Aphthous stomatitis
| Aphthous stomatitis | |
|---|---|
| Other names | Recurrent aphthous stomatitis (RAS), recurring oral aphthae, recurrent aphthous ulceration |
 | |
| Canker sore on the lower lip | |
| Specialty | Oral medicine, dermatology |
| Symptoms | A round, often painful sore inside the mouth that is white or gray with a red border;
Tingling or burning sensation prior to sore development; sodium lauryl sulfate, brushing with a soft-bristled brush after meals and flossing daily. |
| Treatment | mouth rinses; nutritional supplements; oral medication |
| Medication | good oral hygiene, topical agents |
| Frequency | ~30% of people to some degree[1] |
| Deaths | None reported. |
Aphthous stomatitis,
These ulcers occur periodically and heal completely between attacks. In the majority of cases, the individual ulcers last about 7–10 days, and ulceration episodes occur 3–6 times per year. Most appear on the
The condition is very common, affecting about 20% of the general population to some degree.[1] The onset is often during childhood or adolescence, and the condition usually lasts for several years before gradually disappearing. There is no cure, but treatments such as corticosteroids aim to manage pain, reduce healing time and reduce the frequency of episodes of ulceration.
Signs and symptoms
Persons with aphthous stomatitis have no detectable systemic symptoms or signs (i.e., outside the mouth). Signs are limited to the lesions themselves.
Ulceration episodes usually occur about 3–6 times per year.[5] However, severe disease is characterized by virtually constant ulceration (new lesions developing before old ones have healed) and may cause debilitating chronic pain and interfere with comfortable eating. In severe cases, this prevents adequate nutrient intake leading to malnutrition and weight loss.[4]
Aphthous ulcers typically begin as
Causes
The cause is not entirely clear,
Aphthous stomatitis has been associated with other autoimmune diseases, namely
Evidence for the T cell-mediated mechanism of mucosal destruction is strong, but the exact triggers for this process are unknown and are thought to be multiple and varied from one person to the next. This suggests that there are a number of possible triggers, each of which is capable of producing the disease in different subgroups. In other words, different subgroups appear to have different causes for the condition. These can be considered in three general groups, namely primary immuno-dysregulation, decrease of the mucosal barrier and states of heightened antigenic sensitivity (see below).[6] Risk factors in aphthous stomatitis are also sometimes considered as either host-related or environmental.[8]
Immunity
At least 40% of people with aphthous stomatitis have a positive family history, suggesting that some people are genetically predisposed to developing oral ulceration.
Stress has effects on the immune system, which may explain why some cases directly correlate with stress. It is often stated that in studies of students with the condition, ulceration is exacerbated during examination periods and lessened during periods of vacation.[3][6] Alternatively, it has been suggested that oral parafunctional activities such as lip or cheek chewing become more pronounced during periods of stress, and hence the mucosa is subjected to more minor trauma.[9]
Aphthous-like ulceration also occurs in conditions involving systemic immuno-dysregulation, e.g.
