What are aphthous ulcers?
Aphthous ulcers are ulcers that form on the mucous membranes. They are also called aphthae, aphthosis, aphthous stomatitis and canker sores.
Aphthous ulcers are typically recurrent round or oval sores or ulcers inside the mouth on areas where the skin is not tightly bound to the underlying bone, such as on the inside of the lips and cheeks or underneath the tongue. They can also affect the genitalia in males and females.
Recurrent aphthous ulcers are mostly a minor nuisance, but they are associated with significant health problems in some people.
Who is at risk of aphthous ulcers?
Anyone can get aphthous ulcers; 20% of the population have them at least occasionally. They usually first appear in childhood or adolescence, and more commonly in females than males.
Interestingly, smoking may be protective against aphthae, even though smoking make many oral and skin conditions worse.
Non-sexually acquired genital ulceration
Non-sexually acquired genital ulceration (NSGU) re fers to aphthous ulcers in genital sites.
Aphthous ulcers in genital sites are also called non-sexually acquired genital ulcers or Lipschutz ulcers. They are more common in females than in males. They may be accompanied by considerable pain and swelling. Reactive genital ulcers follow an infection.
NSGU is more likely than simple oral aphthosis to be associated with systemic illness, such as:
- Behcet syndrome
- Gluten-sensitive enteropathy (celiac disease)
- Inflammatory bowel disease
- Human immunodeficiency virus (HIV) infection.
What causes aphthous ulcers?
The exact reason why aphthous ulcers develop is not yet clearly defined. Approximately 40% of people who get aphthous ulcers have a family history of the same. Current thinking is that the immune system is disturbed by some external factor and reacts abnormally against a protein in mucosal tissue.
Factors that seem to trigger outbreaks of ulcers include:
- Emotional stress and lack of sleep
- Mechanical trauma, for example self-inflicted bite
- Nutritional deficiencies, particularly vitamins B, iron, and folic acid
- Certain foods including chocolate
- Certain toothpastes
- Menstrual cycle
- Certain medications including nicorandil, given for angina
- Viral infections
What are the signs and symptoms of aphthous ulcers?
Recurrent aphthous ulcers usually begin as a round yellowish elevated spot surrounded by a red halo. This then breaks down into a punched-out ulcer, which is covered with a loosely attached white, yellow or greyish membrane. Surrounding tissue is healthy and unaffected. Sometimes these ulcers can be painful, particularly if they are irritated by movement or from eating certain types of food.
People may experience a single ulcer or multiple ulcers. Multiple ulcers tend to be widely distributed throughout a person's mouth.
There are basically 3 types of aphthous ulcers:
- Recurrent minor aphthous ulcers, which occur in up to 80% of aphthous ulcer cases. They are usually less than 5mm in diameter and heal within 1-2 weeks.
- Major aphthous ulcers, which are large ulcers (more than 10mm) that take weeks or months to heal and do so with scarring.
- Herpetiform ulcers, which are multiple pinpoint ulcers that heal within a month. These are most commonly on the tongue.
What tests should be done in aphthous ulceration?
Most people affected by occasional minor aphthous ulceration do not require tests. They are undertaken if there are recurrent attacks of multiple or severe oral ulcers, or complex aphthosis.
Blood tests may include:
- Blood count, iron, B12 and folate studies
- Gluten antibody tests for celiac disease
- Faecal calprotectin test for Crohn disease
Swabs for microbiology evaluate the presence of Candida albicans, Herpes simplex virus and Vincent's organisms.
What is the treatment for aphthous ulcers?
There is no cure for aphthous ulcers. Most recurrent minor aphthous ulcers heal within 1-2 weeks without any treatment. The main goal of treatment is to lessen the pain and discomfort, and promote healing.
- Protective pastes that form a barrier over the ulcer so that exposure to irritating substances is reduced.
- Superficial tissue cauterization using silver nitrate stick
- Local anaesthetics benzocaine and lignocaine (lidocaine) to reduce pain
- Medicated toothpaste without sodium laureth sulfate
- Antibacterial mouthwashes to reduce secondary infection.
- Avoidance of foods that trigger or exacerbate the ulcers.
- Dietary supplements of vitamins or minerals, if diet is deficient.
- Reduction in stress
Prescribed medicines for aphthous ulceration
Topical prescription medicines include:
- Tetracycline suspension as mouthwash
- Topical corticosteroids as lotions, creams or paste, often triamcinolone in dental paste
- Calcineurin inhibitors: topical pimecrolimus or tacrolimus.
In severe cases, particularly if there are systemic symptoms, anti-inflammatory oral medications may be considered (off-label use):
- Tetracycline, e.g. doxycycline 50-100mg daily for 3-6 months or longer.
- Systemic steroids
- Immunosuppressive agents such as azathioprine, methotrexate, ciclosporin
- Tumour necrosis factor (TNF) antagonists (adalimumab, etanercept, infliximab)