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:
    1. 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
    2. 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

Epidemiology[edit]

  • 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]

  • Regular, round/oval ulcers
  • Painful
  • Erythematous border
  • Recur on regular basis
  • Three different ulcer morphologies exist:
Minor <1cm ∅ (usually 3-5mm)

Classically grey ulcer base that becomes yellow with an erythematous halo as it heals

Usually solitary but can occur in clusters of up to ~6

Occur predominantly on non-keratinised mucosa

7-10 days to heal

Heal without scarring

Recur at intervals of 1-4 months

Minor ulcer
Major >1cm ∅

More painful than minor morphology

Keratinised and non-keratinised mucosa equally involved

Recur more regularly than minor

Can take up to 1 month to heal

Can heal with scarring

Recur frequently

Major ulcer
Herpetiform Clusters of small ulcers (1-2mm) ← initially present as crops of vesicles that quickly develop into ulcers

Can coalesce to form larger ulcers

Keratinised and non-keratinised mucosa equally involved

Heal in ~10 days

Can recur very frequently

Herpetiform ulcers

Differential Diagnosis[edit]

  • 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

Aetiology and Pathogenesis[edit]

  • 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]

  • 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]

  • 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]