Mucosal barrier
The thickness of the mucosa may be an important factor in aphthous stomatitis. Usually, ulcers form on the thinner, non-keratinizing mucosal surfaces in the mouth. Factors which decrease the thickness of the mucosa increase the frequency of occurrence, and factors which increase the thickness of the mucosa correlate with decreased ulceration.[6]
The nutritional deficiencies associated with aphthous stomatitis (vitamin B12, folate, and iron) can all cause a decrease in the thickness of the oral mucosa (atrophy).[6]
Local trauma is also associated with aphthous stomatitis, and it is known that trauma can decrease the mucosal barrier. Trauma could occur during injections of local anesthetic in the mouth, or otherwise during dental treatments, frictional trauma from a sharp surface in the mouth such as broken tooth, or from tooth brushing.[9]
Hormonal factors are capable of altering the mucosal barrier. In one study, a small group of females with aphthous stomatitis had fewer occurrences of aphthous ulcers during the
Aphthous stomatitis is more common in people who smoke,[7][10][unreliable medical source] and there is also a correlation between habit duration and severity of the condition.[11] Tobacco use is associated with an increase in keratinization of the oral mucosa.[6] In extreme forms, this may manifest as leukoplakia or stomatitis nicotina (smoker's keratosis). This increased keratinization may mechanically reinforce the mucosa and reduce the tendency of ulcers to form after minor trauma, or present a more substantial barrier to microbes and antigens, but this is unclear. Nicotine is also known to stimulate production of adrenal steroids and reduce production of TNF-α, interleukin-1 and interleukin-6.[9] Smokeless tobacco products also seem to protect against aphthous stomatitis.[11] Cessation of smoking is known to sometimes precede the onset of aphthous stomatitis in people previously unaffected, or exacerbate the condition in those who were already experiencing aphthous ulceration.[3] Despite this correlation, starting smoking again does not usually lessen the condition.[12]
Antigenic sensitivity
Various
In some instances, recurrent mouth ulcers may be a manifestation of an
Systemic disease
| Systemic disorders associated with aphthous-like ulceration[6] |
|---|
|
Aphthous-like ulceration may occur in association with several systemic disorders (see table). 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.[7][15] 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.[6]
Behçet's disease is a triad of mouth ulcers, genital ulcers and anterior
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.[16]
Other examples of systemic conditions associated with aphthous-like ulceration include reactive arthritis,[7] and recurrent erythema multiforme.[7]
Diagnosis
Diagnosis is mostly based on the clinical appearance and the medical history.[3] The most important diagnostic feature is a history of recurrent, self healing ulcers at fairly regular intervals.[20] Although there are many causes of oral ulceration, recurrent oral ulceration has relatively few causes, most commonly aphthous stomatitis, but rarely Behçet's disease, erythema multiforme, ulceration associated with gastrointestinal disease,[12][20] and recurrent intra-oral herpes simplex infection. A systemic cause is more likely in adults who suddenly develop recurrent oral ulceration with no prior history.[16]
Special investigations may be indicated to rule out other causes of oral ulceration. These include blood tests to exclude anemia, deficiencies of iron, folate or vitamin B12, or celiac disease.[8] However, the nutritional deficiencies may be latent and the peripheral blood picture may appear relatively normal.[8] Some suggest that screening for celiac disease should form part of the routine work up for individuals complaining of recurrent oral ulceration.[9] Many of the systemic diseases cause other symptoms apart from oral ulceration, which is in contrast to aphthous stomatitis where there is isolated oral ulceration. Patch testing may be indicated if allergies are suspected (e.g. a strong relationship between certain foods and episodes of ulceration). Several drugs can cause oral ulceration (e.g. nicorandil), and a trial substitution to an alternative drug may highlight a causal relationship.[3]
Tissue
Classification
Aphthous stomatitis has been classified as a type of non-infectious stomatitis (inflammation of the mouth).[20] One classification distinguishes "common simple aphthae", accounting for 95% of cases, with 3–6 attacks per year, rapid healing, minimal pain and restriction of ulceration to the mouth; and "complex aphthae", accounting for 5% of cases, where ulcers may be present on the genital mucosa in addition to mouth, healing is slower and pain is more severe.[5] A more common method of classifying aphthous stomatitis is into three variants, distinguished by the size, number and location of the lesions, the healing time of individual ulcers and whether a scar is left after healing (see below).
Minor aphthous ulceration
This is the most common type of aphthous stomatitis, accounting for about 80–85% of all cases.
Major aphthous ulceration
This subtype makes up about 10% of all cases of aphthous stomatitis.
Herpetiform ulceration
Herpetiform ulcers,
RAS type ulceration
Recurrent oral ulceration associated with systemic conditions is termed "RAS-type ulceration", "RAS-like ulceration", or "aphthous-like ulcers".[3] Aphthous stomatitis occurs in individuals with no associated systemic disease.[7] Persons with certain systemic diseases may be prone to oral ulceration, but this is secondary to the underlying medical condition (see the systemic disease section).[7] This kind of ulceration is considered by some to be separate from true aphthous stomatitis.[7][15] However, this definition is not strictly applied. For example, many sources refer to oral ulceration caused by anemia and/or nutritional deficiencies as aphthous stomatitis, and some also consider Behçet's disease to be a variant.[6][8]
Treatment
The vast majority of people with aphthous stomatitis have minor symptoms and do not require any specific therapy. The pain is often tolerable with simple dietary modification during an episode of ulceration such as avoiding spicy and acidic foods and beverages.
