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APHTHOUS ULCERATION

• Jennifer E. Guss, MD
• Baylor College of Medicine
• Med-Peds

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APHTHOUS ULCERATION-THE FACTS

• AKA Recurrent aphthous stomatitis, aphthae,
  canker sores
• Definitionrecurrent, painful ulcers of the
  mouth, round or ovoid in shape, with inflammatory
  halos
• Benign and localized condition that must be
  differentiated from oral ulcers occurring as part
  of systemic illnesses

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APHTHOUS ULCERATIONDDX

• Behcets Syndrome
• Gluten Sensitive Enteropathy
• Inflammatory Bowel Disease
• HIV
• Cyclic Neutropenia
• Trauma

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APHTHOUS ULCERSMAKING THE DIAGNOSIS

• How does the clinician differentiate between
  simple aphthous ulcers and other more serious
  conditions?
• Medical History
• Physical Exam
• Labs only if the diagnosis is NOT consistent with
  Aphthous Ulcers in isolation

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EVALUATING THE PATIENT

• H P- most important to differentiate between
  Aphthous Ulceration and oral ulcers as part of a
  chronic and systemic disease. Ruling out a
  secondary cause is esp important if presentation
  is atypical, e.g. first outbreak in teen years.
• Typical Historyrecurrent uclers, typical in
  appearance and shape(ovoid/round) in mouth since
  childhood. Possible fhx of aphthous ulcers.

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EVALUATING THE PATIENT

• PEtypical-round and ovoid ulcers on buccal and
  labial mucosa, non-keratinized surfaces
• Otherwise HEALTHY patient
• Ulcers recur intermittently at varying intervals
  depending on the individual

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APHTHOUS ULCERSCHARACTERISTICS

• Three forms of Ulcers
• 1.Minor
• 2.Major
• 3.Herpetiform

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APHTHOUS ULCERSCHARACTERISTICS

• 80 of ulcers Minor, i.e. 2-8 mm diameter
• Affect nonkeratinized mucosa, usu labial and
  buccal mucosa, floor of mouth, ventral surface of
  tongue
• Rarely occur on hard palate or gingiva
• Heal spontaneously in 10-14 days

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APHTHOUS ULCERSCHARACTERISTICS

• Less common Major, gt/ 1cm diameter, same
  locations as Minor
• Third form, even less common herpetiform
  ulceration-ulcers which are initially multiple
  and pinpoint, may coalesce into single larger
  ulcers
• Major and Herpetiform-pts seek medical care more
  frequently than for minor b/c more painful, last
  several weeks, can affect dorsum of tongue, hard
  palate, buccal and lip mucosa

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APHTHOUS ULCERSDEMOGRAPHICS

• Female
• Under 40 yo
• Caucasions
• Nonsmokers
• High socioeconomic status
• Affects up to 25 general population at some time

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ETIOLOGY

• Unproven but some suggestions
• Hereditary predisposition
• Environmental
• Vitamin and mineral deficiencies associated-iron,
  vitamin B, folate, supplements do not help
• Infectious etiologies unproven
• Are factors that increase risk of outbreaks in
  predisposed people oral trauma, d/c smoking,
  emotional stress/anxiety, food sensitivities(food
  preservatives), hormonal changes related to
  menstrual cycle.

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EVALUATING THE PATIENTCLINICAL SCENARIOS

• 1.Oral Ulcers and persistant diarrhea
• Crohns Dz or UC
• 2.Weight loss, anemia, oral ulcers, and abdominal
  pain after eating wheat-rich meals
• Gluten sensitive enteropathy
• 3.Oral ulcers, genital ulcers, erythema nodosum,
• h/o uveitis
• Behcets Syndrome

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EVALUATING THE PATIENT

• 4.An otherwise healthy 20 yo woman has had
  recurrent painful oral ulcers for the past 10
  years. She denies genital or anal ulcers, skin
  lesions, GI or joint problems. PE shows several
  ulcers, 3mm in diameter, all on her buccal
  mucosa.
• Aphthous Ulcers or Cancker Sores

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EVALUATING THE PATIENTMEDICATIONS CAUSING
APHTHOUS ULCERS

• NSAIDS
• Beta-blockers
• Fosamax
• Patients may also have a drug rash
• Ulcers should resolve with withdrawal of
  medication

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WHEN TO REFER

• Any clinical situation that seems to be a chronic
  and systemic illness
• Any ulcer persisting for more than 3 weeks needs
  to be referred for evaluation for cancer, or for
  other infectious etiology(usu CMV, HSV).

