Aphthous stomatitis: Difference between revisions

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==Clinical Features==
==Clinical Features==
* Regular, round/oval ulcers
* Regular, round/oval ulcers
* Painful
* Painful
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{| class="wikitable" style="border:solid 1px #999999; margin:0 0 1em 1em;"
{| 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]]
|-
|-
! Drug type !|| Intended action || Example(s)
! 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]]
|-
|-
| Topical covering agents / barriers || Reduce pain || Orabase (often combined with [[triamcinolone]]).<ref name=McBride2000>{{cite journal | vauthors = McBride DR | title = Management of aphthous ulcers | journal = American Family Physician | volume = 62 | issue = 1 | pages = 149–54, 160 | date = July 2000 | pmid = 10905785 | url = http://www.aafp.org/afp/2000/0701/p149.html }}</ref>
! Herpetiform
|-
| Clusters of small ulcers (1-2mm) ← initially present as crops of vesicles that quickly develop into ulcers
| Topical [[analgesic]]s / [[anesthetic]]s / [[anti-inflammatory agent]]s || Reduce pain || [[Benzydamine hydrochloride]] mouthwash or spray,<ref name=ScullyPorter2008 /> [[Amlexanox]] paste,<ref name=McBride2000 /><ref name=Baileyetal2011>{{cite journal | vauthors = Bailey J, McCarthy C, Smith RF | title = Clinical inquiry. What is the most effective way to treat recurrent canker sores? | journal = The Journal of Family Practice | volume = 60 | issue = 10 | pages = 621–32 | date = October 2011 | pmid = 21977491 }}</ref> viscous [[lidocaine]],<ref name=McBride2000 /> [[diclofenac]] in [[hyaluronan]].<ref name=Scully2013 />
Can coalesce to form larger ulcers
|-
 
| Topical [[antiseptic]]s || Fasten healing (prevent secondary infection) ||[[Doxycycline]],<ref name=Brocklehurst2012 /> [[tetracycline]],<ref name=Brocklehurst2012 /> [[minocycline]],<ref name=McBride2000 /> [[chlorhexidine gluconate]],<ref name=ScullyPorter2008 /> [[triclosan]].<ref name=ScullyPorter2008 />
Keratinised and non-keratinised mucosa equally involved
|-
 
| Topical mild potency [[corticosteroid]]s || Reduce inflammation || [[Hydrocortisone sodium succinate]].<ref name=Scully2013 />
Heal in ~10 days
|-
 
| Topical moderate potency corticosteroids || Reduce inflammation || [[Beclomethasone dipropionate]] aerosol,<ref name=Scully2013 /> [[fluocinonide]],<ref name=ScullyPorter2008 /> [[clobetasol]],<ref name=Scully2013 /> [[betamethasone sodium phosphate]],<ref name=Scully2013 /> [[dexamethasone]].<ref name=McBride2000 />
Can recur very frequently
|-
| [[File:Stomatitis herpetica.jpg|200px|Herpetiform ulcers]]
| Systemic medications || Various, mostly modulating immune response || [[Prednisolone]],<ref name=Brocklehurst2012 /> [[colchicine]],<ref name=Brocklehurst2012 /> [[pentoxifylline]],<ref name=Brocklehurst2012 /> [[azathioprine]], [[thalidomide]],<ref name=Brocklehurst2012 /> [[dapsone]],<ref name=Brocklehurst2012 /> [[mycophenolate mofetil]],<ref name=Brocklehurst2012 /> [[adalimumab]],<ref name=ScullyPorter2008 /> [[vitamin B12]],<ref name=Brocklehurst2012 /> [[Clofazimine]],<ref name=Brocklehurst2012 /> [[Levamisole]],<ref name=Brocklehurst2012 /><ref name=ScullyPorter2008 /> [[Montelukast]],<ref name=Brocklehurst2012 /> [[Sulodexide]],<ref name=Brocklehurst2012 />
|}
|}


==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==


==Images==
* 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 />
<references />




[[Category:Oral Medicine]]
[[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:
    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

  • 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:
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

  • 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

  • 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