What are aphthous ulcers?

Aphthous Ulcers: Diagnosis and Management

Aphthous ulcers are well-demarcated, oval or round ulcers with a white or yellow pseudomembrane and surrounding erythematous halo that represent the most common type of oral ulcerations, affecting 10-20% of the population. 1, 2

Clinical Characteristics

• Types of aphthous ulcers:

  • Minor aphthous ulcers: Most common (80-90% of cases), small lesions (<1cm) that heal within 7-14 days without scarring 2
  • Major aphthous ulcers: Larger, deeper, more painful, may take weeks to heal and often leave scars 3
  • Herpetiform aphthous ulcers: Multiple small clustered lesions that may coalesce 3

• Location: Typically occur on non-keratinized oral mucosa (inner lips, cheeks, tongue, floor of mouth) 4

• Symptoms: Painful, may interfere with eating, speaking, and swallowing 4

Etiology

Aphthous ulcers are often idiopathic but may be associated with:

• Local factors:

  • Trauma
  • Stress
  • Hard, acidic, or salty foods 5
  • Toothpastes containing sodium lauryl sulfate 5

• Systemic factors:

  • Nutritional deficiencies (iron, folates)
  • Gastrointestinal diseases (celiac disease, inflammatory bowel disease)
  • Immune disorders (HIV infection, neutropenia)
  • Genetic predisposition 3, 4

Diagnostic Approach

For persistent or atypical ulcers:

1. Clinical evaluation: Detailed history and examination focusing on duration, pain characteristics, and associated symptoms 6

2. Laboratory investigations when ulcers persist beyond 2 weeks:

   • Full blood count (to identify anemia or leukemia)
   • Coagulation studies
   • Fasting blood glucose
   • HIV antibody testing
   • Syphilis serology 1, 6

3. Biopsy consideration: Essential for ulcers persisting beyond 2 weeks to rule out malignancy 1, 6

Treatment

Treatment goals include pain relief, reduction of ulcer duration, and restoration of normal oral function 4.

First-line therapy:

• Topical treatments:
  • Topical anesthetics (benzocaine 20%) for immediate pain relief 6
  • Topical antiseptics/anti-inflammatory agents (triclosan, diclofenac) 5
  • Topical corticosteroids for more severe cases 5, 2

For recurrent aphthous stomatitis (RAS):

• Avoid triggers:

  • Hard, acidic, and salty foods
  • Alcohol and carbonated drinks
  • Toothpastes with sodium lauryl sulfate 5

• Systemic therapy for severe or refractory cases:

  • Colchicine (first-line systemic therapy for RAS) 3
  • Pentoxifylline
  • Prednisolone (short course for severe outbreaks)
  • Thalidomide (effective but limited by adverse effects) 3, 5

Important Considerations

• Persistent ulcers (>2 weeks) require specialist referral to rule out malignancy or systemic disease 1, 6
• Recurrent aphthous stomatitis may be a manifestation of underlying systemic conditions like Behçet's disease or inflammatory bowel disease 3
• Differential diagnosis includes herpes simplex virus infection, trauma, medication side effects, and malignancy 2

Common Pitfalls

• Assuming all oral ulcers are benign without proper evaluation
• Neglecting biopsy for persistent ulcers (>2 weeks)
• Failing to investigate for underlying systemic conditions in recurrent cases
• Overlooking the impact on quality of life and need for pain management 6

Treatment should be tailored to the severity of the problem, considering frequency of ulcers, intensity of pain, and response to treatment 5.