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APHTHOUS ULCERTREATMENT

• Multiple treatments available
• Base choice on severity of pain, frequency of
  ulceration, potential of adverse effects of
  medications
• Minor Ulcerations-less painful, goal should be
  prevention.
• Avoid oral trauma-limit use of hard toothbrushes,
  avoid acidic foods and drinks which worsen pain
  and may precipitate ulcers.
• OK to use topical analgesics though efficacy
  unproven e.g.lidocaine or bioadhesives
  e.g.carmellose.
• Antimicrobial mouthwashes may be
  beneficial-Chlorhexidine containing(e.g.Peridex),
  or Triclosan containing(e.g.Plax)

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APHTHOUS ULCERMAJOR OR PAINFUL ULCERS-TREATMENT

• Topical corticosteroids may speed healing and
  reduce pain. BE CERTAIN the patient does not have
  oral candidiasis prior to using!!
• FDA approved
• 1 triamcinalone dental paste called Adcortyl or
  Kenalog in Orabase
• Other stronger preps are not approved and may be
  harmful

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APHTHOUS ULCERMAJOR OR PAINFUL ULCERS-TREATMENT

• Topical antiinflammatories also FDA approved
• 5 amlexanox paste(Aphthasol, Aphtheal)
• Double blind controlled trial applied BID x3d
  showed signif reduction in ulcer size on day 5
  when compared to placebo
• RCT applied QID during prodromal phase vs once
  ulcer was evident. Use during prodromal phase
  decreased the liklihood of having an ulcer on d
  3. Early tx also redued size, pain, and duration
  of ulcers as compared with late or no treatment
  tx.

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APHTHOUS ULCERSTREATMENT OF RECURRENT AND SEVERE
STOMATITIS

• Option 1systemic corticosteroids Prednisone
  30-60mg po daily for one week, then tapered over
  a second week. No data demonstrating better
  efficacy than topical steroids.
• Option 2Thalidomidevery toxic! Neurotoxicity
  and teratogen, so use as last effort. Not FDA
  approved for this indication.
• Thalidomide 100mg po daily for 2 months. 45 of
  patients taking had fewer ulcers or none but only
  while taking tx, as compared with 3 given
  placebo.

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APHTHOUS ULCERSTREATMENT RECS FROM U.S. NATIONAL
GUIDELINE CLEARINGHOUSE

• Take a thorough history should be consistant
  with recurrent aphthous ulcers since childhood in
  an otherwise healthy patient
• Do a good PE. Ulcers should be round or ovoid,
  have a red halo, be on oral mucosa only, esp
  non-keratinized surfaces such as buccal and
  labial
• Recavoid irriantsoral trauma, acidic food/drink

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APHTHOUS ULCERSTREATMENT RECS FROM U.S. NATIONAL
GUIDELINE CLEARINGHOUSE

• TXfirst linetopical lidocane or protective
  bioadhesives
• TXsecond lineRCT support use of topical
  corticosteroids in a paste or 5 amlexanox paste
  for 2 weeks or until ulcers heal
• All patients may benefit from mouth rinse like
  chlorhexidine gluconate which may speed healing
  and reduce pain
• Repeat treatments PRN as ulcers recur

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BIBLIOGRAPHY

• NEJM 355/2 7/13/2006 Aphthous Ulceration,
  Crispian Scully, MD
• NEJM341/17 10/21/1999 Behcets Disease, Sakane,
  Takeno, Suxuki, et al.