Aphthous Ulcers Flashcards
Minor AU
typically small round / ovoid ulcers 2–4 mm diameter, groups of up to 6 at a time, mainly on non-keratinized mucosa of lips, cheeks, floor of mouth, sulci, or ventrum of tongue. They heal in 7–10 days, and recur at intervals of 1–4 months, usually leaving little or no evidence of scarring.
They represent 80% of all aphthous ulcers.
Major AU
1 + cm diameter, occur in groups of up to 6 at a time, any oral site, including keratinized mucosa (palate and dorsum of tongue). Often more painful and persistent, healing slowly over 10–40 days. often scar and recur frequently.
10–15% of all aphthous ulcers.
Herpetiform AU
(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 keratinized mucosa (palate and dorsum of tongue). They heal in 10 days or longer and may recur so frequently that ulceration seems continuous.
When need urgent referral for biopsy
solitary ulcer that has persisted for 3 weeks or longer
(may represent an oral malignancy and warrants urgent referral for biopsy)
Family or personal history of oral ulceration
Over 40% of people with aphthous ulcers have first-degree relatives with the condition.
The onset of aphthous ulcer is usually during childhood and in 80% of cases, is before 30 years of age.
Smoking status
Aphthous ulceration is more common in non-smokers.
If the diagnosis is uncertain, consider arranging:
FBC (rule out anaemia).
Ferritin, folate, vitamin B12 (rule out deficiencies).
An immunoglobulin A-tissue transglutaminase (IgA-tTG) test (?coeliac disease).
Viral serology (rule out HIV or EBV).
ESR and CRP to rule out systemic inflammatory disease such as Behcet’s syndrome
Systemic conditions that present with aphthous-like ulcers include:
- vit B12 deficiency
- folate deficiency
- iron deficiency
- Crohn’s disease
- UC
- Coeliac disease
- Bechets
- reactive arthritis
- immunodeficiency including HIV
- EBV
- HSV
- Dx reactions
- chickenpox
- hand foot and mouth
Consider underlying condition if:
Ulcers first occur later in life, affect atypical sites in the mouth (such as the palate or gums), also affect extra-oral sites (such as genitalia), or are associated with systemic features.
Advice
Avoid ‘trigger factors’ including oral trauma and certain foods and drinks (such as coffee, chocolate, peanuts, and gluten-containing products). Avoiding toothpaste containing sodium lauryl sulfate may be beneficial.
Simple therapies if mild
- topical anaesthetics (lidocaine)
- topical analgesia / anti inflammatory (eg benzydamine)
- topical antimicrobial agents such as chlorhexidine gluconate oral solution, or doxycycline rinses.
If these are insufficient, first-line treatment is usually a topical corticosteroid such as hydrocortisone oromucosal tablets, beclomethasone spray (delivered via an inhaler device — off-license use), or betamethasone soluble tablets. Duration of treatment is decided on a case-by-case basis.
Summary:
Avoidance of precipitating factors, and
Symptomatic treatment for pain, discomfort, and swelling, for example, a short course of a low potency topical corticosteroid, an antimicrobial mouthwash, or a topical analgesic.
Management if severe recurrent AU
a short course of systemic prednisolone can be prescribed
Natural history
Most AU heal within 10-14 days without scarring
Who gets AU?
Anyone - 20% population
Usually first appear in childhood/adolescence
F>M
Can early manifestation of a systemic disease such as Behçet’s disease or GI
Smoking is protective
What causes AU?
Exact reason not clearly defined.
40% have a family history of AU
- ?immune system disturbed by external factor and reacts abnormally against a protein in mucosal tissue
