Aphthous Ulcers

Descriptive text is not available for this imageBASICS

DESCRIPTION

  • Painful circumscribed lesions of the mouth, typically located on the nonkeratinized surfaces (i.e., tongue or buccal mucosa)
  • Greek word aphtha coined by Hippocrates refers to sores of mucosal surfaces.
  • Colloquially called “canker sores”

EPIDEMIOLOGY

  • More common in developed countries
  • Slightly more common in males compared to females
  • Frequently occur in childhood and adolescence but can occur at any point in the lifespan
  • Subtypes: minor (a.k.a. Mikulicz aphthae; 70–85% of cases), major (10–15%), and herpetiform (1–10%)
    • Minor and major typically present with 1 to 5 lesions.
    • Lesions of major subtype are larger ($1 cm in diameter) and heal more slowly than smaller lesions of minor subtype.
    • Herpetiform may present with 10 to 100 lesions.

RISK FACTORS

  • Local trauma
  • Physiologic or emotional stress
  • Personal or family history of autoimmune disease
  • Nutrition
    • Vitamins D, C, and B12 deficiencies
    • Folate, zinc, iron, selenium, and copper deficiencies are also supported by some literature.
    • Diet rich in spicy and/or acidic foods
  • Toothpastes containing sodium lauryl sulfate
  • Alcohol use
  • Poor sleep quality
  • Medications
    • Angiotensin-converting enzyme (ACE) inhibitors
    • β-Blockers
    • Calcineurin and mTOR inhibitors
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Bisphosphonates
  • Endocrine changes (e.g., menstrual cycles)
  • Heavy tobacco smoking (one pack of cigarettes per day for $5 years) may be protective.

Genetics

A large genome-wide association study found 97 variants altering the odds of developing mouth ulcers, many in genes related to T-cell immunity, and imposing a Th1-type (proinflammatory) immune response.

GENERAL PREVENTION

  • Avoid toothpaste with sodium lauryl sulfate.
  • Consume softer, less spicy foods.
  • Vitamin B12 supplementation

ETIOLOGY

  • May be primary or secondary to chronic infection, autoimmune diseases, or immunodeficiencies
  • Aphthae can predate the development of systemic autoimmune disease.

PATHOPHYSIOLOGY

  • Pathophysiology incompletely understood, but oral dysbiosis is theorized to play some role.
  • Immune activation occurs in response to oral keratinocyte antigens. This may involve upregulation of HLA class II within the mouth.
  • Biopsy specimens show markedly elevated IL-2, suggesting the important role played by T lymphocytes.
  • Other cytokines such as tumor necrosis factor (TNF) are also upregulated.
  • Altered enzymatic composition of saliva, although this may be compensatory

COMMONLY ASSOCIATED CONDITIONS

  • Trauma, especially from dentures, implants, or dental instrumentation
  • Infection
    • HIV
    • Tuberculosis
    • Coxsackie virus
    • Epstein-Barr virus
    • Herpes simplex virus (HSV)
  • Gastrointestinal
    • Crohn disease
    • Celiac disease
  • Autoimmune/autoinflammatory
    • Antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitis
    • Behçet disease
    • Mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome
    • Familial Mediterranean fever (rarely)
    • Periodic fever with aphthous stomatitis, pharyngitis, and adenitis (PFAPA)
    • Reactive arthritis
    • Sweet syndrome
    • Relapsing polychondritis
  • Immunodeficiency
    • Cyclic neutropenia
    • Hyper-IgD syndrome
  • Food allergy
  • Drug induced (e.g., methotrexate)
  • Oropharyngeal malignancy (rare; suspect if persistent and no response to therapy)

There's more to see -- the rest of this topic is available only to subscribers.