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Aphthous ulcer

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2] Sara Mehrsefat, M.D. [3] Synonyms and keywords: Canker sore; Sutton’s disease; aphthous stomatitis; recurrent aphthous stomatitis

Overview

Overview

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

An aphthous ulcer or canker sore is a type of mouth ulcer which presents as a painful open sore inside the mouth, caused by a break in the mucous membrane. The condition is also known as aphthous stomatitis, and alternatively as “Sutton’s Disease,” especially in the case of multiple or recurring ulcers.

Historical Perspective

The term aphthae was first used by Hippocrates at between 460-370 B.C., in relation to disorders of the mouth.

Classification

Aphthous ulcer may be classified into 3 groups: major aphthous stomatitis, minor aphthous stomatitis and herpetiform stomatitis.

Pathophysiology

The exact pathophysiology of aphthous ulcer is not fully understood. The pathogenesis of recurrent aphthous ulcer is varies based on underlying medical conditions. It is thought that aphthous ulcer is the result of ​the cross reactivity theory between microbial antigens and mitrocondrial heat shock protein, dysembryoplastic theory, histopathogenesis of glandular cells in myxoma or the thrombotic theory​. Predisposing factors implicated so far in the development of aphthous ulcers are: trauma, smoking cessation, stress, hormonal disorders and food hypersensitivities.

Causes

The exact cause of aphthous ulcers is unknown. Factors that provoke them include stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies, the foaming agent in toothpaste (SLS), and deficiencies in vitamin B12, iron, and folic acid.

Differentiating Gonadoblastoma from Other Diseases

Aphthous ulcer must be differentiated from malignant ulcers, infections, rheumatic and cutaneous disease.

Epidemiology and Demographics

The prevalence of aphthous ulcer is estimated to range from 1,000 to 60,000 cases per 100,000 individuals annually among adult, and 1,000 to 60,000 cases per 100,000 individuals among children.

Risk Factors

Common risk factors in the development of recurrent aphthous ulcers are use of denture or braces, gender, age, family history, oral diseases and stress.

Screening

There is insufficient evidence to recommend routine screening for gonadoblastoma. However, patients with XY gonadal abnormalities should be followed using sonography starting at age 2, every six months, until the gonads are removed.

Natural History, Complications, and Prognosis

The natural history, complications and prognosis of recurrent aphthous ulcers varies with disease severity.

Diagnosis

Diagnostic Study of Choice

There is no single diagnostic study of choice for the diagnosis of aphthous ulcers.

History and Symptoms

Symptoms of aphthous ulcers include oral pain, dysphagia, and oral bumps that may have resolved spontaneously in the past.

Physical Examination

Patients with aphthous ulcers usually present with ulcers that may be may be shallow or deep, present in small (1-5) or large (5-100) numbers, may be scarring or not. These characteristics help physicians to classify the disease.

Laboratory Findings

There are no specific laboratory findings associated with aphthous ulcers.

Electrocardiogram

There are no ECG findings associated with aphthous ulcers.

X-ray

There are no X-ray findings associated with aphthous ulcers.

Ultrasound

There are no echocardiographic and ultrasound findings associated with aphthous ulcers.

CT scan

There are no CT-Scan findings associated with aphthous ulcers.

MRI

There are no MRI findings associated with aphthous ulcers.

Other Imaging Findings

There are no other imaging findings associated with aphthous ulcers.

Other Diagnostic Studies

There are no other diagnostic studies findings associated with aphthous ulcers.

Treatment

Medical Therapy

The majority of cases of aphthous ulcers are self-limited and require only supportive care. Aphthous ulcers normally heal without treatment within 1 to 2 weeks. Good oral hygiene should be maintained, and spicy, acidic, and salty foods and drinks are best avoided, as they may irritate existing ulcers and cause pain. Strong mouthwash such as Listerine has also been known to cause irritation because of its strong ingredients, and many oral care professionals discourage the use of it while having a mouth ulcer.

Surgery

Surgical intervention is not recommended for the management of aphthous ulcers.

