Aphthous ulcers

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What are aphthous ulcers?

Aphthous ulcers are a common, harmless, and non-contagious condition seen as painful sores on the inside of the cheeks, lips, some parts of the gums, and the underside of the tongue. They occur on the mucus membranes and can sometimes be seen on the mucus membranes in the genital area.

Alternate name

  • Canker sores

Are aphthous ulcers a medical emergency?

Aphthous ulcers are not a medical emergency.

Types of aphthous ulcers

Canker sores are of the following types:

  • Recurrent minor ulcers or Mikulicz Ulcers:
    • They are the most common
    • Occur in the 10-40 year age group
    • Smaller than 1cm, cause minimal symptoms
    • Resolve in 7-10 days
    • Leave no scars
    • And may recur once in 1-4 months
  • Major aphthous ulcers or Sutton ulcers:
    • Less common
    • Larger than 1cm
    • Slight swelling may be present around them
    • Quite painful
    • Take longer to heal (10-40 days)
    • May leave scars
    • Recur more frequently
  • Herpetiform ulcers:
    • They are less common
    • Seen in the older age group
    • More common in women
    • Seen as groups of ulcers that can fuse to form larger ulcers
    • Extremely painful
    • Heal in about 10 days
    • May or may not leave scars
    • Recur very frequently

When canker sores are present in the genital area, they are referred to as non-sexual genital ulceration (NSGU) or Lipschultz ulcer. They are more common in women, and are accompanied by extreme pain and swelling, and may sometimes follow an infection.

Causes of aphthous ulcers

The exact cause of canker sores is not known but the following causes are associated with them are:

  • Diet lacking in B12, iron, zinc, or folic acid
  • Emotional stress
  • Lack of sleep
  • Menstruation
  • Allergic response to some toothpaste, or foods such as chocolate, strawberries, spicy or acidic foods
  • Mechanical trauma as in self-inflicted bite, while brushing, or dental treatment

Some systemic conditions can also cause Canker sores and they include:

  • Celiac disease
  • Inflammatory bowel disease: Crohn's disease and ulcerative colitis
  • Behcet’s disease
  • Autoimmune disorders that target the oral mucosa
  • HIV/AIDS

Risk factors for aphthous ulcers

Anybody can get canker sores, but the risks associated are:

  • Family history
  • Adolescent and young age group

Signs & symptoms of aphthous ulcers

Depending on the type of canker sores that are present the symptoms and signs are:

  • Pain may be minimal or extreme
  • Difficulty in eating
  • Presence of one or multiple ulcers
  • The edge is usually red, and sometimes swollen
  • The ulcer becomes a punched out ulcer and gets covered by a white or yellow membrane

Investigations

The following investigations may be done, especially if the aphthous ulcers are recurrent:

  • Laboratory tests -
    • CBP & ESR
    • Serum B12
    • Serum Folate
    • Iron profile
    • Gluten antibody tests: For celiac disease
    • Fecal Calprotectin: For Crohn’s disease

Diagnosis

Diagnosis of aphthous ulcers is based on medical history, clinical evaluation, and results of investigations if any.

Aphthous ulcers treatment options

Most aphthous ulcers resolve on their own and do not require any treatment. Recurrent aphthous ulcers or large and painful aphthous ulcers may require medical intervention.

A. Medical management

The medical management of aphthous ulcers includes:

  • Oral rinses: Oral rinses containing either dexamethasone to reduce inflammation and pain, or lidocaine mouth rinse to reduce pain
  • Topical agents: Include the following
    • Topical covering agents/barriers: Such as sucralfate, or colchicine to reduce pain
    • Topical analgesics: Such as benzydamine hydrochloride to reduce pain
    • Topical anesthetics: Lidocaine to reduce pain
    • Topical anti-inflammatory agents: To reduce pain and inflammation
    • Topical antiseptics: Such as chlorhexidine gluconate, tetracyclines to prevent secondary infection
    • Topical mild steroids: Such as hydrocortisone sodium succinate to prevent inflammation
    • Topical moderate potency steroids: Such as beclomethasone, fluocinonide to reduce inflammation
  • Vitamin or Nutrition supplements: Containing B6, B12, folic acid, and zinc

B. Interventional including surgery and indications for surgery

An interventional procedure such as cauterization of the sores may be done to provide relief from severe pain. The following may be used for chemical cauterization of the sores are:

  • Debacterol: Promotes healing and reduces healing time
  • Silver Nitrate: Does not affect the healing, but reduces pain

C. Role of diet/exercise/lifestyle changes/preventive measures

Some measures that can be taken to deal with aphthous ulcers include:

  • Gentle brushing of teeth
  • Avoiding rough, spicy or acidic food
  • Applying ice to the sores
  • Oral rinsing with salt or baking soda

While aphthous ulcers cannot be completely prevented, the following measure may be taken to reduce the frequency of occurrence,

  • Maintaining good oral hygiene
  • Eating a healthy diet to eliminate nutritional deficiencies
  • Identifying and avoiding foods and irritants that trigger aphthous ulcers
  • Avoiding trauma to the mouth, lips, and tongue
  • Reducing stress

Complications of aphthous ulcers

There are no serious complications that can occur with aphthous ulcers, however, severe cases may lead to difficulty in eating, and hence weight loss and nutritional deficiencies may occur. Individuals with bad oral hygiene may develop secondary infections of the ulcers.

Prognosis

The prognosis of aphthous ulcers is very good, and there are no long term serious complications that occur. Most cases of recurrent aphthous ulcers spontaneously disappear in later adult life.

When to contact the doctor or hospital/how to identify the emergency or complications?

It is advisable to seek medical attention if the following are present:

  • Very large sores are present
  • If the frequency of the ulcers is high, or new ulcers are appearing before the old ones heal
  • Ulcers that are not healing for 14 days or more
  • Ulcers that are present on the lip surface
  • Extreme pain that is not responding to over the counter remedies
  • Extreme difficulty eating or drinking
  • High fever

Indications for hospitalization if required

Hospitalization is not required.

Suggested clinical specialist/departments to consult for this condition

It will be treated by specialists from the department of dermatology.

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