Aphthous stomatitis: Difference between revisions
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* Common condition characterised by the repeated formation of benign and non-contagious aphthae (mouth ulcers) | *Common condition characterised by the repeated formation of benign and non-contagious aphthae (mouth ulcers) | ||
* Also known as "canker sores" (especially in North America) | * Also known as "canker sores" (especially in North America) | ||
* Classification: | * Classification: | ||
*# Simple aphthosis | *# '''Simple aphthosis''' | ||
*#* Most common form of the disease | *#* Most common form of the disease | ||
*#* This is also called Mikulicz ulcers | *#* This is also called Mikulicz ulcers | ||
Line 8: | Line 8: | ||
*#* Usually one to several ulcers lasting up to 14 days | *#* Usually one to several ulcers lasting up to 14 days | ||
*#* Ulcers limited to oral mucosa | *#* Ulcers limited to oral mucosa | ||
*# Complex aphthosis | *# '''Complex aphthosis''' | ||
*#* Ulcers can involve oral and genital mucosa | *#* Ulcers can involve oral and genital mucosa | ||
*#* Usually ulcers are larger (>1cm) and can take several weeks to resolve | *#* Usually ulcers are larger (>1cm) and can take several weeks to resolve | ||
Line 16: | Line 16: | ||
==Epidemiology== | ==Epidemiology== | ||
* Common worldwide - highest prevalence in Middle East, Mediterranean and South | * Common worldwide - highest prevalence in Middle East, Mediterranean and South Asia <ref>[[doi:10.1016/j.otc.2010.09.003|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]]</ref> | ||
* Most individuals start developing recurrent aphthae during adolescence | * Most individuals start developing recurrent aphthae during adolescence | ||
* May decrease in later years and may spontaneously resolve for some | ** May decrease in later years and may spontaneously resolve for some | ||
* More common in higher socioeconomic group | * More common in higher socioeconomic group | ||
* ♀ > ♂ | * ♀ > ♂ | ||
==Clinical Features== | ==Clinical Features== | ||
* Regular, round/oval ulcers | |||
* Painful | |||
* Erythematous border | |||
* Recur on regular basis | |||
* Three different ulcer morphologies exist: | |||
{| class="wikitable" style="border:solid 1px #999999; margin:0 0 1em 1em;" | |||
|- | |||
! 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 | |||
| [[File:Mouth Ulcer.jpg|200px| 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 | |||
|[[File:Aphthous ulcer in the back of the mouth.jpg|200px|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 | |||
| [[File:Stomatitis herpetica.jpg|200px|Herpetiform ulcers]] | |||
|} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
* 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''') | |||
** '''S'''ystemic | |||
*** 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) | |||
** '''M'''alignancy | |||
*** Oral | |||
*** Invasion from nearby tissue | |||
** '''L'''ocal causes | |||
*** Trauma → sharp teeth/restorations, iatrogenic, self-inflicted | |||
*** Burns → hot food/drink, chemical, radiation | |||
** '''A'''phthous stomatitis | |||
** '''D'''rugs | |||
*** Nicorandil | |||
*** ACEi | |||
*** NSAIDs | |||
==Aetiology and Pathogenesis== | ==Aetiology and Pathogenesis== | ||
* 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 <ref>[[doi:10.1007/s00005-013-0261-y|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]]</ref> | |||
* 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 <ref>[[doi:10.3109/00016359409029036|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]]</ref> | |||
* Some observational evidence suggesting smoking confers some protection | |||
* Stress and hormonal disturbances can also be predisposing factors | |||
==Management== | ==Management== | ||
* 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== | ==Prognosis and Complications== | ||
* 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== | ==References== | ||
<references /> | |||
[[Category:Oral Medicine]] |
Revision as of 21:07, 6 February 2021
- 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
- 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
- Regular, round/oval ulcers
- Painful
- Erythematous border
- Recur on regular basis
- Three different ulcer morphologies exist:
Differential Diagnosis
- 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
- 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
- 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
- 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
- ↑ 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