Primary Prevention

There is no established method for prevention of aphthous ulcers. Dental hygiene and regular dentistry visits though are highly advised for improving bucal health and reducing the risk of aphthous ulcers.

Secondary Prevention

There is no established method for prevention of aphthous ulcers. Dental hygiene and regular dentistry visits though are highly advised for improving bucal health and reducing the risk of aphthous ulcers.


References

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Historical Perspective

Historical Perspective

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

  • The term aphthae was first used by Hippocrates at between 460-370 B.C., in relation to disorders of the mouth.

Historical perspective

  • The term aphthae was first used by Hippocrates at between 460-370 B.C., in relation to disorders of the mouth.[1]
  • In 1898, the first clinical description of the aphthous stomatitis was reported by Von Mikulicz and Kumme as a Mikuliez aphthea
  • In 1911, stomatitis aphthae recurrens cicatricicans was first described by Sutton.
  • In 1961, stomatitis aphthae recurrens herpetiformis was first described by Cooke.[2]

References

  1. ↑ Ship, Jonathan A. “Recurrent aphthous stomatitis: an update.” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology 81.2 (1996): 141-147.
  2. ↑ Rogers RS (1977). “Recurrent aphthous stomatitis: clinical characteristics and evidence for an immunopathogenesis”. J Invest Dermatol. 69 (6): 499–509. doi:10.1111/1523-1747.ep12687958. PMID 336797.

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Classification

Classification

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2], Sara Mehrsefat, M.D. [3]

Overview

Aphthous ulcer may be classified into 3 groups: major aphthous stomatitis, minor aphthous stomatitis and herpetiform stomatitis.

Classification

Aphthous ulcer may be classified into:

  • Major aphthous stomatitis – Most common. Few ulcers or even just a single one, smaller than 1cm. Usually these lesions are self-resolving. Affects the lips, tongue lateral aspects and cheeks.
  • Minor aphthous stomatitis – Few ulcers of size greater than 1 cm. Often found in the back of the mouth. Painful and deeper than minor aphthous stomatitis, usually leaving a scar as it heals.
  • Herpetiform stomatitis – Least common. Wide number of ulcers, usually more than 10, with size varying between 1-3mm and may leave scars as it heals. Ulcers may coalesce and become larger. More common in young adults in the 20s or 30s.[1]

References

  1. ↑ Riera Matute G, Riera Alonso E (2011). “[Recurrent aphthous stomatitis in Rheumatology]”. Reumatol Clin. 7 (5): 323–8. doi:10.1016/j.reuma.2011.05.003. PMID 21925448.

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Pathophysiology

Pathophysiology

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2], José Eduardo Riceto Loyola Junior, M.D.[3]

Overview

The exact pathophysiology of aphthous ulcer is not fully understood. The pathogenesis of recurrent aphthous ulcer is varies based on underlying medical conditions. It is thought that aphthous ulcer is the result of ​the cross reactivity theory between microbial antigens and mitrocondrial heat shock protein, dysembryoplastic theory, histopathogenesis of glandular cells in myxoma or the thrombotic theory​. Predisposing factors implicated so far in the development of aphthous ulcers are: trauma, smoking cessation, stress, hormonal disorders and food hypersensitivities.

Pathophysiology

Pathogenesis

The exact pathophysiology of aphthous ulcers is not fully understood. It is thought that the pathogenesis of recurrent aphthous ulcer is varies based on underlying medical conditions and environmental exposures. Predisposing factors implicated so far in the development of aphthous ulcers are: trauma, smoking cessation, stress, hormonal disorders and food hypersensitivities.

Trauma

Stress

  • Despite the fact that many patients report having oral ulcers before stressful moments such as exams or job interviews, there is a lack of evidence to support that stress can be indeed a predisposing factor.[4]

Smoking

  • There seems to exist a negative correlation between oral ulcers and smoking, with oral ulcers appearing after smoking cessation.[5] Another evidence of this negative correlation is the fact that nicotine tablets seem to control the surgeance of ulcers.[6]

Hormonal Disorders

Microbial Factors

Abnormal Immunologic Response

Abnormal immunological responds also considered as a viable theory in pathogenesis of aphthous stomatitis.

