Apthous ulcer

The term aphtha means ulcer. It has been used for many years to describe areas of ulceration on mucous membranes. Aphthous stomatitis is a condition which is characterized by recurrent discrete areas of ulceration which are almost always painful. An Apthous 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 called aphthous stomatitis especially if there are multiple or recurring mouth ulcers. Recurrent aphthous stomatitis (RAS) can be distinguished from other diseases with similar appearing oral lesions, such as certain viral exanthems, by their tendency to recur, their multiplicity, and chronicity. Recurrent aphthous stomatitis is one of the most common of all oral conditions. At least 10% of the population suffers from it. Women are more often affected than men. About 30 - 40 % of patients with recurrent aphthae report a family history.

Presentations of apthous stomatitis

Apthous ulcers are classified according to the diameter of the lesion.

Recurrent Aphthous Stomatitis

Recurrent Aphthous Stomatitis, often referred to as canker sores, is a T-cell mediated localized destruction of oral mucosa associated with an increased relative ratio of CD8+ T-cells to CD4+ T-cells.

Minor Aphthous Ulcerations

This is the most common and least severe form of the disease. Ulcers develop in childhood and adolescence and continue sporadically throughout life. Ulcers occur exclusively on non-keratinized, moveable mucosa, such as buccal and lingual mucosa (cheeks), the floor of the mouth, and the soft palate. It is characterized as a yellow-gray ulcer surrounded by an erythematous halo less than 1cm in diameter. The tend to heal without scarring in 7-10 days. Typical treatment is with topical steroids, although treatment is not necessary for healing to occur.

Major Aphthous Ulcerations

Major aphthous ulcers have the same appearance as minor ulcerations but are greater than 10 mm in diameter and are extremely painful. They usually take more than a month to heal and frequently leave a scar. These typically develop after puberty with frequent recurrences. They occur on moveable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces. The lesions heal with scarring and cause severe pain and discomfort.

Herpetiform Aphthous Ulcerations

This is the most severe form. It occurs more frequently in females and onset is often in adulthood. It is characterized by small, numerous 1-3mm lesions, and form clusters. They typically heal in less than a month without scarring. Palliative treatment is almost always necessary.^*

Symptoms

Apthous ulcers often begin with a tingling or burning sensation at the site of the future mouth ulcer. In a few days, they often progress to form a red spot or bump, followed by an open ulcer.

The apthous ulcer appears as a white or yellow oval with an inflamed red border. Sometimes a white circle or halo around the lesion can be observed. The grey, white, or yellow coloured area within the red boundary is due to the formation of layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is often extremely painful, especially when agitated, may be accompanied by a painful swelling of the lymph nodes below the jaw, which can be mistaken for toothache.

Causes

The exact cause of apthous ulcers is unknown, but in some cases they are thought to be caused by an overreaction by the body's own immune system. Factors that appear to provoke them include stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies and deficiencies in vitamin B12, iron and folic acid. Some drugs, such as nicorandil, have been linked with mouth ulcers.

Apthous ulcers are thought to form when the body becomes aware of and attacks chemicals which it does not recognize. The presence of the unrecognized molecules garners a reaction by the lymphocytes, which trigger a reaction that causes the damage of a mouth ulcer.

Trauma to the mouth is a common cause of apthous ulcers. Physical trauma, such as toothbrush abrasion, poking with sharp food, accidental biting (this can be particularly common with sharp canine teeth), or dental braces can cause mouth ulcers by breaking the mucous membrane. Other factors, such as chemical irritants or thermal injury, may also lead to the development of ulcers. However in many cases, the precise cause is unknown.

A common cause of apthous ulcers is gluten intolerance, in which case consumption of wheat, rye, or barley can result in chronic mouth ulcers. If gluten intolerance is the cause, prevention means taking most breads, pastas, cakes, pies, cookies, scones, biscuits, beers etc. out of the diet and substituting gluten-free varieties where available. Artificial sugars, such as those found in diet cola and sugarless gum, have been reported as causes of apthous ulcers as well. They can also be linked to an increased intake of acids such as ascorbic acid (one form of Vitamin C) or citric acid. In this case the sores disappear after intake decreases (for example, by substituting ascorbate salts for ascorbic acid).

