Ulcer, Aphthous

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Basics

Description

  • Self-limited, painful ulcerations of the nonkeratinized oral mucosa, which are often recurrent
  • Synonyms: canker sores; aphthae; aphthous stomatitis
    • Comes from aphth meaning “to set on fire” or “to inflame” in Greek; first used by Hippocrates (460–370 BC) to categorize oral disease (1)
  • Classification based on severity (2)
    • Simple aphthosis
      • Common
      • Episodic
      • Infrequent (<7 episodes annually)
      • Prompt healing, few ulcers
      • Minimal pain, little disability, limited to oral cavity
      • Self-limiting
      • Resolution in 1 to 2 weeks
      • Responds well to local treatments
    • Complex aphthous ulcers
      • Uncommon
      • Episodic or continuous
      • Slow healing
      • Few to many ulcers
      • Frequent or continuous ulceration
      • Short or non-existent disease free intervals
      • Marked pain
      • Major disability
      • Often need systemic treatments
      • May have genital aphthae
  • Ulcer morphology (2,3,4)
    • Minor aphthous ulcers
      • Age of onset 5–19 years
      • Usually <10 mm in diameter
      • Self-limited, healing within 4 to 14 days
      • Rarely affects the roof of the mouth
      • Nonscarring
    • Major aphthous ulcers
      • Age of onset 10–19 years
      • Usually >10 mm in diameter
      • Can affect the roof of the mouth and pharynx
      • May take weeks to months to heal
      • Generally more painful than minor aphthous ulcers
      • May cause scarring and be accompanied by fever and malaise
    • Herpetiform ulcers (4)
      • Age of onset 20–29 years
      • Usually 1 to 2 mm in diameter, form larger lesions when coalesced
      • No association with herpes simplex virus
      • Occur in small clusters numbering 10s to 100s, lasting 1 to 4 weeks
      • Generally more painful than minor aphthous ulcers
      • Scarring unusual
      • May also affect the palate, gingiva, and pharynx
      • More common in women

Epidemiology

  • Most common ulcerative disease of the oral mucosa (4), affecting 5–25% of the population (3)
  • More common in patients between 10 and 40 years of age, women, Caucasians, nonsmokers, and those of higher socioeconomic status (3,4)
  • Less frequent with advancing age
  • Less frequent in pregnancy
  • Increase in occurrence during luteal phase of menstrual cycle (5)
  • Minor aphthous ulcers
    • Most common: 70–85% of all aphthae (3)
  • Major aphthous ulcers
    • 10–15% of all aphthae (3)
  • Herpetiform
    • Least common: 5–10% of all aphthae (3)

Incidence
5% to 50% depending on ethnic and socioeconomic groups (4)

Prevalence
Lifetime prevalence of 5–60% (4)

Etiology and Pathophysiology

Exact etiology unknown, and likely multifactorial; association with stress-induced rise in salivary cortisol, multiple human leukocyte antigens (HLAs), cell-mediated immunity (4)

Risk Factors

  • Genetic factors: children with both parents having recurrent aphthous stomatitis (RAS) have a 90% chance of developing aphthosis themselves (4) with greater severity
  • Associations with specific HLA subtypes (4)
  • DNA polymorphisms for NOD-like receptor 3, TLR 4, IL-6
  • Local trauma: sharp teeth, dental treatments, or mucosal injury secondary to toothbrushing
  • Sodium lauryl sulfate–containing toothpaste
  • Increased stress and anxiety
  • Nutritional deficiencies: iron, zinc, vitamin B complex, and folate
  • Homocysteinemia
  • Immunodeficiency
  • Recent cessation of tobacco use
  • Food sensitivity: to benzoic acid/cinnamaldehyde
  • Medications (1)
    • NSAIDs
    • β-Blockers
    • Alendronate
    • Methotrexate
    • ACE inhibitors
  • Neutropenia
  • Anemia
  • Endocrine alterations (i.e., menstrual cycle) (3)
  • Helicobacter pylori infection
  • Underlying medical disorders (e.g., celiac, irritable bowel syndrome, Behçet disease)
  • S. sanguinis (2)[A]