  • The exact pathogenesis of recurrent aphthous ulcer in patients with abnormal immunologic responds is not fully understood. It is thought abnormality in immunologic response may result in aphthous ulcer by following mechanisms:[12][13]
    • Deposition of immune complexes within the oral epithelium;
    • Elevated level of salivary immunoglobulin A ;
    • Alteration of the CD4/CD8 ratio ;
    • Increased levels of several cytokines such as interleukin-2, interferon-g, and [[tumor necrosis factor-a|tumor necrosis factor-a (TNF-a)];
    • Infiltration of the mucosal tissue by lymphocytes is theorized to be associated to a keratinocyte-associated antigen that has not been identified. The production of TNF-a results in keratinocyte death by mediating endothelial cell adhesion and neutrophil chemotaxis.[14]

Behcet’s syndrome

  • It is though that recurrent aphthous ulcer in Behcet syndrome may be caused by abnormal inflammatory response in patients. Abnormal Inflammatory respond in patient with behcet syndrome is mediated by T lymphocytes and plasma cells.[15]

HIV infected individuals

  • The exact pathogenesis of aphthous ulcer in HIV is remain unclear. Aphthous ulceration may occasionally arise in HIV disease as a initial finding. However, it can be a common finding in AIDS patients with CD4+ lymphocyte counts below 100cells/mm3.[16][17]

Crohn’s disease

  • The exact pathogenesis of aphthous ulcer in Crohn’s disease is not fully understood. It is though aphthous ulcer in patients with Crohn’s disease is a result of inflammation of salivary glands.[18]

Celiac disease

  • There is a commonly held belief that another cause of aphthous ulcers is gluten intolerance (Celiac disease), whereby consumption of wheat, rye, barley and sometimes oats can result in chronic mouth ulcers. However, two small studies of patients with celiac disease have demonstrated no link between the disease and aphthous ulcers.[19][20] If patients with aphthous ulcers do happen to have gluten intolerance, they may experience benefit in eliminating breads, pastas, cakes, pies, scones, biscuits, beers and so on from their diet and substituting gluten-free varieties where available.[19]

