Causes and Variants of Apthous ulcer
Apthous ulcers are also known as CANKER SORES or APTHOUS STOMATITIS. The term 'apthae' means ulcer.They are painful open sores inside the mouth. These are recurrent in nature hence named as RECURRENT APTHOUS ULCERATIONS(RAUs).They are not contagious.Burning is the prodromal symptom which occur 24-48 hrs before ulcer appears.
Regions
These RAUs affect mostly the non- keratinised and loosely attached tissue of the oral cavity. The areas which are commonly affected are buccal mucosa, labial mucosa, floor of the mouth, ventral surface of the tongue and soft palate.
Etiology
RAUs are idiopathic in nature. They appear to be multifactorial in origin with a strong component being Immune mediated .Various causes of RAUs are :
-Immunological abnormalities (t -cell mediated)
-Bacterial and Viral infections
-Genetic predisposition
-Hematological factors
-Nutritional deficiencies like vitamin B-12 deficiency, iron deficiency and folic acid deficiency
- Systemic disorders like Behcet`s disease and Crohn`s disease.
Prevalence
These ulcers occurrence depends on the countries and the socio economic status .Its prevalence is more in females than males. Ulcer outbreaks are frequent during mensuration. Remissions are common during pregnancy.
Precipitating factors
Risk factors for RAUs include :
-Mechanical Trauma
-Recent dental treatments
-Cessation of smoking
-Environmental and Dietary Allergies
-Hormonal imbalance
-Stress and Psychological factors.
Variants
There are three different entities of RAUs. They are :
1. minor apthous ulcers
2. major apthous ulcers
3. herpetiform ulcers
1. MINOR APTHOUS ULCERS :-These apthae are smaller than 10 mm in diameter, well circumscribed, round, covered by a yellow –gray puesdomembrane and surrounded by an erythematous halo. These are confined to oral mucosa and tend to occur at same site. They heal without scarring within 10 to 14 days. Prevalent in both non –HIV populations and HIV populations.
2. MAJOR APTHOUS ULCERS :- It is also called as Sutton`s Disease. These lesions are greater than 10 mm in diameter, well circumscribed ,round ,deep lesions with indurated margins. They occur in any area of oral mucosa .Mostly interfere with speech and eating. They persists for about 3 weeks. Lesions heal slowly leaving scars, which result in decreased mobility of uvula and tongue and destructions of portions of oral mucosa.
3. HERPETIFORM ULCERS :- These are multiple small (>1mm) shallow ,round with perilesional erythema up to 100 in number. These apthae begin as a small pin head size erosions gradually enlarge and coalesce. They present continuously for 1-3 yrs and show short remisssions.
Diagnosis
Diagnosis of RAUs is a diagnosis of exclusion. The clinical impression should be confirmed with histologic examination and by response to treatment.
Management
a) Mild cases :- Symptomatic treatment is provided.
-Topical protective emollient base (orabase)
-Topical tetracycline mouthwash(250 mg/ml)
-Topical corticosteroids like triamcinolone acetate 3-4 times daily
-Chlorhexidine mouthwash
-2-4% viscous Lidocaine solution(10ml)
Replacement therapy with vitamin B-12,ferritin,folate and iron.
b) Severe cases :-
-flucocinolone gel
-clobetasol cream or beclomethasone spray
-intralesional cortisone injection
-chlotertracycline mouthwash
-dapsone or thalidomide can be used in cases.
