Aphthous stomatitis
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- Common condition characterised by the repeated formation of benign and non-contagious aphthae (mouth ulcers)
- Also known as "canker sores" (especially in North America)
- Classification:
- Simple aphthosis
- Most common form of the disease
- This is also called Mikulicz ulcers
- Individual usually experiences several episodes per year
- Usually one to several ulcers lasting up to 14 days
- Ulcers limited to oral mucosa
- Complex aphthosis
- Ulcers can involve oral and genital mucosa
- Usually ulcers are larger (>1cm) and can take several weeks to resolve
- Some experience such frequent episodes that they are rarely without ulcers
- Must exclude diagnosis of Behçet's syndrome before diagnosis is made
- Simple aphthosis
Epidemiology[edit | edit source]
- Common worldwide - highest prevalence in Middle East, Mediterranean and South Asia [1]
- Most individuals start developing recurrent aphthae during adolescence
- May decrease in later years and may spontaneously resolve for some
- More common in higher socioeconomic group
- ♀ > ♂
Clinical Features[edit | edit source]
- Regular, round/oval ulcers
- Painful
- Erythematous border
- Recur on regular basis
- Three different ulcer morphologies exist:
Differential Diagnosis[edit | edit source]
- Many other causes of oral ulceration
- Important to consider differentials, especially in the following circumstances:
- Persistent ulcers (>2 weeks)
- Painless
- Associated with systemic disease/symptoms
- Involvement of other sites around the body (skin, genitals, conjunctiva)
- Presence of red flags for malignancy (induration, lymphadenopathy, weight loss, night sweats)
- Differentials for oral ulceration: (So Many Laws and Directives)
- Systemic
- Blood (haematological) conditions → anaemia, haematinic deficiencies (Fe, B12, folate), neutropenia, leukaemia
- Infections → ANUG, chickenpox, herpangina, HSV, HIV, syphilis, TB, EBV, Coxsackie
- Gastrointestinal disease → coeliac, Crohn's disease, ulcerative colitis
- Skin (mucocutaneous) conditions → Behçet syndrome, lichen planus, Pemphigus, Pemphigoid)
- Malignancy
- Oral
- Invasion from nearby tissue
- Local causes
- Trauma → sharp teeth/restorations, iatrogenic, self-inflicted
- Burns → hot food/drink, chemical, radiation
- Aphthous stomatitis
- Drugs
- Nicorandil
- ACEi
- NSAIDs
- Systemic
Aetiology and Pathogenesis[edit | edit source]
- Aetiology and pathogenesis are largely unknown (likely multifactorial)
- Theories suggest altered immune regulation involving oral mucosa → exaggerated pro-inflammatory process and/or weak anti-inflammatory response [2]
- Genetic predisposition possible (common for patients to have family history of RAS)
- Certain foods as well as vitamin/mineral deficiencies have been implicated but no strong evidence
- Sodium lauryl sulfate (found in toothpastes) can make RAS worse/more frequent for some patients [3]
- Some observational evidence suggesting smoking confers some protection
- Stress and hormonal disturbances can also be predisposing factors
Management[edit | edit source]
- Rule out differentials (if differentials suspected/identified these need to be addressed)
- Correct any underlying deficiencies
- Good oral hygiene and avoidance of precipitating factors
- Chlorhexidine mouthwash can help prevent superinfection
- Alleviate symptoms (analgesia)
- Benzydamina mouthwash (Difflam)
- Lidocaine barrier gels
- Oral analgesia (paracetamol)
- Topical corticosteroids
- No evidence that adrenal suppression occurs with long-term/repeated application
- Examples:
- Hydrocortisone
- Betamethasone phosphate - 0.5mg tablets, every 6 hours, use as mouthwash
- Triamcinolone
- Beclometasone - metered dose inhaler applied topically - 1 puff [200mg] to lesion every 6 hours
- Topical tetracycline mouthwash
- Rarely used
- Reduces severity but not course
- Avoid in <12yrs old due to tetracycline staining of developing teeth
Prognosis and Complications[edit | edit source]
- Symptoms tend to decrease with age (especially in edentulous)
- Patients should be reassured that these are common and whilst no cure exists, they can be controlled
- No long-term consequences are known
References[edit | edit source]
- ↑ Chattopadhyay, Amit, and Kishore V Shetty. “Recurrent aphthous stomatitis.” Otolaryngologic clinics of North America vol. 44,1 (2011): 79-88, v. doi:10.1016/j.otc.2010.09.003
- ↑ Slebioda, Zuzanna et al. “Etiopathogenesis of recurrent aphthous stomatitis and the role of immunologic aspects: literature review.” Archivum immunologiae et therapiae experimentalis vol. 62,3 (2014): 205-15. doi:10.1007/s00005-013-0261-y
- ↑ Herlofson, B B, and P Barkvoll. “Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study.” Acta odontologica Scandinavica vol. 52,5 (1994): 257-9. doi:10.3109/00016359409029036