Associated conditions

References

  1. ↑ Herlofson BB, Barkvoll P (1996). “The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers”. Acta Odontol Scand. 54 (3): 150–3. PMID 8811135.
  2. ↑ Herlofson BB, Barkvoll P (1994). “Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study”. Acta Odontol Scand. 52 (5): 257–9. PMID 7825393.
  3. ↑ Wray D, Ferguson MM, Hutcheon WA, Dagg JH (1978). “Nutritional deficiencies in recurrent aphthae”. J Oral Pathol. 7 (6): 418–23. PMID 105102 PMID 105102 Check |pmid= value (help).
  4. ↑ Pedersen A (1989). “Psychologic stress and recurrent aphthous ulceration”. J Oral Pathol Med. 18 (2): 119–22. doi:10.1111/j.1600-0714.1989.tb00747.x. PMID 2746521.
  5. ↑ DORSEY C (1964). “MORE OBSERVATIONS ON RELIEF OF APHTHOUS STOMATITIS ON RESUMPTION OF CIGARETTE SMOKING. A REPORT OF THREE CASES”. Calif Med. 101: 377–8. PMC 1515817. PMID 14229748.
  6. ↑ Bittoun R (1991). “Recurrent aphthous ulcers and nicotine”. Med J Aust. 154 (7): 471–2. PMID 2005845.
  7. ↑ Ferguson MM, McKay Hart D, Lindsay R, Stephen KW (1978). “Progeston therapy for menstrually related aphthae”. Int J Oral Surg. 7 (5): 463–70. doi:10.1016/s0300-9785(78)80038-6. PMID 102602.
  8. ↑ Ferguson MM, Carter J, Boyle P (1984). “An epidemiological study of factors associated with recurrent aphthae in women”. J Oral Med. 39 (4): 212–7. PMID 6594461.
  9. ↑ Lindemann RA, Riviere GR, Sapp JP. Serum antibody responses to indigenous oral mucosal antigens and selected laboratory-maintained bacteria in recurrent aphthous ulceration. Oral Surg Oral Med Oral Pathol 1985;59:585.
  10. ↑ Leimola-Virtanen R, Happonen RP, Syrjanen S. Cytomegalovirus (CMV) and Hel- icobacter pylori (HP) found in oral mucosal ulcers. J Oral Pathol Med 1995;24: 14–7.
  11. ↑ Pedersen A, Hornsleth A. Recurrent aphthous ulceration: a possible clinical mani- festation of reaction of varicella zoster of cytomegalovirus infection. J Oral Pathol Med 1993;22:64–8.
  12. ↑ Pekiner FN, Aytugar E, Demirel GY, et al. Interleukin-2, interleukin-6 and T reg- ulatory cells in peripheral blood of patients with Behcet’s disease and recurrent aphthous ulcerations. J Oral Pathol Med 2012;41(1):73–9.
  13. ↑ Hasan A, Shinnick T, Mizushima Y, et al. Defining a T-cell epitope within HSP 65 in recurrent aphthous stomatitis. Clin Exp Immunol 2002;128(2):318–25.
  14. ↑ Natah SS, Häyrinen-Immonen R, Hietanen J, Malmström M, Konttinen YT (2000). “Immunolocalization of tumor necrosis factor-alpha expressing cells in recurrent aphthous ulcer lesions (RAU)”. J Oral Pathol Med. 29 (1): 19–25. doi:10.1034/j.1600-0714.2000.290104.x. PMID 10678712.
  15. ↑ Klein P, Weinberger A, Altmann VJ, et al. Prevalence of Behcet syndrome among adult patients consulting three major clinics in a Druze town in Israel. Clin Rheu- matol 2010;29(10):1163–6.
  16. ↑ Di Alberti L, Porter SR, Speight P, et al. Detection of human herpesvirus-8 DNA in oral ulcer tissues of HIV infected individuals. Oral Dis 1997;3(Suppl 1):S133–4.
  17. ↑ Ramos-Gomez FJ, Flaitz C, Catapano P, Murray P, Milnes AR, Dorenbaum A. Classification, diagnostic criteria, and treatment recommendations for orofacial manifestations in HIV-infected pediatric patients. Collaborative Workgroup on Oral Manifestations of Pediatric HIV Infection. J Clin Pediatr Dent 1999; 23: 85–96.
  18. ↑ Schnitt SJ, Antonioli DA, Jaffe B, Peppercorn MA. Granulomatous inflammation of minor salivary gland ducts: a new oral manifestation of Crohn’s disease. Hum Pathol 1987; 18: 405–7.
  19. ↑ 19.0 19.1 Bucci P, Carile F, Sangianantoni A, D’Angio F, Santarelli A, Lo Muzio L. (2006). “Oral aphthous ulcers and dental enamel defects in children with celiac disease”. Acta Paediatrica. 95 (2): 203–7. PMID 16449028.
  20. ↑ Sedghizadeh PP, Shuler CF, Allen CM, Beck FM, Kalmar JR. (2002). “Celiac disease and recurrent aphthous stomatitis: a report and review of the literature”. Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics. 94 (4): 474–8. PMID 12374923.

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Causes

Causes

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2] José Eduardo Riceto Loyola Junior, M.D.[3]

Overview

The exact cause of aphthous ulcers is unknown. Factors that provoke them include stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies, the foaming agent in toothpaste (SLS), and deficiencies in vitamin B12, iron, and folic acid.

