Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) is a commonly observed inflammatory disorder characterized by ulcers of the oral mucosa. It is considered to be the most common form of oral ulceration to affect humans with a prevalence of 5-6%.10 While several etiologic factors such as trauma, psychological stress, allergies, microbial factors, nutritional factors (e.g., iron deficiency) and immunological imbalances have been proposed, the aetiology of RAS remains unresolved.11

Aphthous ulcers can vary in size but typically present as round shallow ulcers with a well-defined erythematous halo (Figure 2). Commonly affected sites are the tongue, labial, and buccal mucosa. Three clinical presentations have been described and are summarized in Table 1.10 Aphthous ulcers are characteristically painful and may impair the patient’s ability to eat, drink, and speak.

Figure 2. Aphthous Ulcers Upper & Lower Lip 27-year-old Male.

Table 1. Aphthous Ulcer Classification.
Minor Major Herpetiform
Percentage 75% - 85% 10% - 15% 5% - 10%
Characteristics Painful ulcers with shallow necrotic centers, raised margins, and erythematous halos.
Size < 10mm > 10mm 2mm - 3mm
Location non-keratinised mucosa
Duration 10 – 14 days Weeks – months < 1 month
Scarring No Possible No
* Any mucosal tissues may be effected in conditions of immunocompromise

Therapeutic Strategies

Many patients consider RAS a trivial annoyance and do not seek treatment. However, for patients who experience significant discomfort and desire therapy the goal is to provide symptom relief, promote healing, and reduce future recurrence.

Patients who experience occasional minor aphthous ulcers may respond well to any number of OTC topical protective emollients (e.g., Orabase®) used alone or in combined with a topical anesthetic (e.g., Benzocaine®). Another option is to prescribe an extemporaneous soothing mouthwash to improve patient comfort. One popular formulation consists of a mixture of 30 mL diphenhydramine 12.5 mg/5 mL, 60 mL of the antacid Mylanta or Maalox, and 4 g of sucralfate. The solution is to be used as a swish and spit or swallow as needed.12

For severe cases of RAS, the use of a gel formulation of a very high or high-potency topical glucocorticoid such as betamethasone, fluocinonide, and clobetasol is recommended. It is suggested that the gel be applied directly to the ulcer 2-3 times a day, alone or in combination with Orabase®.10 For multisite disease, the use of a topical glucocorticoid mouthwash formulation such as dexamethasone solution or elixir (swish with 10-15 ml and expectorate 2-4 times a day) may be beneficial.

An isolated recalcitrant aphthous ulcer, may respond to direct lesion injection with a triamcinolone acetonide (10mg/mL, injecting 0.1mg/cm3).13 For a severe episodic outbreak of RAS, an empirical short-term course of a systemic glucocorticoid such as prednisone 0.5 mg/kg/day as a single dose in the morning, tapered down over 2 weeks may be prescribed in conjunction with a topical regimen described above.11

Patients who experience severe chronic disease may require prolonged systemic therapy with an agent such as colchicine, a drug that suppresses leukocyte recruitment and activation; pentoxifylline, a drug that inhibits neutrophil adhesion and activation; or thalidomide (a highly teratogenic drug that is available on a very restricted basis in strict protocols) to maintain disease control.14 The prolonged use of a systemic regimen warrants referral to a physician who can monitor for and manage potential adverse effects associated with systemic therapy.

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