer support groups and update them on the latest research. My next lecture will be on March 31 in Pasadena Foothills Wellness Community at 6pm.

Not sure if you were able to listen last Sunday when one of my patients and I were on the radio with Selma Schimmel. She does radio talk shows on cancer every Sunday from 1 to 3, providing experts on the air for patients to call in with questions. On the show was Hannah Vogler from the Colon Club. This is another helpful resource. Patients can chat with each other and discuss all kind of issues related to their therapy, diagnosis, experiences with their doctors, what is new etc. Read the history of the Colon club , which is amazing.

The Colon Club is an excellent place to exchange your experiences and identify some additional resources and ideas about how to deal with side effects, look for new treatment options, and find another person going through the same treatment who can understand you very well.

It has been very clear to me that the patient support groups such as the Colon Club, Wellness Communities, and others are an essential part of  success in the treatment of colon cancer. I find it amazing what some of patients have created and are overwhelmed with their generosity to give back to the community.

Your experiences and advice to your fellow patients have a completely different value than my expertise. Both are very important to get the best outcome. We need the facts, we need emotional support, and we need honesty to find the best treatment, the best hospital, the best doctor, and the best environment to ensure we get the best outcome. Some of these are only possible when patients help each other.

We often suggest that newly diagnosed patients talk to someone who has gone through the same therapy or someone in a similar situation such as a young woman with family or a patient who may need a colostomy. These interactions are incredibly valuable and part of our way of helping, but we need you in our quest to make our patients feel comfortable and reduce their anxiety. You as patients know these things much better and can explain them to your fellow patients. The power and impact patient advice can have should not be underestimated.

Patient-directed support groups and academic centers working together will increase quality of life as well as the success of all of our interventions. Make sure you take advantage of what have other patients have to offer.

There are some cautions. I have seen some of my patients have a hard time with support groups, not because they are not happy or have any bad experiences, but because they get to know other patients very well who have the same disease and see some of them progress and pass away. It is very difficult in many cases to deal with their loss and face their own fears of dying.

It is so important that cancer patients and their caregivers know how to manage pain because patients in pain do not eat, do not drink do not exercise, and do not interact. One of the major misconception for pain control is that the patient will become addicted. Patients may want to save medicine for it when it gets really bad. It needs to be very clear that the best pain control is early intervention. When pain is developing is the time take a painkiller. Don’t wait til it reaches 10/10.

In fact studies have shown that when you wait too long, the benefit is much less and you may end up taking more because it is much more difficult to control pain when it is out of control. The problem of addiction for cancer patients is really not a clinical problem. Over the last 17 years I have seen very few patients where we had problems getting them off pain medication. The benefit is bigger by far than these few issues. Patients have more energy, eat better, avoid dehydration, and are emotionally better off, all of which are basic for better treatment outcomes.

Patient with pain are usually exhausted. They feel drained and can’t sleep at night, and, because of the pain, don’t eat and lose weight.

It is absolutely critical to communicate clearly with your oncologist to make sure your pain is adequately treated. There are basic principles and steps which should be followed to have the best outcome. We usually start with over-the-counter painkillers such as Advil®, Aleve®, or Tylenol.  But they may not be enough. Then we use stronger combinations such as Percocet®, Vicodin®, or Lortab®.

It is critical for pain control to take the pain medication on a regular time schedule. To try to save these medications and wait until the pain peaks is absolutely wrong. Take them as they are prescribed every 4 or 6 hours. It is also important to have a medication for breakthrough pain in case you still have pain despite taking your prescribed medicine on a regular schedule. If pain still continues, sometimes increasing the dose may help. In other cases you may need a stronger breakthrough drug.

With NSAIDs such as Aleve or Advil, you need to watch out for your stomach. It can get upset, particularly if you have a history of gastritis or ulcer. Make sure your oncologists knows about your history.

If pain is difficult to control with these measures and you need breakthrough medicine more than four or five times a day, you may need a longer acting morphine agent. In recent years significant advances have been made to develop highly active morphine medications, such as patches or lollipops. These patches only need to changed every three days and deliver small doses of pain medicine through the skin. Interestingly, some patients develop pain on the third day, and studies have shown that some patients need to change the patch every two days because they are detoxifying the drug faster.

Document how often you take breakthrough pain medication and the pattern of your pain to allow your doctor to make more effective recommendations.

There are a couple of important fact you need to know: When you put on a patch it takes at least 10 hours to reach levels which can be effective and the absorption through the skin varies significantly among patients. If you get sick with nausea, vomiting or feeling dizzy or woozy, take the patch off immediately and consult with your oncologist. If you suddenly don’t need any breakthrough drugs, you may need to reduce the dose of the patch, perhaps due to the effect of chemotherapy or radiation.

Pain management is not easy and requires often a pain management team which has special expertise in pain medications and technologies such as nerve blocks to handle patients whose problems continue.

The most common side effect of pain medications is constipation which should be handled with stool softener right away.  Constipation needs to be monitored and discussed with your oncologist.

The most important issues are if your pain is not well-controlled or if you are having side effects from the pain medicine, you need to contact your doctor’s office to make sure that you don’t need adjustments or interventions.