Causes

Trauma

Trauma to the mouth is the most common trigger of aphthous ulcers and includes:[1][2][3]

  • Toothbrush abrasions
  • Laceration with sharp foods or objects
  • Accidental biting (particularly common with sharp canine teeth)
  • Dental braces

Drugs

Common medications, that can result in recurrent aphthous stomatitis, include:

Genetic Factors

The role of genetic factors is the best-defined underlying cause of aphthous ulcer. Certain genetically specific HLAs which have been identified in aphthous ulcer patients include:[4]

  • HLA-A2
  • HLA-B5, B12, B44, B51, B52
  • HLA-DR2 and HLA-DR7
  • HLA-DQ series

Nutritional Factors

Aphthous ulcers are commonly seen in nutritional deficiencies. Low serum levels of following elements may result in recurrent aphthous ulcer:[5]

Allergic Factors

It is thought that aphthous ulcer may be caused by hypersensitivity to certain allergens such as:[6][7]

  • Environmental allergens
  • Food allergens
    • Milk
    • Chocolate
    • Cheese
    • Nuts
    • Tomatoes
    • Wheat

SLS containing Toothpaste

The large majority of toothpastes sold in the U.S. contain Sodium lauryl sulfate (SLS), which is known to cause aphthous ulcers in certain individuals.[8][9]

Microbial Factors

It is thought that aphthous ulcers may be caused by microbial factors such as:[10][11][12]

Systemic Disease

Common systemic conditions that may be caused in aphthous ulcer are include:[14][15]

Others

References

  1. ↑ Herlofson BB, Barkvoll P (1996). “The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers”. Acta Odontol Scand. 54 (3): 150–3. PMID 8811135.
  2. ↑ Herlofson BB, Barkvoll P (1994). “Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study”. Acta Odontol Scand. 52 (5): 257–9. PMID 7825393.
  3. ↑ Wray D, Ferguson MM, Hutcheon WA, Dagg JH (1978). “Nutritional deficiencies in recurrent aphthae”. J Oral Pathol. 7 (6): 418–23. PMID 105102 PMID 105102 Check |pmid= value (help).
  4. ↑ Albanidou‐Farmaki, E., et al. “HLA haplotypes in recurrent aphthous stomatitis: a mode of inheritance?.” International journal of immunogenetics 35.6 (2008): 427-432.
  5. ↑ Nolan A, McIntosh WB, Allam BF, Lamey PJ. Recurrent aphthous ulceration: vitamin B1, B2 and B6 status and response to replacement therapy. J Oral Pathol Med 1991; 20: 389–91.
  6. ↑ Wray D, Vlagopoulos TP, Siraganian RP. Food allergens and basophil histamine release in recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol 1982; 54(4):388–95.
  7. ↑ Pacor ML, Di Lorenzo G, Martinelli N, et al. Results of double-blind placebo- controlled challenge with nickel salts in patients affected by recurrent aphthous stomatitis. Int Arch Allergy Immunol 2003;131(4):296–300.
  8. ↑ Herlofson BB, Barkvoll P (1994). “Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study”. Acta Odontol Scand. 52 (5): 257–9. PMID 7825393 PMID 7825393 Check |pmid= value (help).
  9. ↑ Herlofson BB, Barkvoll P (1996). “The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers”. Acta Odontol Scand. 54 (3): 150–3. PMID 8811135 PMID 8811135 Check |pmid= value (help).
  10. ↑ Lindemann RA, Riviere GR, Sapp JP. Serum antibody responses to indigenous oral mucosal antigens and selected laboratory-maintained bacteria in recurrent aphthous ulceration. Oral Surg Oral Med Oral Pathol 1985;59:585.
  11. ↑ Leimola-Virtanen R, Happonen RP, Syrjanen S. Cytomegalovirus (CMV) and Hel- icobacter pylori (HP) found in oral mucosal ulcers. J Oral Pathol Med 1995;24: 14–7.
  12. ↑ Pedersen A, Hornsleth A. Recurrent aphthous ulceration: a possible clinical mani- festation of reaction of varicella zoster of cytomegalovirus infection. J Oral Pathol Med 1993;22:64–8.
  13. ↑ 13.0 13.1 13.2 Edgar NR, Saleh D, Miller RA (2017). “Recurrent Aphthous Stomatitis: A Review”. J Clin Aesthet Dermatol. 10 (3): 26–36. PMC 5367879. PMID 28360966.
  14. ↑ Klein P, Weinberger A, Altmann VJ, et al. Prevalence of Behcet’s disease among adult patients consulting three major clinics in a Druze town in Israel. Clin Rheu- matol 2010;29(10):1163–6.
  15. ↑ Lewkowicz N, Lewkowicz P, Banasik M, Kurnatowska A, Tchórzewski H (2005). “Predominance of Type 1 cytokines and decreased number of CD4(+)CD25(+high) T regulatory cells in peripheral blood of patients with recurrent aphthous ulcerations”. Immunol Lett. 99 (1): 57–62. doi:10.1016/j.imlet.2005.01.002. PMID 15894112 PMID 15894112 Check |pmid= value (help).

