Aphtous Ulcers, types of aphthous ulcers,causes/etiology of aphthous ulcers and treatment

What are aphthous mouth ulcers?

Aphthous mouth ulcers are painful sores that can occur anywhere inside the mouth. They are the most common type of mouth ulcer. At least 1 in 5 people can develop aphthous mouth ulcers at some stage in their life. Women are affected more often than men.

There are three types:

Minor aphthous ulcers
Major aphthous ulcers
Herpetiform ulcers

Minor aphthous ulcers

 are the most common (8 in 10 cases). They are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are not usually very painful.

Major aphthous ulcers

 occur in about 1 in 10 cases. They tend to be 10 mm or larger across. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, but will heal leaving a scar. They can be very painful and eating may become difficult.

Herpetiform ulcers

these occur in about 1 in 10 cases. These are tiny pinhead-sized ulcers, about 1-2 mm across. Multiple ulcers occur at the same time, but some may join together and form irregular shapes. Each ulcer lasts one week to two months. Despite the name, they have nothing to do with herpes or the herpes virus.

Etiology

In some cases the ulcers are related to other factors or diseases. These include:
Injury -such as badly fitting dentures, a graze from a harsh toothbrush, etc.
Changes in hormone levelsSome women find that mouth ulcers occur just before their period. In some
women, the ulcers only develop after the menopause.
Some ex-smokers find they develop ulcers only after stopping smoking.
A lack of iron, or a lack of certain vitamins (such as vitamin B12 and folic acid) may be a factor in some
cases.

Rarely, a food allergy may be the cause.

Mouth ulcers run in some families. So, a genetic factor may play a part in some cases.

Stress or anxiety is said to trigger aphthous mouth ulcers in some people.
Some medications can cause mouth ulcers. Examples of medicines that can cause mouth ulcers are:
nicorandil, anti-inflammatory medicines (eg, ibuprofen) and oral nicotine replacement therapy.
Mouth ulcers are more common in people with Crohn's disease, coeliac disease, HIV infection, and Behçet's disease. However, these ulcers are not the aphthous type
Identify and correct predisposing factors for recurrent aphthous stomatitis (RAS). Ensure that patients brush atraumatically (eg, with a small-headed, soft toothbrush) and avoid eating particularly hard or sharp foods (eg, toast, potato crisps) and avoid other trauma to the oral mucosa.
SLS should be avoided if implicated as a predisposing factor. Any iron or vitamin deficiency should be corrected once the cause of that deficiency has been established. If an obvious relationship to certain foods is established, these should be excluded from the diet. Patch testing may be indicated to reveal allergies. The occasional patient who relates ulcers to her menstrual cycle or to use of an oral contraceptive may benefit from suppression of ovulation with a progestogen or a change in the oral contraceptive.
In most cases, the natural history of RAS is one of eventual remission. However, for some patients, remission occurs spontaneously several years later; thus, treatment is indicated in these patients if discomfort is significant. Relief of pain and reduction of ulcer duration are the main goals of therapy. There is a huge range of supposed or possible remedies available, but objective evidence shows the most efficacy from corticosteroids and antimicrobials used topically.[4, 5]

Vitamin B12 used orally may have some effect
Topical corticosteroids (TCs) remain the mainstays of treatment. A spectrum of different TCs can be used. At best, TCs reduce painful symptoms but not the rate of ulcer recurrence. The commonly used preparations are as follows:
Hydrocortisone hemisuccinate pellets (Corlan), 2.5 mg used 4 times daily
Triamcinolone acetonide in carboxymethyl cellulose paste (Adcortyl in orabase [withdrawn in some countries], Kenalog), administered 4 times daily
Betamethasone sodium phosphate as a 0.5-mg tablet dissolved in 15 mL of water to make a mouth rinse, used 4 times daily for 4 minutes each time
Hydrocortisone and triamcinolone preparations are popular because neither causes significant adrenal suppression; however, ulcers still recur.
Betamethasone, fluocinonide, fluocinolone, fluticasone, and clobetasol are more potent and effective than
hydrocortisone and triamcinolone, but they carry the possibility of some adrenocortical suppression and a predisposition to candidiasis.
Topical tetracyclines may reduce the severity of ulceration, but they do not alter the recurrence rate. A doxycycline capsule of 100 mg in 10 mL of water administered as a mouth rinse for 3 minutes or tetracycline 500 mg plus nicotinamide 500 mg administered 4 times daily may provide relief and reduce ulcer duration. Avoid tetracyclines in children younger than 12 years who might ingest them and develop tooth staining.
Chlorhexidine gluconate and bioadhesive (Gelclair) mouth rinses reduce the severity and pain of ulceration but not the frequency.
Anti-inflammatory agents can help; a spectrum of topical agents such as benzydamine and amlexanox may help. Benzydamine hydrochloride mouthwash, though no more beneficial than a placebo, can produce transient pain relief.
If RAS fails to respond to local measures, systemic immunomodulators may be required. A wide spectrum of agents has been suggested as beneficial, but few studies have been performed to assess their efficacy (or their adverse effects are significant). Thalidomide 50-100 mg daily is effective against severe RAS, although ulcers tend to recur within 3 weeks. Teratogenicity, neuropathy, and other adverse effects dissuade most physicians from its use.
Few, if any, of the other medications used for RAS have undergone serious scientific evaluation. These include biologics, transfer factor, gamma-globulin therapy, sodium cromoglycate lozenges, dapsone, colchicine, pentoxifylline, levamisole, colchicine, azathioprine, prednisolone, azelastine, alpha 2-interferon, ciclosporin, deglycerinated liquorice, 5-aminosalicylic acid (5-ASA), prostaglandin E2 (PGE2), sucralfate, diclofenac, and aspirin.