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Tuesday, February 12, 2013

Aphthous Stomatitis

Aphthous ulcer (pron.: /ˈæfθəs/ AF-thəs), also known as a canker sore, is a type of mouth ulcer that presents as a painful open sore inside the mouth[1] or upper throat characterized by a break in the mucous membrane. Its cause is unknown, but they are not contagious.[2] The condition is also known as aphthous stomatitis (stomatitis is inflammation of the mucous lining), and alternatively as Sutton's Disease, especially in the case of major, multiple, or recurring ulcers.[3]



The term aphtha means ulcer; it has been used for many years to describe areas of ulceration on mucous membranes. Therefore, the term aphthous ulcer is redundant and the term aphthous stomatitis is preferred. Aphthous stomatitis is a condition characterized by recurrent discrete areas of ulceration that are almost always painful. Recurrent aphthous stomatitis (RAS) can be distinguished from other diseases with similar-appearing oral lesions, such as certain oral bacteria or herpes simplex, by their tendency to recur, and their multiplicity and chronicity. Recurrent aphthous stomatitis is one of the most common oral conditions. At least 10% of the population has it, and women are more often affected than men. About 30–40% of patients with recurrent aphthae report a family history.[4]

Classification

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

Minor ulceration

Minor aphthous ulcers indicate that the lesion size is between 3–10 mm (0.1–0.4 in). They are most common aphthous ulcers. The appearance of the lesion is that of an erythematous halo with yellowish or grayish color. Pain that affects quality of life is the obvious characteristic of the lesion. When the ulcer is white or grayish, the ulcer will be painful and the affected lip may swell. They may last about 2 weeks.

Major ulcerations

Major aphthous ulcers have the same appearance as minor ulcerations, but are greater than 10 mm in diameter and are 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 movable non-keratinizing oral surfaces, but the ulcer borders may extend onto keratinized surfaces. They can occur on tongue, lips, cheeks and in rare cases on the uvula.

Herpetiform 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, 1–3 mm lesions that form clusters. They typically heal in less than a month without scarring. Supportive treatment is sometimes necessary, depending on the amount of pain the patient experiences.[6]

Signs and symptoms

Aphthous ulcers can affect people of any age. Frequency of aphthous ulcers is reported to be more in females as compared to males. Most commonly aphthous ulcers are seen on the lining of cheeks, tongue, lips and roof of mouth. Aphthous ulcers usually begin with a tingling or burning sensation at the site of the future aphthous ulcer. In a few days, they often progress to form a red spot or bump, followed by an open ulcer.

The aphthous 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 gray, white, or yellow 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 painful, especially when agitated, may be accompanied by a painful swelling of the lymph nodes below the jaw; another symptom is fever. A sore on the gums may be accompanied by discomfort or pain in the teeth. Canker sores are very sensitive to spicy foods, and, if secondary infection occurs in canker sores, then antibiotics may also be required to treat it.

Causes and epidemiology

Canker sores are a very common oral lesion. Epidemiological studies show an average prevalence between 15% and 30%.[8][9] The frequency of canker sores varies from fewer than 4 episodes per year (85% of all cases) to more than one episode per month (10% of all cases) including people suffering from continuous recurrent aphthous stomatitis.[9]

The exact cause of many aphthous ulcers is unknown but citrus fruits (e.g., oranges and lemons), physical trauma, lack of sleep, sudden weight loss, food allergies, immune system reactions,[10] and deficiencies in vitamin B12, iron, and folic acid[11] may contribute to their development. Nicorandil and certain types of chemotherapy are also linked to aphthous ulcers.[12] One recent study showed a strong correlation with allergies to cow's milk.[13] Aphthous ulcers are a major manifestation of Behçet disease,[14] and are also common in people with Crohn's disease.[15]


Trauma to the mouth is the most common trigger.[16][17][18] Physical trauma, such as that caused by toothbrush abrasions, laceration with sharp or abrasive foods (such as toast or potato chips/crisps), accidental biting (particularly common with sharp canine teeth), after losing teeth, or dental braces can cause aphthous ulcers by breaking the mucous membrane. Other factors, such as chemical irritants or thermal injury, may also lead to the development of ulcers. Using a toothpaste without sodium lauryl sulfate (SLS) may reduce the frequency of aphthous ulcers.[19][20][21][22] One smaller study found no connection between SLS in toothpaste and aphthous ulcers.[23] While a more recent study (from 2012) concluded that SLS-free did not reduce the number of ulcers and episodes, but it did affect the ulcer-healing process and reduces pain in daily lives in patients with recurrent aphthous stomatitis.[24] Celiac disease has been suggested as a cause of aphthous ulcers[25][26] and some patients benefited from eliminating gluten from their diets.[25]