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Basics

Description

  • Self-limited, painful ulcerations of the nonkeratinized oral mucosa, which are often recurrent
  • Synonyms: canker sores; aphthae; aphthous stomatitis
    • Comes from aphth meaning “to set on fire” or “to inflame” in Greek; first used by Hippocrates (460–370 BC) to categorize oral disease (1)
  • Classification based on severity (2)
    • Simple aphthosis
      • Common
      • Episodic
      • Infrequent (<7 episodes annually)
      • Prompt healing, few ulcers
      • Minimal pain, little disability, limited to oral cavity
      • Self-limiting
      • Resolution in 1 to 2 weeks
      • Responds well to local treatments
    • Complex aphthous ulcers
      • Uncommon
      • Episodic or continuous
      • Slow healing
      • Few to many ulcers
      • Frequent or continuous ulceration
      • Short or non-existent disease free intervals
      • Marked pain
      • Major disability
      • Often need systemic treatments
      • May have genital aphthae
  • Ulcer morphology (2,3,4)
    • Minor aphthous ulcers
      • Age of onset 5–19 years
      • Usually <10 mm in diameter
      • Self-limited, healing within 4 to 14 days
      • Rarely affects the roof of the mouth
      • Nonscarring
    • Major aphthous ulcers
      • Age of onset 10–19 years
      • Usually >10 mm in diameter
      • Can affect the roof of the mouth and pharynx
      • May take weeks to months to heal
      • Generally more painful than minor aphthous ulcers
      • May cause scarring and be accompanied by fever and malaise
    • Herpetiform ulcers (4)
      • Age of onset 20–29 years
      • Usually 1 to 2 mm in diameter, form larger lesions when coalesced
      • No association with herpes simplex virus
      • Occur in small clusters numbering 10s to 100s, lasting 1 to 4 weeks
      • Generally more painful than minor aphthous ulcers
      • Scarring unusual
      • May also affect the palate, gingiva, and pharynx
      • More common in women

Epidemiology

  • Most common ulcerative disease of the oral mucosa (4), affecting 5–25% of the population (3)
  • More common in patients between 10 and 40 years of age, women, Caucasians, nonsmokers, and those of higher socioeconomic status (3,4)
  • Less frequent with advancing age
  • Less frequent in pregnancy
  • Increase in occurrence during luteal phase of menstrual cycle (5)
  • Minor aphthous ulcers
    • Most common: 70–85% of all aphthae (3)
  • Major aphthous ulcers
    • 10–15% of all aphthae (3)
  • Herpetiform
    • Least common: 5–10% of all aphthae (3)

Incidence
5% to 50% depending on ethnic and socioeconomic groups (4)

Prevalence
Lifetime prevalence of 5–60% (4)

Etiology and Pathophysiology

Exact etiology unknown, and likely multifactorial; association with stress-induced rise in salivary cortisol, multiple human leukocyte antigens (HLAs), cell-mediated immunity (4)

Risk Factors

  • Genetic factors: children with both parents having recurrent aphthous stomatitis (RAS) have a 90% chance of developing aphthosis themselves (4) with greater severity
  • Associations with specific HLA subtypes (4)
  • DNA polymorphisms for NOD-like receptor 3, TLR 4, IL-6
  • Local trauma: sharp teeth, dental treatments, or mucosal injury secondary to toothbrushing
  • Sodium lauryl sulfate–containing toothpaste
  • Increased stress and anxiety
  • Nutritional deficiencies: iron, zinc, vitamin B complex, and folate
  • Homocysteinemia
  • Immunodeficiency
  • Recent cessation of tobacco use
  • Food sensitivity: to benzoic acid/cinnamaldehyde
  • Medications (1)
    • NSAIDs
    • β-Blockers
    • Alendronate
    • Methotrexate
    • ACE inhibitors
  • Neutropenia
  • Anemia
  • Endocrine alterations (i.e., menstrual cycle) (3)
  • Helicobacter pylori infection
  • Underlying medical disorders (e.g., celiac, irritable bowel syndrome, Behçet disease)
  • S. sanguinis (2)[A]

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