Aphthous stomatitis is a condition characterized by painful ulcers in the oral cavity that recur at intervals ranging from a few days to several years. The ICD-10 code for this condition is K12.0.
It is the most common type of lesion affecting the oral mucosa, occurring in 15-30% of the population.Women are affected more frequently than men. Although the disease can begin at any age, it typically manifests in the second and third decades of life. Familial cases are common, with approximately 30-40% of patients having another family member affected.
Although the condition has been known since the time of Hippocrates, its etiology remains unclear. Several predisposing factors are thought to contribute to its development, including heredity, trauma, food hypersensitivity, stress, infections (such as Streptococcus sanguis and S. mitis, herpes simplex virus type 1, varicella-zoster virus, cytomegalovirus), systemic diseases (such as Behçet's disease), gastrointestinal disorders, nutritional deficiencies, Sweet's syndrome, HIV infection, endocrine disorders, immunologic disorders, and others. Although these predisposing factors may play a role in the development of recurrent aphthous stomatitis (RAS), the disease is considered idiopathic and its etiology is unknown.
Current evidence supports the concept of an immunological nature of the pathological processes and a disturbance in cellular immune response. Furthermore, several studies have shown a negative association between aphthous stomatitis and smoking.The main clinical characteristics of aphthous stomatitis are recurrent painful ulcers in the oral cavity with intervals of several days, weeks, or even months. The prodromal stage is usually characterized by discomfort and sometimes erythema for 1-3 days. Following this stage, a painful ulcer rapidly develops in the oral cavity. The lesions are typically localized to non-keratinized or poorly keratinized oral mucosa, such as the cheeks, lips, tongue, floor of the mouth, soft palate, and ventral surface of the tongue. Occasionally, adjacent areas of the gums and hard palate can also be affected.
The onset of lesions usually occurs in childhood or adolescence and is slightly more common in females. It should be noted that the condition may be associated with any of the following systemic diseases:- Behçet's disease
- Sweet's syndrome
- PFAPA syndrome (Fever, Adenitis, Pharyngitis, Aphthous stomatitis) - a syndrome characterized by periodic fever, adenitis, pharyngitis, and aphthous stomatitis
- Crohn's disease
- Ulcerative colitis
- Celiac disease
- HIV infection
- Malabsorption syndrome
- Iron deficiency
- Neutropenia
- Minor recurrent aphthae: This is the most common form of the condition. Clinically, it presents as small, painful, oval-shaped ulcers 2-6 mm in diameter. The ulcer is covered by a yellow-white necrotic membrane and surrounded by an erythematous border. These ulcers can be solitary or multiple (2-6). They persist for 6-10 days, heal without scarring, and usually recur at intervals of 1-5 months.
- Major recurrent aphthae: They are less common and represent a more severe form of the disease. The ulcers are deep, painful, 1-2 cm in diameter, and the number of ulcers ranges from 1 to 3. They may last for about 3-4 weeks, occasionally leave scars when healed, and often recur at intervals of 1-3 months.
- Herpetiform ulcers: This is the rarest form of the disease. The lesions consist of multiple (10-100 or more) small ulcers 1-3 mm in diameter and tend to cluster together. These ulcers persist for 1-2 weeks, often recur over a period of 1 to 3 years or more, and are more typical in women. Compared to other forms of the disease, this form tends to occur at a later age.
- Erosive lichen planus
- Syphilis
- Hand-foot-and-mouth disease
- Pemphigus vulgaris
- Dermatitis herpetiformis
- Chronic ulcerative stomatitis
- Herpes simplex virus
- HIV infection
- Chemical burn
- Squamous cell carcinoma
- Behcet disease
General therapeutic recommendations:
- It is important to rule out aphthous-like ulcers associated with systemic diseases during treatment.
- The majority of patients are healthy individuals.
- Successful therapy requires an accurate diagnosis and control over provoking etiological factors.
- The treatment of the condition should aim to achieve the following goals: pain and discomfort relief, reduction in the duration of the disease, and prevention of recurrences.
Recommended treatment methods:
- Control over potential provoking etiological factors: Patients should be encouraged to keep a food diary to identify potential triggers associated with the appearance of aphthous changes. Patients should avoid minor trauma to the oral mucosa. Stress factors and hormonal changes in women should also be taken into account.
Local treatment can help reduce pain and shorten the duration of the disease, but they do not prevent recurrences.
Local anesthetics such as 2% viscous lidocaine, benzocaine, and benzidamine hydrochloride may provide temporary pain relief. More recently, 5% amlexanox as an oral paste and 3% diclofenac in a 2.5% hyaluronan-based gel have been used to reduce pain.
Topical tetracyclines have been used with partial success. One 250 mg capsule is dissolved in 30 ml of water, and then 5 ml of the solution is used to rinse the mouth 4-6 times a day. The treatment is repeated for 3-5 days. Other anti-inflammatory and antimicrobial agents, such as chlorhexidine and listerine, have been used with unsatisfactory results.
The most effective topical preparations are 1% triamcinolone acetonide adhesive paste (Orabase) or 0.05% clobetasol propionate gel (Temovate) applied to the ulcer 6 times daily for 4-6 days. Intralesional injections of triamcinolone acetonide or betamethasone dipropionate with potassium phosphate may be successful, especially for large aphthous ulcers.
Systemic measures:
Systemic corticosteroids (prednisone, betamethasone) in moderate doses of 20-30 mg or 2-3 mg, respectively, for 4-8 days are effective for large ulcers or herpetiform ulcers. In recurrent episodes or when new ulcers appear before the healing of old ones, systemic medications can help prevent new lesions.
Some studies shows that 20 mg of prednisone or 2 mg of betamethasone dipropionate for 10-15 days, followed by injections of betamethasone propionate and potassium phosphate for 2 months, can significantly increase the intervals between recurrences. Long-term use of systemic corticosteroids is contraindicated due to side effects.
In severe cases with high recurrence rates and in patients with HIV infection, thalidomide at a dose of 100-300 mg/day for 2-3 months can lead to complete remission of ulcers for a prolonged period. However, the teratogenicity and polyneuropathy of thalidomide preclude routine use.
Alternative and experimental treatment methods:
Various other systemic medications have been used in severe cases with conflicting results. These include:
- Dapsone: 25-50 mg/day for several weeks.
- Levamisole hydrochloride.
- Azathioprine.
- Colchicine.
- Interferon.
- Cyclosporine.
- Pentoxifylline.
- Acyclovir.
- Etretinate.