There is no indication that aphthous ulcers are related to menstruation, pregnancy, or menopause.[27] Smokers appear to be affected less often.[28]

Prevention

Oral measures

  • Regular use of non-alcoholic mouthwash may help prevent or reduce the frequency of sores. Informal studies suggest that mouthwash may help to temporarily relieve pain.[29] A study from 2011 found that using mouthwash containing Rosa damascena extract was more effective than the placebo in the treatment of recurrent aphthous stomatitis.[30]
  • In some cases, aphthous ulcers may be minimized by avoiding toothpastes containing sodium dodecyl sulfate (sometimes called sodium lauryl sulfate, or with the acronyms SLS or SDS), a detergent found in most toothpastes. Using toothpaste free of this compound has been found in several studies to help reduce the amount, size, and recurrence of ulcers.[31][32][33]
  • Dental braces are a common physical trauma that can lead to aphthous ulcers and the dental bracket can be covered 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.

Nutrition

Zinc deficiency has been reported in people with recurrent aphthous ulcers.[34] The few small studies looking into the role of zinc supplementation have reported mostly positive results, in particular for those people with zinc deficiency,[35] although some research has found no therapeutic effect.

Treatment

A number of treatments for apthous ulcers exist, including analgesics, anesthetics agents, antiseptics, anti-inflammatory agents, steroids, sucralfate, tetracycline suspension, Debacterol, and silver nitrate.[37]
Suggestions to reduce the pain caused by an ulcer include avoiding spicy food, rinsing with salt water or over-the-counter mouthwashes, proper oral hygiene, and non-prescription local anesthetics. Active ingredients in the latter generally include benzocaine,[38] benzydamine or choline salicylate,[39] and phenol.[40]

Anesthetic mouthwashes containing benzydamine hydrochloride have not been shown to reduce the number of new ulcers or significantly reduce pain,[41] and evidence supporting the use of other topical anesthetics is very limited, though some individuals may find them effective.[42] In general, their role is limited; the duration of their effectiveness is usually short, and does not provide pain control throughout the day. Such medications may cause complications in children.[43]

Evidence is limited for the use of antimicrobial mouthwashes but suggests that they may reduce the painfulness and duration of ulcers and increase the number of days between ulcerations, without reducing the number of new ulcers.[44]

Corticosteroid preparations containing hydrocortisone hemisuccinate or triamcinolone acetonide to control symptoms are effective in treating aphthous ulcers (Triamcinolone Acetonide was used in the product 'Adcortyl in Orabase' which was well known amongst ulcer sufferers but discontinued in the UK during 2009).[42][45][46]

The application of silver nitrate will cauterize the sore; a single treatment decreases pain but does not affect healing time[47] though in children it can cause tooth discoloration if the teeth are still developing.[48] The use of tetracycline is controversial, as is treatment with levamisole, colchicine, gamma-globulin, dapsone, estrogen replacement and monoamine oxidase inhibitors.[38]

While commonly used, magic mouthwash, a combination of a number of ingredients including viscous lidocaine, benzocaine, milk of magnesia, kaolin-pectate, chlorhexidine, or diphenhydramine, has little evidence to support its use.[49][50]

 

