Aphthous ulcers are erythematous, small, round, or ovoid oral ulcers with circumscribed margins, typically presenting first in childhood or adolescence, and not associated with systemic disease.
Cause
Complications
Diagnosis
Differential
Genetic predisposition — a positive family history can be found in up to 40% of people.
Smoking cessation.
Iron, folic acid, or vitamin B12 deficiency.
Hormonal factors — in some women, ulcers coincide with the luteal phase of the menstrual cycle and may remit with oral contraceptives or during pregnancy.
Local trauma to the oral mucosa (for example, caused by sharp and/or broken teeth, dentures and orthodontic appliances, and biting during chewing).
Anxiety.
Exposure to certain foods (typically chocolate, coffee, peanuts, and/or gluten products).
Secondary bacterial infection is a potential, but uncommon, complication.
Minor aphthous ulcers typically heal within 10–14 days without scarring.
Major aphthous ulcers may take several weeks to heal and often leave a scar.
Herpetiform aphthous ulcers usually heal in 10–14 days.
Many people have infrequent recurrences (once or twice a year), but some have almost continuous disease activity.
Aphthous like ulcers- present like aphthous ulcers but underlying systemic disorder e.g B12/folate/Fe deficiency, coeliac disease, crohns, UC etc
Other- herpes simplex virus, intraoral secondary herpes simplex, adverse drug reaction, chickenpox, hand foot and mouth
Oral malignancy- solitary ulcer or oral mucose swelling more than 3 weeks. Begins early as red or white patch and grows outwards. Cervical lymphadenopathy may be present. Risk factors-heavy smoker/alcohol, over 45 years old, male
Clinical Hx- duration of ulcer, FHx or personal Hx of ulcers, smoking status
Rule out systemic disorders as causes
Examine oral cavity
Uncertainty diagnosis- B12, folate and ferritin, FBC, IgA-tTG (coeliac), Virology test (HIV or EBV), ESR and CRP
Major aphthous ulcers are around 1 cm in diameter or larger, occur in groups of up to 6 at a time, and involve any oral site, including the keratinised mucosa (palate and dorsum of tongue). They heal slowly over 10 to 40 days, often with scarring, and may recur frequently.
Herpetiform aphthous ulcers (uncommon) present as multiple pinhead-sized discrete ulcers that increase in size and coalesce to leave large areas of ulceration. They are often extremely painful and can involve any oral site, including the keratinised mucosa (palate and dorsum of tongue). They heal in 10 days or longer and may recur so frequently that ulceration seems continuous.
Minor aphthous ulcers present, small round or ovoid ulcers of 2 to 4 mm in diameter, occur in groups of up to 6 at a time, and are found mainly on the non-keratinised mucosa of the lips, cheeks, floor of the mouth, sulci, or ventrum of the tongue. They heal in 7 to 10 days, and recur at intervals of 1 to 4 months, generally leaving little or no evidence of scarring.
Examine for local trauma e.g. broken teeth, dentures
Management
Treat or refer on if any underlying cause identified
Advise of trigger factors
Assess need for treatment- Pain relief, reduction of ulcer
Information leaflet
1st Line- Hydrocortisone oromucosal tablets- 1 Lozenge QDS. Beclomethasone soluble tablets 500mcgs qds to be dissolved in 20 mL water and rinsed around the mouth. Not to be swallowed.
Prescribing
Other therapies that can be used either alone or in addition include topical anaesthetics such as lidocaine, topical analgesic/anti-inflammatory agents such as benzydamine, and topical antimicrobial agents such as chlorhexidine gluconate oral solution, or doxycycline rinses.
For people with severe recurrent aphthous ulceration, a short course of systemic prednisolone can be prescribed.
Consider prescribing or advising the use of an oral vitamin B12 (cyanocobalamin) supplement, irrespective of serum vitamin B12 levels.
Referral- Consider specialist referral if ulceration is severe and does not respond to topical treatments or systemic corticosteroids.