APHTHOUS ULCERS

Aphthous Ulcer is a common condition characterized by the repeated formation of benign and non-contagious mouth ulcers (aphthae) in otherwise healthy individuals. Recurrent Aphthous stomatitis (RAS)is a common ulcerative inflammatory condition of the oral cavity; it typically starts in childhood or adolescence as small recurrent, painful, round or ovoid ulcers (Aphthous Ulcer) with well-defined erythematous (red) margins, like a halo, and a central yellow or gray floor.

Epidemiology and Pathophysiology

The exact cause of Aphthous Ulcers is still unknown; the condition may in fact manifest from a group of disorders of quite different etiologies rather than from a single entity. There is a genetic basis for some Recurrent Aphthous Stomatitis.

• Predisposing factors may include any of the following:
• Stress
• Trauma
• Endocrine (Hormonal) factors in some women
• Cessation of smoking
• Allergies to food
• Hematinic deficiency
• Immune deficiencies
• Drugs, especially NSAIDs,
• Sodium lauryl sulfate (SLS) a major ingredient in toothpastes

Most patients with RAS are otherwise healthy.RAS has been reported in all races. A slight female predominance exists. RAS normally first arises in childhood or adolescence, predominantly between the ages of 10 and 19 years, with the frequency decreasing in subsequent years.

It is interesting to note that the prevalence of presentation has been found to be five times greater in children with high socioeconomic status

Clinical presentation

The 3 main clinical types of RAS are as follows:

• Minor Aphthous ulcers (MiAUs, 80% of all RAS)
• Major Aphthous ulcers (MjAUs)
• Herpetiform ulcers.

The differences

Physical

RAS ulcers, which can occur in otherwise healthy patients, are relatively small recurrent, round or ovoid ulcers with well-circumscribed erythematous margins presenting like a halo and with a yellow or gray floor.

For 2-48 hours before an ulcer develops, RAS is characterized by a prodromal burning sensation.Ulcers commonly present on lining oral mucosa, such as buccal and labial mucosa, and on the tongue, rather than on attached oral mucosa

Differentials

• Hematinic deficiency (e.g., iron, folate, vitamin B-12)
• Celiac disease
• Crohn’s disease
• Neumann bipolar aphthosis
• Behçet syndrome
• Sweet syndrome
• HIV infection, neutropenia, and other immunodeficiencies
• Periodic fever, Aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (PFAPA) in children

Treatment

• Patient Education
  • Patient education regarding this condition may facilitate early treatment during prodromal (period between initial symptoms and appearance of ulcer) phases to minimize the discomfort.
  • Children with extensive ulcers should receive proper diet and hydration, as they may avoid food intake as well as hydration.
  • When using palliative measures such as topical numbing medication, the patient must be cautioned against trauma to anesthetized areas while eating or sleeping.
  • The patient should avoid precipitating factors, such as allergens, trauma, and other potential triggers.
• Diet
  • Patient advice:
  • Avoid Foods that can precipitate the Ulcer.
  • Avoid hot food.
  • Avoid Very Spicy Foods.
  • Avoid eating particularly hard or sharp foods (e.g., toast, potato crisps) and avoid other trauma to the oral mucosa.
• Medical/dental care
  • Identify and correct the predisposing factors for recurrent Aphthous stomatitis RAS.
  • Ensure that patients brush atraumatically (e.g., with a small-headed, soft toothbrush).Patch testing may be indicated to reveal allergies.Analgesics, steroidsand Lignocaine may be beneficial.
• Drugs
  • Chlorhexidine gluconate mouth rinses reduce the severity and pain of ulceration but do not affect the frequency.Medications are available but have unproven efficacy or may have serious adverse effects, because of the systemic effects of those drugs

Conclusion

Minor Aphthous ulcers (MiAUs) are usually self-limiting, with the usual duration being about 10-14 days without any active treatment. Major Aphthous ulcers (MjAUs) can last up to a month. A third type of RAS, the Herpetiform ulcers, is devastating, lasting from 10 days to about 100 days. Ulcers respond well to topical medications, although sometimes a systemic medication may be necessary.