References

  1. ^ "aphthous ulcer" at Dorland's Medical Dictionary
  2. ^ "Mouth sores: MedlinePlus Medical Encyclopedia". Archived from the original on 29 May 2010. Retrieved 2010-05-31.
  3. ^ "Sutton's disease". Whonamedit? A dictionary of medical eponyms. Retrieved October 2011.
  4. ^ Jurge S, Kuffer R, Scully C, Porter SR (2006). "Mucosal disease series. Number VI. Recurrent aphthous stomatitis". Oral Dis 12 (1): 1–21. doi:10.1111/j.1601-0825.2005.01143.x. PMID 16390463.
  5. ^ Dorfman J, The Center for Special Dentistry.
  6. ^ Bruce AJ, Rogers RS (2003). "Acute oral ulcers". Dermatol Clin 21 (1): 1–15. doi:10.1016/S0733-8635(02)00064-5. PMID 12622264.
  7. ^ Bouquot, Brad W. Neville , Douglas D. Damm, Carl M. Allen, Jerry E. (2002). Oral & maxillofacial pathology (2. ed. ed.). Philadelphia: W.B. Saunders. pp. 253-284. ISBN 0721690033.
  8. ^ J.M. Casiglia, G.W. Mirowski, C.L. Nebesio (October 2006). "Aphthous stomatitis". Emedecine.
  9. ^ a b T. Axéll, V. Henricsson (1985). "The occurrence of recurrent aphthous ulcers in an adult Swedish population". Acta Odontol Scand.
  10. ^ Lewkowicz N, Lewkowicz P, Banasik M, Kurnatowska A, Tchorzewski H. (2005). "Predominance of Type 1 cytokines and decreased number of CD4(+)CD25(+high) T regulatory cells in peripheral blood of patients with recurrent aphthous ulcerations". Immunol Lett. 99 (1): 57–62. doi:10.1016/j.imlet.2005.01.002. PMID 15894112.
  11. ^ Wray D, Ferguson M, Hutcheon W, Dagg J (1978). "Nutritional deficiencies in recurrent aphthae". J Oral Pathol 7 (6): 418–23. doi:10.1111/j.1600-0714.1978.tb01612.x. PMID 105102.
  12. ^ "Non Hodgkin's Lymphoma Cyberfamily — Side effects". NHL Cyberfamily. Archived from the original on 7 August 2006. Retrieved August 10, 2006.
  13. ^ Besu I, Jankovic L, Magdu IU, Konic-Ristic A, Raskovic S, Juranic Z. (2009). "Humoral immunity to cow's milk proteins and gliadin within the etiology of recurrent aphthous ulcers?". Oral Diseases 15 (8): 560–564. doi:10.1111/j.1601-0825.2009.01595.x. PMID 19563417.
  14. ^ Internationalstudygroupforbehc (May 1990). "Criteria for diagnosis of Behçet's disease. International Study Group for Behçet's Disease". Lancet 335 (8697): 1078–80. doi:10.1016/0140-6736(90)92643-V. PMID 1970380.
  15. ^ Current Medical Diagnosis & Treatment 2007, Forty-Sixth Ed (2007), Edited by McPhee, SJ. MD, Papadakis, MA. MD and Tierney, LM, Jr., MD with Associate Authors – The McGraw-Hill Companies, Inc, New York, USA
  16. ^ http://www.patient.co.uk/showdoc/40024908/
  17. ^ http://www.health-disease.org/skin-disorders/aphthous-ulcer.htm
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  19. ^ The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study. (1997)
  20. ^ Herlofson B, Barkvoll P (1994). "Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study" (PDF). Acta Odontol Scand 52 (5): 257–9. doi:10.3109/00016359409029036. PMID 7825393.
  21. ^ Herlofson B, Barkvoll P (1996). "The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers". Acta Odontol Scand 54 (3): 150–3. doi:10.3109/00016359609003515. PMID 8811135.
  22. ^ Chahine L, Sempson N, Wagoner C (1997). "The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study". Compend Contin Educ Dent 18 (12): 1238–40. PMID 9656847.
  23. ^ Healy C, Paterson M, Joyston-Bechal S, Williams D, Thornhill M (1999). "The effect of a sodium lauryl sulfate-free dentifrice on patients with recurrent oral ulceration". Oral Dis 5 (1): 39–43. doi:10.1111/j.1601-0825.1999.tb00062.x. PMID 10218040.
  24. ^ Shim, Y. J.; Choi, J. -H.; Ahn, H. -J.; Kwon, J. -S. (2012). "Effect of sodium lauryl sulfate on recurrent aphthous stomatitis: A randomized controlled clinical trial". Oral Diseases: no. doi:10.1111/j.1601-0825.2012.01920.x. PMID 22435470. edit
  25. ^ a b Bucci P, Carile F, Sangianantoni A, D'Angio F, Santarelli A, Lo Muzio L. (2006). "Oral aphthous ulcers and dental enamel defects in children with celiac disease". Acta Paediatrica 95 (2): 203–7. doi:10.1080/08035250500355022. PMID 16449028.
  26. ^ Sedghizadeh PP, Shuler CF, Allen CM, Beck FM, Kalmar JR. (2002). "Celiac disease and recurrent aphthous stomatitis: a report and review of the literature". Oral Surgery Oral Medicine Oral Pathology Oral Radiology & Endodontics 94 (4): 474–8. doi:10.1067/moe.2002.127581. PMID 12374923.
  27. ^ McCartan BE, Sullivan A (September 1992). "The association of menstrual cycle, pregnancy, and menopause with recurrent oral aphthous stomatitis: a review and critique.". Obstetrics and gynecology 80 (3 Pt 1): 455–8. PMID 1495706.