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Differentiating Aphthous ulcer from other Diseases

Differentiating Aphthous ulcer from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]
For more differentials of other oral lesions look here

Overview

Aphthous ulcer must be differentiated from malignant ulcers, infections, rheumatic and cutaneous disease.

Differential Diagnosis

Aphthous ulcer must be differentiated from:

Aphthous ulcer must be differentiated from other diseases causing oral lesions such as leukoplakia and herpes simplex virus infection.

Disease Presentation Risk Factors Diagnosis Affected Organ Systems Important features Picture
Diseases predominantly affecting the oral cavity
Oral Candidiasis
  • Denture users
  • As a side effect of medication, most commonly having taken antibiotics. Inhaled corticosteroids for the treatment of lung conditions (e.g, asthma or COPD) may also result in oral candidiasis which may be reduced by regularly rinsing the mouth with water after taking the medication.
  • Clinical diagnosis
  • Confirmatory tests rarely needed
 Localized candidiasis

Invasive candidasis

Tongue infected with oral candidiasis – By James Heilman, MD – Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=11717223.jpg
Herpes simplex oral lesions
  • Stress
  • Recent URTI
  • Female sex
  • The symptoms of primary HSV infection generally resolve within two weeks
Oral herpes simplex infection – By James Heilman, MD – Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=19051042.jpg
Aphthous ulcers
  • Painful, red spot or bump that develops into an open ulcer
  • Physical examination
  • Diagnosis of exclusion
  • Oral cavity
  • Self-limiting , Pain decreases in 7 to 10 days, with complete healing in 1 to 3 weeks
Apthous ulcer on the lower surface of the tongue – By Ebarruda – Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=7903358
Squamous cell carcinoma
Squamous cell carcinoma – By Luca Pastore, Maria Luisa Fiorella, Raffaele Fiorella, Lorenzo Lo Muzio – http://www.plosmedicine.org/article/showImageLarge.action?uri=info%3Adoi%2F10.1371%2Fjournal.pmed.0050212.g001, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=15252632
Leukoplakia
  • Vulvar lesions occur independent of oral lesions
Leukoplakia – By Aitor III – Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9873087
Melanoma
Oral melanoma – By Emmanouil K Symvoulakis, Dionysios E Kyrmizakis, Emmanouil I Drivas, Anastassios V Koutsopoulos, Stylianos G Malandrakis, Charalambos E Skoulakis and John G Bizakis – Symvoulakis et al. Head & Face Medicine 2006 2:7 doi:10.1186/1746-160X-2-7 (Open Access), [1], CC BY-SA 2.0, https://commons.wikimedia.org/w/index.php?curid=9839811
Fordyce spots
Fordyce spots – Por Perene – Obra do próprio, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=19772899
Burning mouth syndrome
Torus palatinus
Torus palatinus – By Photo taken by dozenist, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=846591
Diseases involving oral cavity and other organ systems
Behcet’s disease
Behcet’s disease – By Ahmet Altiner MD, Rajni Mandal MD – http://dermatology.cdlib.org/1611/articles/18_2009-10-20/2.jpg, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=17863021
Crohn’s disease
Agranulocytosis
Syphilis[3]
oral syphilis – By CDC/Susan Lindsley – http://phil.cdc.gov/phil_images/20021114/34/PHIL_2385_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=2134349
Coxsackie virus
  • Symptomatic treatment
Coxsackie virus stomatitis – Adapted from Dermatology Atlas.[4]
Chicken pox
Chickenpox – By James Heilman, MD – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=52872565
Measles
  • Unvaccinated individuals[5][6]
  • Crowded and/or unsanitary conditions
  • Traveling to less developed and developing countries
  • Immunocompromized
  • Winter and spring seasons
  • Born after 1956 and never fully vaccinated
  • Health care workers
Koplick spots (Measles) – By CDC – http://phil.cdc.gov/PHIL_Images/20040908/4f54ee8f0e5f49f58aaa30c1bc6413ba/6111_lores.jpg, Public Domain, https://commons.wikimedia.org/w/index.php?curid=824483

