Aphthous Stomatitis
Systemic disease
Aphthous-like ulceration may occur in association with several systemic disorders (see list below). These ulcers are clinically and histopathologically identical to the lesions of aphthous stomatitis, but this type of oral ulceration is not considered to be true aphthous stomatitis by some sources.
Some of these conditions may cause ulceration on other mucosal surfaces in addition to the mouth such as the conjunctiva or the genital mucous membranes. Resolution of the systemic condition often leads to decreased frequency and severity of the oral ulceration.
- Behçet's disease
- Coeliac disease
- Cyclic neutropenia
- Nutritional deficiencies
- IgA deficiency
- Immunocompromised states, e.g. HIV/AIDS
- Inflammatory bowel disease
- and others...
Behçet's disease
Anterior uveitis in a person with Behçet's disease
Behçet's disease is a triad of mouth ulcers, genital ulcers and anterior uveitis (of the eye). The main feature of Behçet's disease is aphthous-like ulceration, but this is usually more severe than seen in aphthous stomatitis without a systemic cause, and typically resembles major or herpetiform ulceration or both. Aphthous-like ulceration is the first sign of the disease in 25–75% of cases.
Behçet's is more common in individuals whose ethnic origin is from regions along the Silk Road (between the Mediterranean and the Far East). It tends to be rare in other countries such as the United States and the United Kingdom.
Cyclic neutropenia
In cyclic neutropenia, there is a reduction in the level of circulating neutrophils in the blood that occurs about every 21 days. Opportunistic infections commonly occur and aphthous-like ulceration is worst during this time.
Blood deficiencies
Haematinic deficiencies (vitamin B12, folic acid and iron), occurring singly or in combination, and with or without any underlying gastrointestinal disease, may be twice as common in people with RAS. However, iron and vitamin supplements only infrequently improve the ulceration.
The relationship to vitamin B12 deficiency has been the subject of many studies. Although these studies found that 0–42% of those with recurrent ulcers suffer from vitamin B12 deficiency, an association with deficiency is rare.
Even in the absence of deficiency, vitamin B12 supplementation may be helpful due to unclear mechanisms.
Haematinic deficiencies can cause anaemia, which is also associated with aphthous-like ulceration.
Gastrointestinal disorders
Gastrointestinal disorders are sometimes associated with aphthous-like stomatitis, e.g. most commonly coeliac disease, but also inflammatory bowel disease such as Crohn's disease or ulcerative colitis.
The link between gastrointestinal disorders and aphthous stomatitis is probably related to nutritional deficiencies caused by malabsorption. Less than 5% of people with RAS have Coeliac disease, which usually presents with severe malnutrition, anaemia, abdominal pain, diarrhoea and glossitis.
Sometimes aphthous-like ulcerations can be the only sign of coeliac disease. Despite this association, a gluten-free diet does not usually improve the oral ulceration.