Assess and eliminate possible irritating factors, e.g. sharp tooth edges or a rubbing prosthesis.
Any ulcer that has not healed in 2 weeks usually warrants biopsy which can be taken with a punch or knife. Always keep in mind the possibility of oral cancer.
Aetiology and treatment
Traumatic ulcers
Mechanical
Caused by e.g. biting, a chipped tooth or a rubbing prosthesis
Usually heals without sutures; however, ulcers that split the mucosa or the skin of the lip should be closed by suturing.
Thermal
Caused by hot food or drink
Chemical
Caused by e.g. ASA or a substance used in dentistry
Can be clinically categorized as small (≤ 1 cm), large (> 1 cm) and herpetiform (numerous very small ulcers). Small aphthae are common.
Small and large ulcers typically occur on the labial and buccal mucous membranes (often in the oral vestibule; picture F1), more rarely on the tongue and gums. Herpetiform aphthae may occur anywhere in the oral cavity.
The aetiology is unknown. Genetic predisposition has been found in some patients.
The ulcers will heal within 1-6 weeks, depending on their size.
Possible triggering factors include e.g. stress, mucosal trauma, cessation of smoking, certain foods, haematological abnomalities (deficiency of iron Iron Deficiency Anaemia, folic acid, vitamin B12Megaloblastic Anaemia or zinc), hormonal changes and toothpastes containing sodium lauryl sulfate (SLS) 1.
In some patients, the use of SLS free toothpaste may reduce the occurrence of aphthae.
If treatment is considered necessary, topical glucocorticoid products (paste or adhesive tablet) as well as chlorhexidine mouthwashes may be tried.
An extemporaneous gel made of 4 substances (betamethasone 0.1% cream 5 g, lidocaine hydrochloride 2% gel 5 g, chlorhexidine gluconate 1% gel 5 g and nystatin 100 000 IU/ml oral suspension 5 g) effectively alleviates aphthous pain.
In large, frequently recurring ulcers, mouth rinsing with tetracycline may be tried: a capsule containing 500 mg of tetracycline is dissolved in a glass of water, and the mouth is rinsed with the solution without swallowing it 4 times daily for 4-5 days.
A topical anaesthetic or a product that forms a protective film over the aphtha may be helpful for the pain.
Application of liquid containing hydroxymethoxybenzenesulphonic acid and sulphuric acid will necrotize the aphtha and after the painful application the area is pain-free.
Aphtha-like ulceration in other diseases
Conditions that may be associated with aphtha-like ulcers
An acute, immune-mediated inflammatory disease of the skin an/or mucosal membranes
Skin changes typically occur in the extremities as erythematous concentric rings (cockades, or bull's eye lesions). They may be associated with bullae, and vesicular or erosive changes may be found on the lips and the oral mucosa (picture F2) 2. Sometimes the oral lesions occur without clear skin changes.
The disease may affect several mucosal areas (e.g. genitals, pharynx, oesophagus, larynx, eyes).
Usually in young adults
The disease is self-limiting but may recur even several times.
The aetiology is unknown, but in about 50% of the cases it is possible to identify a triggering factor. Such factors include: infections (particularly HSV or mycoplasma), drugs, vaccination, chemicals, malignancies, immunological diseases and radiotherapy.
Similar but more severe and extensive conditions known as Stevens-Johnson syndrome and Lyell's syndrome (toxic epidermal necrolysis) are considered as independent diseases; see Erythema Multiforme.
Diagnosis
Diagnosis is usually based on the clinical picture and on the patient history that reveals a triggering factor.
If an HSV or mycoplasma infection is suspected the diagnosis should be appropriately confirmed.
Immunofluorescence of a fresh biopsy specimen (a non-specific finding) can be used to exclude other clinically similar diseases, if needed.
Treatment
Elimination of the cause, sufficient hydration, pain medication as required
Topical glucocorticoid preparations are usually effective in relieving symptoms caused by oral lesions.
Topical anaesthetic spray may be applied to make eating and drinking easier.
Chlorhexidine (2 mg/ml) mouthwashes 2-3 times daily to prevent the emergence of infectious complications and to maintain good oral hygiene
In a recurrent disease triggered by Herpes simplex virus, prophylactic medication with aciclovir may be beneficial.
Severe forms of the disease warrant hospitalization and systemic glucocorticoids.
Neoplasias
Oral squamous cell carcinoma may present as a chronic ulcer typically on the lateral aspects of the tongue, in the floor of the mouth or on the buccal or soft-palate mucous membranes. See also Cancers of the Head and Neck.
References
Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician 2019;100(2):82-88. [PubMed]
Chavan M, Jain H, Diwan N et al. Recurrent aphthous stomatitis: a review. J Oral Pathol Med 2012;41(8):577-83. [PubMed]
Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol 2012;51(8):889-902. [PubMed]
Challacombe SJ, Alsahaf S, Tappuni A. Recurrent Aphthous Stomatitis: Towards Evidence-Based Treatment? Current Oral Health Reports (2015);Vol. 2(3):158-167 http://qmro.qmul.ac.uk/xmlui/handle/123456789/12137.
Tarakji B, Gazal G, Al-Maweri SA et al. Guideline for the diagnosis and treatment of recurrent aphthous stomatitis for dental practitioners. J Int Oral Health 2015;7(5):74-80. [PubMed]
Bulur I, Onder M. Behçet disease: New aspects. Clin Dermatol 2017;35(5):421-434. [PubMed]