Another possible cause of apthous ulcers may be opportunistic activity by combinations of otherwise normal bacterial fauna, such as aerobic streptococci, Neisseria, Actinomyces, spirochetes, and bacteroides ^*. According to small-scale experiments by at least one patent applicant (Hau, US Patent No. 6,248,718), topical preparations of high doses of penicillin resulted in accelerated healing of mouth ulcers.

Repeat episodes of apthous ulcers can be indicative of an immunodeficiency, signalling low levels of immunoglobulin in the mucous membrane of the mouth. Chemotherapy is a common cause of mouth ulcers. Mouth ulcers may also be symptoms or complications of several diseases listed in the following section. The treatment depends on the believed cause.

A common urban myth is that apthous ulcers are directly connected to the onset of the herpes simplex virus, but in reality ulcers associated with herpes (or cold sores) are of an entirely different nature from mouth ulcers, which are not contagious.

Home treatment

Apthous ulcers normally heal without treatment within 1–2 weeks. Good oral hygiene should be maintained, and spicy/acidic/salty foods and drinks are best avoided as they may irritate existing ulcers.

The pain can be treated with several pain-relieving gels like Anbesol, Bonjela, Campho-Phenique, Orabase B, Zilactin or Kanka, available in drugstores. Some people claim that such gels also accelerate the healing of their ulcers.

Another purported remedy is the use of Dexaltin Oral Paste (Dexamethasone 1–mg/g).

Triamcinolone Acetonide dental paste can be very effective; the steroid reduces the immune system's response in the area of the ulcer. It is available by prescription only.

Use of a hydrogen peroxide antiseptic mouthwash can help to clean debris and bacteria that can accumulate in an ulcer, thus reducing complications associated with its presence. This treatment is widely available at pharmacies from companies such as Colgate, whose product is called Peroxyl. Diluting 3% food grade hydrogen peroxide (commonly available in drug stores) with equal parts water can be as effective and less expensive

A recentstudy ^* of the Oral-B product Amosan suggests that it may reduce anaerobic bacteria, such as those found in oral wounds. The study did not, however, demonstrate the efficacy of the product in treating mouth ulcers.

Other home remedies vary in efficacy. Certain techniques heal mouth ulcers for some people, but there are no treatments with widespread medical support. Most seem to be based on an antiseptic, an antacid, or both. Purported home remedies include the following:

Gently clean the mouth ulcers by roughening with a toothbrush; when clean, apply antiseptic.
Swab the mouth ulcers with sea-buckthorn fruit oil or hydrogen peroxide.
Rinse the mouth with an antiseptic mouthwash (e.g. Listerine), which can relieve pain for a few hours.
Apply glyoxide directly to the ulcers and swish around mouth.
Rinse the mouth with salt water—1 teaspoon of salt dissolved in 1 cup (250 ml) of warm water (a.k.a. a saline solution).
Take Lysine-L supplements.
Rinse mouth and especially the affected area with sage tea 3 times a day. The improvement can be seen as early as within 24 hours.
Paint half-strength gentian violet solution on the ulcer.^*
Gargle a mouthful of warm vinegar with a half-tablespoon of salt for about 30 seconds, 3 times per day; this may be extremely painful, but healing can be seen in as early as 2 days.
Apply oil of cloves using a cotton swab or Q-tip. This is initially very painful, but will result in a period of time where the affected area is quite numb, allowing painless chewing or talking.
Some have applied anise directly on the ulcer.
Hold an asprin tablet against the ulcer until the asprin begins to dissolve away.
Hold moderately concentrated alcohol in the mouth over the area of the ulcer, presumably because of alcohol's diuretic effect (and, likewise, the more concentrated, the more diuretic), although there is no direct evidence to support this.

Antacid techniques suggested include the following:

Swab the ulcers with Milk of Magnesia.
Apply powdered alum directly to the ulcers—available in the spice aisle at grocery stores; this can be very painful, but is proven to work.
Make a paste of baking soda and water; apply directly to the ulcers. ^*
Make a paste of crushed Tums (antacid) and water—apply directly to the ulcers.
Rinse the mouth with a baking soda-water mix—1 teaspoon of baking soda dissolved in 1 cup (250 ml) of warm water.
Avoid acidic foods such as tomato, citrus, soft drinks, and vinaigrette salad dressings.
Make a mix of half Mylanta and half Benadryl and hold in the mouth for up to three minutes.

