Vitamin B-12 deficiency is very common, even in developed countries. It has been linked to canker sores or recurrent aphthous ulcers (RAS). If you frequently get these painful oral ulcers, it is advisable to make sure you are not at risk for vitamin B-12 deficiency.

Some reasons for vitamin B-12 deficiency are listed below. If you suspect you may have vitamin B-12 deficiency, you may consider taking a vitamin B-12 supplement and talk to your doctor about ordering a test to measure your vitamin B-12 levels to better guide your treatment plan.

Inadequate intake

• This is a common deficiency even in developed countries.
• Vitamin B-12 is only found in animal foods, so those who are strict vegans can become deficient.
• It is recommended that you take a supplement if you don’t consume animal products.

Pregnancy or lactation

• If you are pregnant or breastfeeding, your body will use up vitamin B-12 more quickly for DNA synthesis.

H. pylori infection

• H. pylori is a common type of infection that causes acute or chronic inflammation and thinning of your stomach lining.
• It is highly related to gastric ulcers, and gastric atrophy.
• H. pylori infection interferes with vitamin B-12 release from proteins in animal foods.

Pernicious Anemia

• This is a result of an autoimmune disorder where the stomach cells and their receptors are destroyed by your body’s antibodies.
• These cells then are unable to absorb vitamin B-12.

HIV/AIDS

• Low vitamin B-12 levels is common in HIV/AIDS patients, especially in advance stages of the disease.

Crohn’s disease

• Inflammation of intestinal cells interferes with absorption of vitamin B-12.

Behcet's disease

• Inflammation of intestinal cells interferes with absorption of vitamin B-12.

Celiac disease

• Inflammation of intestinal cells interferes with absorption of vitamin B-12.

Gastric bypass surgery/gastrectomy/gastritis

• The low gastric pH in these conditions prevents the release of vitamin B-12 from food proteins.

Pancreatic insufficiency

• Pancreatic enzymes are needed to promote release of vitamin B-12 from food proteins.

Intestinal overgrowth of unfriendly bacteria due to antibiotic use.

• The inflammation interferes with vitamin B-12 absorption.

Excess alcohol use

• Related to poor nutrition. Alcohol interferes with vitamin B-12 absorption.

Nitrous oxide use

• Nitrous oxide inactivates vitamin B-12.

Fish Tapeworm infection

• This worm competes for vitamin B-12 intake from your body.

Low stomach acidity

• Common in the elderly.
• Vitamin B-12 is released from food proteins more efficiently in an acidic environment.

Medications

• The most common cause of medications related to vitamin B-12 deficiency is due to those that impair gastric acid or other digestive enzymes.
• Antacid medications such as Pepcid, Tagamet, Protonix, Prevacid, and Prilosec.
• Metformin (Glucophage). This medication interferes with calcium levels and calcium is needed to promote vitamin B-12 uptake. Sometimes calcium supplementation helps reverse vitamin B-12 deficiency in patients taking Glucophage.

Final Thoughts

If you have recurrent canker sores, and any of the above applies to you, it is advisable to investigate further and request your doctor for confirming tests.

If your vitamin B-12 level results are low, you may be prescribed a vitamin B-12 supplement or an OTC supplement, depending on the severity and cause of the low levels.

If your vitamin B-12 levels are low due to one of your medications, there are alternatives that your doctor or pharmacist can recommend. For many patients, once their vitamin B-12 levels are within normal range, their canker sores typically disappear.

Sandie Tran, Pharm.D.