  28. ^ Tüzün B, Wolf R, Tüzün Y, Serdaroğlu S (May 2000). "Recurrent aphthous stomatitis and smoking.". International Journal of Dermatology 39 (5): 358–60. doi:10.1046/j.1365-4362.2000.00963.x. PMID 10849126.
  29. ^ Studies mostly agree that antiseptic mouthwashes can help prevent recurrences:
    * Meiller TF, Kutcher MJ, Overholser CD, Niehaus C, DePaola LG, Siegel MA (1991). "Effect of an antimicrobial mouthrinse on recurrent aphthous ulcerations". Oral Surg. Oral Med. Oral Pathol. 72 (4): 425–9. doi:10.1016/0030-4220(91)90553-O. PMID 1923440.
    * Skaare AB, Herlofson BB, Barkvoll P (1996). "Mouthrinses containing triclosan reduce the incidence of recurrent aphthous ulcers (RAU)". J. Clin. Periodontol. 23 (8): 778–81. doi:10.1111/j.1600-051X.1996.tb00609.x. PMID 8877665.
    But this is not accepted by all reports:
    * Barrons RW (2001). "Treatment strategies for recurrent oral aphthous ulcers". Am J Health Syst Pharm 58 (1): 41–50; quiz 51–3. PMID 11194135.
  30. ^ Evaluation of Rosa damascena mouthwash in the treatment of recurrent aphthous stomatitis: a randomized, double-blinded, placebo-controlled clinical trial.
  31. ^ Herlofson BB, Barkvoll P (1996). "The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers". Acta Odontol Scand 54 (3): 150–3. doi:10.3109/00016359609003515. PMID 8811135.
  32. ^ Chahine L, Sempson N, Wagoner C (1997). "The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study". Compend Contin Educ Dent 18 (12): 1238–40. PMID 9656847.
  33. ^ Healy CM, Paterson M, Joyston-Bechal S, Williams DM, Thornhill MH (1999). "The effect of a sodium lauryl sulfate-free dentifrice on patients with recurrent oral ulceration". Oral Dis 5 (1): 39–43. doi:10.1111/j.1601-0825.1999.tb00062.x. PMID 10218040.
  34. ^ Wang SW, Li HK, He JS, Yin TA (1986). "[The trace element zinc and aphthosis. The determination of plasma zinc and the treatment of aphthosis with zinc] [The trace element zinc and aphthosis. The determination of plasma zinc and the treatment of aphthosis with zinc]" (in French). Rev Stomatol Chir Maxillofac 87 (5): 339–43. PMID 3467416.
  35. ^ Orbak R, Cicek Y, Tezel A, Dogru Y (2003). "Effects of zinc treatment in patients with recurrent aphthous stomatitis". Dent Mater J 22 (1): 21–9. PMID 12790293.
  36. ^ Wray D (1982). "A double-blind trial of systemic zinc sulfate in recurrent aphthous stomatitis". Oral Surg. Oral Med. Oral Pathol. 53 (5): 469–72. doi:10.1016/0030-4220(82)90459-5. PMID 7048184.
  37. ^ Altenburg A, Zouboulis CC (September 2008). "Current concepts in the treatment of recurrent aphthous stomatitis". Skin Therapy Lett. 13 (7): 1–4. PMID 18839042.
  38. ^ a b ped/2672 at eMedicine
  39. ^ "Aphthous Mouth Ulcers". Patient UK. February 2007. Retrieved May 9, 2008.
  40. ^ "Phenol (Oromucosal route)". A.D.A.M. Retrieved 2011-08-16.
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  42. ^ a b "Aphthous ulcer – Management". Clinical Knowledge Summaries (Prodigy). National Library for Health. Archived from the original on 3 June 2008. Retrieved May 9, 2008.
  43. ^ "12.3.1 Drugs for oral ulceration and inflammation". British National Formulary for Children. British Medical Association, the Royal Pharmaceutical Society of Great Britain, Royal College of Paediatrics and Child Health, and the Neonatal and Paediatric Pharmacists Group. 2006. pp. 601–4.
  44. ^ "Aphthous ulcer – Evidence: Evidence on antimicrobial mouthwash". Clinical Knowledge Summaries (Prodigy). National Library for Health. Archived from the original on 3 June 2008. Retrieved May 10, 2008.
  45. ^ Scully C (July 2006). "Clinical practice. Aphthous ulceration". N. Engl. J. Med. 355 (2): 165–72. doi:10.1056/NEJMcp054630. PMID 16837680.
    Commented in: "Clinical review – aphthous ulceration". Medicines Information Web Site (Trent and West Midlands regional Medicines Information services). July 13, 2006. Archived from the original on 4 June 2008. Retrieved May 9, 2008.
  46. ^ Scully C, Shotts R (July 2000). "Mouth ulcers and other causes of orofacial soreness and pain". BMJ 321 (7254): 162–5. doi:10.1136/bmj.321.7254.162. PMC 1118165. PMID 10894697.
  47. ^ Alidaee MR, Taheri A, Mansoori P, Ghodsi SZ (September 2005). "Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial". Br. J. Dermatol. 153 (3): 521–5. doi:10.1111/j.1365-2133.2005.06490.x. PMID 16120136.
  48. ^ Rauch, D. "Canker sores: Treatment". MedlinePlus. Archived from the original on 9 May 2008. Retrieved May 8, 2008.
  49. ^ "data.memberclicks.com".
  50. ^ "Global Family Doctor - Wonca Online | Item search".


 

 






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