Recurrent Aphthous Stomatitis

Introduction

Recurrent aphthous stomatitis is a condition in which there is painful ulceration. It is commonly seen in the oral mucosa. There is the presence of recurrent solitary or multiple ulceration. The ulceration is painful without any association with systemic diseases. The ulcers are commonly known as canker sores and usually occur in the non-keratinized oral mucous membrane. It is triggered by trauma stress, menstruation stress, and allergy. The cause of recurrent aphthous stomatitis is multifactorial. First, there is the activation of the cell-mediated immune system. It occurs more frequently in smokers. It is less commonly found in people who practice good oral hygiene.

What Is Recurrent Aphthous Stomatitis?

Recurrent aphthous stomatitis is characterized by recurrent painful solitary or multiple ulceration of the oral mucosa. In this condition, the ulcers heal spontaneously. It is a common condition, and the cause is unclear. Multiple factors involve exposure to preservatives and toothpaste ingredients, genetic predisposition, and abnormal immune system functioning.

What Are the Causes of Recurrent Aphthous Stomatitis?

Given below are the causes of Recurrent aphthous stomatitis:

• Systemic Causes - Nutritional deficiencies such as folic acid, vitamin B12, and iron cause aphthous ulcers. Certain diseases, such as Crohn's disease and celiac disease, cause malabsorption resulting in recurrent aphthous stomatitis.

• Microorganism - Streptococcus sanguis are found to be causing aphthous stomatitis. Viruses such as Varicella zoster, Cytomegalovirus, and Adenovirus cause aphthous stomatitis.

• Stress - Acute psychological stress precipitates recurrent aphthous stomatitis.

• Allergies - Allergies from certain food, hay fever, drug allergy, and asthma can cause recurrent aphthous stomatitis.

• Endocrine Factor - Hormones are important in the cause of recurrent aphthous stomatitis. Aphthous ulcers appear during pregnancy, menopause, and menstruation. However, ulcers are higher during the menstruation and post-ovulation periods.

• Genetic Predisposition - Recurrent aphthous stomatitis is frequently seen in children with parents suffering recurrent aphthous stomatitis. HLA-B51 is found to be responsible for the recurrence of aphthous ulcers.

• Immunological Abnormalities - There is the presence of mucosal destruction of the spinous layer of oral mucosa due to T cell-mediated immunological reaction. Immunoglobulin G (IgG) and Immunoglobulin M (IgM) are binding in the spinous layer of oral mucosa and mucosal healing defect caused by cytokine (small protein controlling growth and immune system) inhibition.

What Are the Types of Recurrent Aphthous Ulcers?

The ulcers are classified based on the morphology and severity of ulceration:

Based on Morphology:

• Minor Aphthous Ulcers - It is also known as canker sores. The ulcers are oval-shaped and less than one centimeter in size. The healing of ulcers takes place without scarring.

• Major Aphthous Ulcer - It is also known as periodontitis mucosa necrotica and Sutton's disease. The shape of ulcers is oval or crater shaped with a ragged border. The ulcers heal without scarring.

• Herpetiform Ulcers - There are clusters of small ulcerations less than size 0.5 centimeters.

Based on Severity:

• Simple Aphthous - A recurrent attack of aphthous ulcer with an aphthous-free distinct period.

• Complex Aphthosis - The presence of three or more oral ulcers is seen, which recurs frequently. Various forms of complex recurrent aphthous stomatitis are in cyclic neutropenia, celiac disease, and Bechet's syndrome.

What Are the Clinical Features of Recurrent Aphthous Stomatitis?

• Age - It is usually seen between the second to third decades of life.

• Gender - It is more common in women.

• Site - It usually occurs in the non-keratinized mucosal surfaces such as buccal mucosa and labial mucosa, tongue, and pharynx.

• Prodromal Signs - It usually begins with a burning sensation for twenty-four hours. There is a stinging sensation, and ulcers appear after forty to eight hours.

• Appearance - The ulcers are solitary or multiple with superficial erosions. The ulcers are surrounded by localized edema, and superficial surface erosion is seen. A grayish membrane and yellowish necrotic slough cover the erosion of the surface.

• Signs - The ulcers are very painful. Eating and drinking water is difficult.

• Duration - The minor aphthous ulcers heals within ten days, whereas major aphthous ulcers and herpetiform ulcers heal slowly. It heals in more than fourteen days. The lesion frequency is between two to six lesions at every episode. There is the presence of several episodes in a year, and healing takes place with or without scarring.

What Are the Differential Diagnosis of Recurrent Aphthous Stomatitis?

Given below are the differential diagnosis of recurrent aphthous stomatitis:

• Recurrent Herpes Simplex Infection - The ulcers are shallow with clusters of grayish or whitish vesicles. In addition, there is the presence of prodromal symptoms.

• Bednar's Aphthae - This is a traumatic lesion seen in the palatal mucosa of newborns. It occurs due to careless wiping of the oral cavity.

• Erosive Lichen Planus - The border of the lesion is whitish.

• Cyclic Neutropenia - It appears in a significant three-week period with a generally compromised state. Therefore, the complete blood count should be taken into consideration.

What Are the Treatment Plans for Recurrent Aphthous Stomatitis?

Listed below is the treatment plan for recurrent aphthous stomatitis:

• Nutritional Supplements - Nutritional supplements such as Vitamin B12, ferritin, iron, and folate are indicated.

• Topical Corticosteroid - Topical ointments are given to relieve pain; however, they do not prevent reoccurrence. Therefore, Triamcinolone acetonide 0.1 percent is applied to the affected part.

• Topical Steroid - Betamethasone syrup and 0.1 percent Dexamethasone elixir are prescribed to rinse and expectorate. It gives symptomatic relief.

• Topical Anesthetic - Benzydamine hydrochloride and two percent Lidocaine helps in reducing the pain.

• Amlexanox - 5 percent Amlexanox is given to apply on the lesion during the prodromal phase. It has anti-inflammatory properties.

• Beclomethasone Spray - It is given when there is a severe aphthous ulcer. Also, it is given when the location of ulcers is difficult to reach, such as the tonsillar pillar.

Conclusion

Recurrent aphthous stomatitis is a common condition in which there is the presence of painful ulceration. Painful ulceration occurs on the lips, cheeks, soft palate, and the floor of the mouth. The ulcer is noncontagious and can appear as solitary or in clusters. Each episode of recurrent aphthous stomatitis usually lasts for seven to ten days. Proper evaluation and diagnosis are required. It can be an early manifestation of systemic diseases such as gastrointestinal, celiac, and ulcerative colitis. Treatment should be done for symptomatic relief. In most cases, ulcers disappear without treatment. Multivitamin supplements help in prevention. Maintenance of good oral hygiene is advised, along with proper hydration. Stress should be avoided as it plays an important role in recurrent aphthous stomatitis.