References

  1. ↑ Ann M. Gillenwater, Nadarajah Vigneswaran, Hanadi Fatani, Pierre Saintigny & Adel K. El-Naggar (2013). “Proliferative verrucous leukoplakia (PVL): a review of an elusive pathologic entity!”. Advances in anatomic pathology. 20 (6): 416–423. doi:10.1097/PAP.0b013e3182a92df1. PMID 24113312. Unknown parameter |month= ignored (help)
  2. ↑ Andrès E, Zimmer J, Affenberger S, Federici L, Alt M, Maloisel F. (2006). “Idiosyncratic drug-induced agranulocytosis: Update of an old disorder”. Eur J Intern Med. 17 (8): 529–35. Text “pmid 17142169” ignored (help)
  3. ↑ title=”By Internet Archive Book Images [No restrictions], via Wikimedia Commons” href=”https://commons.wikimedia.org/wiki/File:A_manual_of_syphilis_and_the_venereal_diseases%2C_(1900)_(14595882378).jpg“
  4. ↑ “Dermatology Atlas”.
  5. ↑ Feikin DR, Lezotte DC, Hamman RF, Salmon DA, Chen RT, Hoffman RE (2000). “Individual and community risks of measles and pertussis associated with personal exemptions to immunization”. JAMA. 284 (24): 3145–50. PMID 11135778.
  6. ↑ Ratnam S, West R, Gadag V, Williams B, Oates E (1996). “Immunity against measles in school-aged children: implications for measles revaccination strategies”. Can J Public Health. 87 (6): 407–10. PMID 9009400.

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Epidemiology and Demographics

Epidemiology and Demographics

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[5]

Overview

The prevalence of aphthous ulcer is estimated to range from 1,000 to 60,000 cases per 100,000 individuals annually among adult, and 1,000 to 60,000 cases per 100,000 individuals among children.

Epidemiology and Demographics

Prevalence

Aphthous ulcer is a very common oral lesion. The frequency of canker sores varies from fewer than 4 episodes per year (85% of all cases) to more than one episode per month (10% of all cases) including people suffering from continuous RAS.[1]

  • The prevalence of aphthous ulcer is estimated to range from 1,000 to 60,000 cases per 100,000 individuals annually among adult, and 1,000 to 60,000 cases per 100,000 individuals among children.
  • In Sweden, the prevalence of aphthous ulcer is range from 5,000 to 30,000 per 100,000 individuals.[2][1]
  • In the United States, the overall prevalence of recurrent aphthous ulcers was 1000 per 100,000 persons
  • In the United States, the prevalence of recurrent aphthous ulcer among children was estimated 1500 per 100,000 individuals, and the the prevalence among adults was estimated 850 per 100,000 individuals.[3][4][5][6]
  • Minor RAS is the most common form, being 80% of all the cases of RAS.[7]

Gender

Gender is associated with an increased risk of developing aphthous ulcers. Women are more often affected by the disease than men.

