Aphthous Stomatitis
Exam Pass Notes
Key Takeaways
- Very common oral mucosal condition characterised by recurrent aphthous ulcers
- Exact cause unknown but involves immune system hyper-reactivity
- Minor, major and herpetiform clinical types
- Diagnose by clinical appearance, no testing needed usually
- Treat with topical steroids, anaesthetics, antiseptics
- May resolve spontaneously with age
- Not infectious, not oral cancer
Introduction
- Aphthous stomatitis is the most common disease of the oral mucosa, affecting about 20% of the population
- It is characterised by recurrent formation of benign mouth ulcers (aphthae) in otherwise healthy people
- Also called recurrent aphthous stomatitis (RAS) or canker sores
- Onset often during childhood/adolescence, lasts for years before disappearing
- No cure, treatment aims to manage pain and speed healing
Signs and Symptoms
- Round or oval ulcer with yellow/grey fibrinous membrane, surrounded by red halo
- Single or multiple ulcers, widely distributed in mouth
- 3 types:
- Minor ulcers (<5mm), heal in 1-2 weeks (80-85% of cases)
- Major ulcers (>10mm), take weeks to heal, may scar (10% of cases)
- Herpetiform ulcers (multiple pinpoint ulcers, very painful, heal in <1 month)
- Symptoms include burning/tingling before ulcer appears, pain worsened by acidic or abrasive foods
Causes
- Exact cause unknown, likely multifactorial
- Genetic predisposition in ~40%
- Triggers: stress, trauma, nutritional deficiency, hormones, allergies, smoking, infections
- Immune-mediated - T cells, cytokines like TNF-alpha involved
- May be associated with autoimmune diseases
Immunology
- Genetic types (HLA) linked but not definitive
- Stress affects immune system
- More common with immunodeficiency
Mucosal Barrier
- More common on thinner non-keratinised mucosa
- Atrophy of mucosa from nutritional deficiencies predisposes
- Trauma decreases mucosal barrier
- Hormones and contraceptives alter barrier
- Smoking increases keratinisation, less common in smokers
Antigenic Sensitivity
- Viruses like HSV, CMV detected but unclear role
- Allergies to foods, toothpaste ingredients may trigger
- Especially sodium lauryl sulphate (SLS) in toothpaste
Systemic Associations
- Behçet's disease - severe oral/genital ulcers + uveitis
- Blood deficiencies - B12, folate, iron
- Coeliac disease - gluten sensitivity
- Cyclic neutropenia - fluctuating neutrophils
- Immunodeficiency e.g. HIV/AIDS
Diagnosis
- Based on clinical appearance and history
- Recurrent self-healing ulcers at regular intervals
- Blood tests if severe/complex ulcers or systemic cause suspected
- Patch testing for allergies
- Biopsy not usually needed
Classification
- Minor ulcers (<10mm), non-keratinised mucosa, heal in 1-2 weeks without scarring (80-85% of cases)
- Major ulcers (>10mm), deeper, take 3-4 weeks to heal, may scar (10% of cases)
- Herpetiform ulcers (<1mm), multiple, very painful, heal in <2 weeks without scarring
Treatment
- Mainly topical agents - steroids, anaesthetics, antiseptics
- Orabase, benzydamine, viscous lidocaine
- Systemic meds like thalidomide for severe cases
- Treat any nutritional deficiencies
- Stress reduction, avoid trauma/allergens
Prognosis
- Not serious, not oral cancer, not infectious
- Symptoms range from minor nuisance to disabling
- May resolve spontaneously in later life
Epidemiology
- 20% lifetime prevalence
- More common in developed nations, higher socioeconomic groups
- Peak onset age 10-19 years
- Lasts for years before disappearing
- Equal in males/females
- Possibly more common in individuals of Caucasian descent compared to those of African descent