Combination therapies recommend the use of the antiseptic before the antacid, that is, swab mouth ulcers with hydrogen peroxide and then swab them with Milk of Magnesia.

A good temporary remedy for the pain of the mouth ulcer is to numb the affected area with ice. Although this may cause intense pain in the beginning, it is highly effective and lasts for about half an hour, depending on the number of ice cubes used and the time spent using the ice cubes.

Treatment for severe cases

Treatments based on antibiotics and steroids such as Dexamethasone Elixir are reserved for severe cases, and should be used only under medical supervision. Tetracycline suspension is a common antibiotic prescribed for mouth ulcers. Some doctors may also prescribe a local anesthetic, such as lidocaine, for cases of multiple or severe apthous ulcers. If it does not heal within a week, a doctor or dentist may cauterize it using a silver nitrate applicator or laser. This procedure immediately burns off the ulcer, causing it to completely disappear within a few hours or two to three days.

In very severe cases, a doctor may prescribe a steroid treatment. One such steroid is methylprednisolone (usually in a dose-pack), taken orally for a period of 7 days. Alternatively, the doctor may directly inject a steroid into the site of the ulcer (this treatment is performed with kenalog. Between 0.2 and 0.4 cc of kenalog is injected into the site of the ulcer, which will usually be completely healed 72 to 96 hours after the injection).

Some dentists recommend a sulfuric acid solution for treating mouth ulcers, such as debacterol.

Another choice doctors have is to prescribe Aphthasol (amlexanox oral paste, 5%), the only Food and Drug Administration (FDA) approved treatment specifically indicated for Aphthous ulcers.

The miracle cures that are advertised should be viewed with skepticism. However, aqueous sulphuric acid products as listed above can provide significant pain relief, if not treating the underlying causes.

Prevention

In some cases, switching toothpastes can prevent mouth ulcers from occurring, with some being able to reduce the occurrence of ulcers by approximately 80%. Sodium dodecyl sulfate (sometimes called sodium lauryl sulfate or simply SLS), a detergent found in most toothpastes, is thought to increase the incidence of mouth ulcers. Using toothpaste free of this compound has been found to help many people by reducing the amount and size of ulcers and in some cases, completely stopping them. A few individuals have noticed that switching to a toothpaste with baking soda prevented re-occurrence of mouth ulcers.

Many people have found that taking Lysine-L supplements can help to reduce the frequency of mouth ulcer appearances. Additionally, zinc deficiency has been observed in people with recurrent mouth ulcers, and zinc supplementation decreased recurrence of the mouth ulcers ^*.

Some people have reported that the frequency of mouth ulcer occurrences decreased greatly after a particularly large amalgam tooth filling was replaced by some other kind of dental restoration. However, the connection between amalgam fillings and mouth ulcers is not universally accepted, and such replacement can be costly.

Dental braces are a common physical trauma that can lead to mouth ulcers and can be treated with wax to reduce abrasion of the mucosa. Avoidance of other types of physical and chemical trauma will prevent some ulcers, but since such trauma is usually accidental, this type of prevention is not usually practical.

Alternative medicine

Chinese medicine points to one's diet or emotions as potential causes of such symptoms of 'heat in the mouth'. Greasy/fried foods or 'energetically hot' food (for example: spicy food, alcohol, potato chips) may also trigger mouth ulcers. Emotions such as anger, frustration, resentment, or stress can also impede the proper flow of one's energy and create 'heat' in the body, with such manifestations as mouth ulcers, red eyes, sore throats, insomnia or constipation. In order to neutralize this 'hot energy' certain, 'energetically cool' foods such as herbal teas and certain fruits and vegetables must be consumed. Some other examples of such 'cooling' foods include coconut juice (surprisingly the kernel is opposite and is classified 'hot'), green bean soup, and ginseng tea.

External links

Oral pathology | Otolaryngology

References

http://dentistry.ouhsc.edu/intranet-Web/ContEd/OPCE/aaHomeOPCE.html

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