Family

About 30–40% of patients with recurrent aphthous ulcers report a family history of the disease. [8][9][10]

References

  1. ↑ 1.0 1.1 T. Axéll, V. Henricsson (1985). “The occurrence of recurrent aphthous ulcers in an adult Swedish population”. Acta Odontol Scand.
  2. ↑ J.M. Casiglia, G.W. Mirowski, C.L. Nebesio (2006). “Aphthous stomatitis”. Emedecine. Unknown parameter |month= ignored (help)
  3. ↑ Kleinman DV, Swango PA, Pindborg JJ. Epidemiology of oral mucosal lesions in United States Schoolchildren: 1986–87. Community Dent Oral Epidemiol 1994; 22:243–53.
  4. ↑ Field EA, Allan RB. Oral ulceration—aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment Pharmacol Ther 2003;18: 949–62.
  5. ↑ Ferguson MM, Wray D, Carmichael HA, et al. Coeliac disease associated with recurrent aphthae. Gut 1980;21:223–36.
  6. ↑ Soames JV, Southam JC. Oral pathology. 3rd edition. Oxford (UK): Oxford University Press; 1998.
  7. ↑ Shulman JD, Beach MM, Rivera-Hidalgo F (2004). “The prevalence of oral mucosal lesions in U.S. adults: data from the Third National Health and Nutrition Examination Survey, 1988-1994”. J Am Dent Assoc. 135 (9): 1279–86. doi:10.14219/jada.archive.2004.0403. PMID 15493392.
  8. ↑ [1]
  9. ↑ [2]
  10. ↑ [3]

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Risk Factors

Risk Factors

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

Common risk factors in the development of recurrent aphthous ulcers are use of denture or braces, gender, age, family history, oral diseases and stress.

Risk Factors

Risk factors for developing aphthous ulcers include:

  • Eating barbecue;
  • Use of denture or braces;
  • Adequate brushing time;
  • Other oral diseases;
  • Gender – being a female;
  • Age – between the ages of 10-40;
  • Family history of aphthous ulcers;
  • Some studies suggests that anxiety, depression, and psychological stress may be associated with RAS.[1]

References

  1. ↑ Shi L, Wan K, Tan M, Yin G, Ge M, Rao X; et al. (2015). “Risk factors of recurrent aphthous ulceration among university students”. Int J Clin Exp Med. 8 (4): 6218–23. PMC 4483853. PMID 26131228.

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Natural History, Complications and Prognosis

Natural History, Complications and Prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: José Eduardo Riceto Loyola Junior, M.D.[2]

Overview

The natural history, complications and prognosis of recurrent aphthous ulcers varies with disease severity.

Natural History

  • The most common form, the minor, is characterized by ovoid or circular lesions, smaller than 1cm in diameter, in number that varies from 1 to 5, covered by a thin pseudomembrane of white-gray color. It spontaneously resolves after 10-14 days leaving no scar.
  • The major form is less common, present with ulcers larger than 1cm in diameter, being deeper and associated with dysphagia. It can last for several weeks and may leave scars. They often affect the lip, tongue and soft palate.
  • The herpetiform form is rarer and presents with pinpoint ulcers that are small in size (0.1-0.2cm) that may be present in large numbers or coalesce forming large lesions. These lesions may take 7-14 days to resolve usually leaving a scar. It is not related to the HSV.[1]

Complications

  • Complications are rare, and mostly due to associated diseases than the ulcers. The more severe forms of the disease may cause scarring.

Prognosis

  • Aphthous ulcers usually heal on their own. The pain usually decreases in a few days. Other symptoms disappear in 10 to 14 days.
  • Prognosis of the associated medical conditions is highly variable and should be assessed individually.

References

  1. ↑ Queiroz SIML, Silva MVAD, Medeiros AMC, Oliveira PT, Gurgel BCV, Silveira ÉJDD (2018). “Recurrent aphthous ulceration: an epidemiological study of etiological factors, treatment and differential diagnosis”. An Bras Dermatol. 93 (3): 341–346. doi:10.1590/abd1806-4841.20186228. PMC 6001102. PMID 29924245.
Diagnosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | Histological Findings

Treatment

Treatment

Medical Therapy | Primary Prevention | Secondary Prevention

Case Studies

Case Studies

Case #1

Related Chapters


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