Medication
The first line of therapy for aphthous stomatitis are topical agents rather than systemic medication,[7] with topical corticosteroids being the mainstay treatment.[3][16] Systemic treatment is usually reserved for severe disease due to the risk of adverse side effects associated with many of these agents. A systematic review found that no single systemic intervention was found to be effective.[7] Good oral hygiene is important to prevent secondary infection of the ulcers.[3]
Occasionally, in females where ulceration is correlated to the menstrual cycle or to birth control pills, progestogen or a change in birth control may be beneficial.[3] Use of nicotine replacement therapy for people who have developed oral ulceration after stopping smoking has also been reported.[9] Starting smoking again does not usually lessen the condition.[12] Trauma can be reduced by avoiding rough or sharp foodstuffs and by brushing teeth with care. If sodium lauryl sulfate is suspected to be the cause, avoidance of products containing this chemical may be useful and prevent recurrence in some individuals.[22] Similarly patch testing may indicate that food allergy is responsible, and the diet modified accordingly.[3] If investigations reveal deficiency states, correction of the deficiency may result in resolution of the ulceration. For example, there is some evidence that vitamin B12 supplementation may prevent recurrence in some individuals.[22]
| Medications | ||
|---|---|---|
| Drug type | Intended action | Example(s) |
| Topical covering agents / barriers | Reduce pain | Orabase (often combined with triamcinolone).[23] |
| Topical anti-inflammatory agents |
Reduce pain | hyaluronan.[3]
|
| Topical antiseptics | Speed healing (prevent secondary infection) | |
| Topical mild potency corticosteroids | Reduce inflammation | Hydrocortisone sodium succinate.[3] |
| Topical moderate potency corticosteroids | Reduce inflammation | |
| Systemic medications | Various, mostly modulating immune response | mycophenolate mofetil,[7] adalimumab,[16] vitamin B12,[7] Clofazimine,[7] Levamisole,[7][16] Montelukast,[7] Sulodexide,[7]
|
Other
Surgical excision of aphthous ulcers has been described, but it is an ineffective and inappropriate treatment. A 2023 systematic review found that supplementation with vitamin B12, zinc sulfate and omega-3 seem to be beneficial in the management of RAS.[24]
Anecdotal evidence suggests that vitamin C may have a beneficial preventative impact on ulceration.[citation needed] However, the benefits of vitamin C are limited to the first 8 to 12 hours after the first tingling is sensed. Thereafter, vitamin C has far less effect. Vitamin C may cure the condition in 24 - 48 hours only if it is consumed within the first 8 to 12 hours.
Prognosis
By definition, there is no serious underlying medical condition, and most importantly, the ulcers do not represent oral cancer nor are they infectious. However, aphthae are capable of causing significant discomfort. There is a spectrum of severity, with symptoms ranging from a minor nuisance to disabling.[4] Due to pain during eating, weight loss may develop as a result of not eating in severe cases of aphthous stomatitis. Usually, the condition lasts for several years before spontaneously disappearing in later life.[3]
Epidemiology
Aphthous stomatitis affects between 5% and 66% of people, with about 20% of individuals in most populations having the condition to some degree.[6][8] This makes it the most common disease of the oral mucosa.[20] Aphthous stomatitis occurs worldwide, but is more common in developed countries.[3]
Within nations, it is more common in higher socioeconomic groups.[3] Males and females are affected in an equal ratio, and the peak age of onset between 10 and 19 years.[7] About 80% of people with aphthous stomatitis first developed the condition before the age of 30.[6] There have been reports of ethnic variation. For example, in the United States, aphthous stomatitis may be three times more common in white-skinned people than black-skinned people.[16]
History, society and culture
"Aphthous affectations" and "aphthous ulcerations" of the mouth are mentioned several times in the treatise "Of the Epidemics" (part of the
Aphthous stomatitis was once thought to be a form of recurrent herpes simplex virus infection, and some clinicians still refer to the condition as "herpes" despite this cause having been disproven.[26]
The informal term "canker sore" is sometimes used, mainly in North America,[27] either to describe this condition generally, or to refer to the individual ulcers of this condition,[28] or mouth ulcers of any cause unrelated to this condition. The origin of the word "canker" is thought to have been influenced by Latin, Old English, Middle English and Old North French.[29] In Latin, cancer translates to "malignant tumor" or literally "crab" (related to the likening of sectioned tumors to the limbs of a crab). The closely related word in Middle English and Old North French, chancre, now more usually applied to syphilis, is also thought to be involved.[29] Despite this etymology, aphthous stomatitis is not a form of cancer but rather entirely benign.
