Minor aphthous ulceration: clinical characteristics and management

Minor Aphthous Ulceration

Discussion of the etiology, pathogenesis, presentation and management of minor aphthous ulceration

Aphthous ulcers are a common but painful problem in the general population. There are three general classificatory categories of this condition: minor, major and herpetiform. [1] Minor aphthae are commonly located on the labial or buccal mucosa, the soft palate and the floor of the mouth. [1]

In essence aphthous ulceration or canker sores are ulcers that "...form on the mucous membranes of the mouth or genitals" [2]. The most common type of an aphthous ulcer is the recurrent minor aphthous ulcer or recurrent aphthous stomatitis. These sores can be singular or multiple and also tends to be less than one centimeter in size. The major form of this condition is usually much larger (more than 10mm) and can involve much deer ulceration. Herpetiform ulcers are multiple pinpoint ulcers usually found on the tongue. [2]

The incidence of minor aphthous ulceration varies in different populations and has been documented as 5-66% and 50% world-wide. Studies also show that Minor Aphthae is particularly common in the United States. [3] There is also certain comorbidity present and the conditions tend to occur or are associated with chronic gastrointestinal malabsorption disturbances such as Crohn's disease and celiac disease. [3]

2. Etiology and Pathogenesis

While Aphthous ulcers are of the most commonly found human oral mucosal disease, the cause or causes of this condition are not clearly understood and are described as "indeterminate" [3]. Another important aspect is that aphthous is not preventable, although treatment of the symptoms of the ulcers is possible. This has meant that contemporary research has focused largely on the various factors and health conditions that are considered to precipitate the condition. Since the etiology of aphthous ulcers is indeterminate, "...research has focused upon a variety of potentiating factors" [3]. These factors include the following.

A stress, nutritional deficiencies, trauma, hormonal changes, diet, immunologic disorders.

A foods, allergies, progesterone levels, psychologic factors, and a familial history. [3]

Among the factors that are often related to the emergence of minor aphthous ulceration are emotional stress and the accompanying lack of sleep. Nutritional deficiencies that can contribute to the development of these ulcers include a lack of vitamins B, iron, and folic acid. [2] There have also been studies which indicate that certain toothpastes can provoke this condition as well as menstrual cycles. [2]

Previous research was of the view that the cause of aphthous ulcerations was due to an L-form of Streptococcus since this organism was often isolated from the lesions. However, "A more common belief is that the lesions may become secondarily infected with streptococci." [3] the consensus in modern research is that this condition is an idiopathic disorder with an unclear etiology. What is also agreed upon by medical researchers in that aphthous ulcerations are related to and mediated by immunological determinants.

The pathophysiology of aphthous ulcers also not clearly understood. McBride state that, "Histologically, aphthae contain a mononuclear infiltrate with a fibrin coating. Patients with recurrent aphthae may have alteration of local cellmediated immunity. Systemic T- and B-cell responses have also been reported as altered in patients with recurrent aphthae" [1].

3. Treatment and management

There are conventionally five types of treatment and management for oral aphthae. These are: antibiotic, anti-inflammatory, immune modulatory, symptomatic and alternative. [1] the use of antibiotic treatment is empiric and is based on the assumption that some infectious agent is the underlying cause of the ulcer or ulcers. The antibiotic agents most commonly used in treatment are Tetracycline and minocycline. [1]

Certain anti-inflammatory agents have also been found to be a means of accelerating the healing process, as well as relieving the symptoms of the condition. These agents have been found to be particular effective in the management of recurrent minor aphthous ulcers. [1] a preparation of Triamcinolone 0.1% can be applied to ulcers two to four times a day. This treatment also provides a protective local coating for the ulcer. [1]

The use of Immune Modulators in the management and treatment of aphthous ulcers is more aligned to research in those patients who have HIV / AIDS. In these patients the healing times of the ulcers may be protracted due to the depressed immune response. A treatment for ulcers that has been found to be effective is Thalidomide (Thalomid). [1]

However, as McBride (2001) points out,"... Thalidomide is contraindicated in non-HIV infected patients because of its potential for significant side effects and teratogenicity..." [1].

There are a number of other strategies and agents that can provide relief to the sufferer of this condition. One of these is the use of 2% viscous lidocaine applied with a cotton swab several times daily. [1] benzocaine preparations that can be obtained from pharmacies can also be used to alleviate the symptoms of the ulcers and over-the-counter agents such as Orabase or Zilactin-B coat aphthous ulcers and provide local protection. [1] Prescription topical corticosteroids such as Kenalog can help to deal with painful ulcers that are difficult to heal. [2]

There is an extensive range of alternative remedies that claim to help with the alleviation of symptoms and the promotion of the healing process. For example, the use of Vitamin C, vitamin B complex and lysine "...may speed healing when taken orally at the onset of lesions..." [1]. Other remedies include herbal combinations, such as sage and chamomile mouthwash. Echinacea is also reported to speed healing through its positive effect on the modulation of the immune system. Other natural remedies that has often been cited as helpful in the control of the symptoms of this condition include carrots, celery and cantaloupe juices. However the literature also notes that these agents and remedies have not been tested on scientific and controlled tests.