An aphtha (plural aphthae) is a non specific term that refers to an ulcer of the mouth. The word is derived from the Greek word aphtha meaning "eruption" or "ulcer".
The current most widely used medical term is "recurrent aphthous stomatitis" or simply "aphthous stomatitis".[4] Historically, many different terms have been used to refer to recurrent aphthous stomatitis or its sub-types, and some are still in use. Mikulicz's aphthae is a synonym of minor RAS,[9] named after Jan Mikulicz-Radecki. Synonyms for major RAS include Sutton's ulcers (named after Richard Lightburn Sutton), Sutton's disease,[33] Sutton's syndrome and periadenitis mucosa necrotica recurrens.[3][9] Synonyms for aphthous stomatitis as a whole include (recurrent) oral aphthae, (recurrent) aphthous ulceration and (oral) aphthosis.[6][15]
In traditional Chinese medicine, claimed treatments for aphthae focus on clearing heat and nourishing Yin.[34]
Rembrandt Gentle White toothpaste did not contain sodium lauryl sulfate, and was specifically marketed as being for the benefit of "canker sore sufferers". When the manufacturer Johnson & Johnson discontinued the product in 2014, it caused a backlash of anger from long-term customers, and the toothpaste began to sell for many times the original price on the auction website eBay.[35][36]
See also
- Acute necrotizing ulcerative gingivitis, also known as "trench mouth"—another painful, non-contagious mouth infection with similar symptoms
- Mouth ulcer
References
- ^ ISBN 9781603275200.
- Ancient Greekἄφθα (áphtha) 'mouth ulcer', στόμα (stóma) 'mouth', and -ῖτις (-îtis) 'pertaining to'
- ^ ISBN 978-0-7020-4948-4.
- ^ ISBN 978-1-60327-519-4.
- ^ PMID 18839042.
- ^ ISBN 978-1-4160-3435-3.
- ^ PMID 22972085.
- ^ ISBN 978-0-443-07265-9.
- ^ PMID 22144824.
- PMID 29166496.
- ^ PMID 24217985.
- ^ ISBN 978-0-443-06784-6.
- ^ a b "Canker sore". Mayo Foundation for Medical Education and Research. March 24, 2012. Retrieved July 7, 2014.
- S2CID 73484189.
- ^ PMID 21925448.
- ^ PMID 17850936.
- S2CID 31095457.
- PMID 21812866.
- ^ Dorfman J, The Center for Special Dentistry Archived August 1, 2015, at the Wayback Machine
- ^ ISBN 978-0-443-10125-0.
- ^ "International Classification of Diseases-10". World Health Organization. Retrieved February 16, 2013.
- ^ PMID 21977491.
- ^ PMID 10905785.
- ^ Mirza, Waqas (January 10, 2023). "Oral supplemental interventions for the 6 management of recurrent aphthous stomatitis (ras) – A systematic review and meta-analysis". ETD Home. Retrieved February 3, 2023.
- ^ Wikisource:Of the Epidemics
- ISBN 1-55009-186-7.
- ^ "Canker". Oxford dictionaries. Archived from the original on July 12, 2012. Retrieved July 12, 2014.
- ^ "Aphthous stomatitis". Merriam-Webster, Incorporated. Retrieved July 12, 2014.
- ^ a b "Chancre and Canker". Douglas Harper. Retrieved September 1, 2013.
- PMID 22884485.
- PMID 8060829.
- ISBN 978-1-60406-279-3.
- PMID 10932907.
- ISBN 978-0-203-49389-2.
- ^ Deardorff J (March 5, 2014). "Loss of canker sore toothpaste angers loyal users". Chicago Tribune. Retrieved April 12, 2014.
- ISBN 978-0-312-98139-6.
External links
Learning materials related to Oral ulceration at Wikiversity- Aphthous stomatitis at Curlie
