Aphthous ulceration

Aphthous ulceration, also known as Recurrent Aphthous Stomatitis (RAS), is a common inflammatory condition characterized by recurrent, painful ulcerations affecting the non-keratinized oral mucosa without association with systemic infection.

It represents the most common ulcerative disease of the oral cavity, affecting approximately 10–25% of the general population. Lesions typically recur at variable intervals and significantly impair eating, swallowing, speech, and oral hygiene.

Commonly affected sites include:

• Labial mucosa

• Buccal mucosa

• Ventral surface of tongue

• Floor of mouth

• Soft palate

Keratinized tissues such as gingiva and hard palate are usually spared.

Pathophysiology

The exact etiology remains multifactorial and incompletely understood. Current evidence supports an immune-mediated mucosal destruction process.

Major mechanisms involved:

1. Immune Dysregulation

• Cell-mediated immune response predominates

• Increased T-lymphocyte activation

• Cytotoxic CD8+ cells destroy epithelial cells

• Elevated pro-inflammatory cytokines:

  • TNF-α

  • Interleukin-2

  • Interferon-γ

This leads to epithelial breakdown and ulcer formation.

2. Predisposing Factors

RAS occurs in genetically susceptible individuals exposed to triggering factors:

Local factors

• Minor oral trauma

• Tooth brushing injury

• Dental procedures

• Sharp tooth margins or prosthesis

Systemic factors

• Iron deficiency anemia

• Vitamin B12 deficiency

• Folate deficiency

• Zinc deficiency

• Hormonal fluctuations

• Psychological stress

• Food hypersensitivity

Associated systemic diseases

• Behçet disease

• Celiac disease

• Inflammatory bowel disease

• HIV infection

• Neutropenia

Signs and Symptoms

Prodromal Stage

Occurs 24–48 hours before ulcer formation:

• Burning sensation

• Tingling

• Localized itching

• Mucosal tenderness

Ulcerative Stage

• Round or oval ulcer

• Yellow-gray fibrinous base

• Surrounded by erythematous halo

• Severe localized pain

• Difficulty eating acidic or spicy foods

• Pain during speech or swallowing

Diagnostic Criteria

Diagnosis is mainly clinical.

Classification

1. Minor Aphthous Ulcers (Mikulicz type)

• Size: 2–4 mm

• Number: 1–6 ulcers

• Located on non-keratinized mucosa

• Heal within 7–10 days

• No scarring

• Most common (~80%)

2. Major Aphthous Ulcers (Sutton disease)

• Size: 1–3 cm

• Deep painful ulcers

• Significant tissue destruction

• Healing: weeks to months

• Often heal with scarring

• May interfere with nutrition

3. Herpetiform Aphthous Ulcers

• Multiple clustered ulcers (10–100 lesions)

• Size: 1–5 mm

• May coalesce

• Heal within 7–10 days

• Not related to herpes virus infection

Differential Diagnosis

Important conditions to exclude:

• Oral herpes simplex infection

• Oral candidiasis

• Traumatic ulcer

• Oral lichen planus

• Pemphigus vulgaris

• Squamous cell carcinoma

• Drug-induced ulceration

• Tuberculous ulcer

• HIV-related ulcers

Investigations

Usually not required in typical recurrent cases.

Indications for investigation:

• Severe or persistent ulcers

• Onset in adulthood

• Non-healing >3 weeks

• Systemic symptoms

Recommended tests

• Full blood count

• Serum ferritin

• Vitamin B12 level

• Folate level

• HIV testing (when indicated)

• ESR/CRP

• Biopsy for suspicious lesions

Treatment

Treatment Goals

• Pain reduction

• Accelerate healing

• Reduce recurrence

• Maintain nutrition and oral intake

Non-Pharmacological Management

• Avoid spicy, acidic, or rough foods

• Maintain optimal oral hygiene

• Use soft toothbrush

• Eliminate traumatic dental factors

• Stress reduction strategies

• Correct nutritional deficiencies

• Adequate hydration

Protective agents:

• Warm saline mouth rinse

• Sodium bicarbonate mouth rinse

• Protective oral pastes

Pharmacological Treatment

(Aligned with Tanzania STG & NEMLIT recommendations)

Topical Therapy (First Line)

Triamcinolone acetonide 0.1% oral paste

• Apply directly to ulcer

• 12 hourly for 5–7 days

OR

Chlorhexidine gluconate 0.2% mouthwash

• Rinse 8 hourly for 5–7 days

• Reduces secondary infection

Analgesics

Paracetamol 1 g PO every 8 hours when required

Avoid NSAIDs if ulcer worsens.

Systemic Therapy (Severe Disease)

Prednisolone oral regimen:

• 20 mg PO 8 hourly × 3 days

• Then 10 mg 8 hourly × 2 days

• Then 5 mg 8 hourly × 2 days

Used only in severe or major aphthous ulceration.

Adjunct Therapies (Specialist Level)

• Topical lidocaine viscous gel

• Tetracycline mouth rinse

• Colchicine

• Dapsone

• Thalidomide (specialist supervision only)

Referral Criteria

Refer to dental/oral medicine specialist if:

• Ulcer persists >3 weeks

• Recurrent severe disease

• Suspicion of malignancy

• Systemic illness suspected

• Weight loss or dysphagia present

• Immunocompromised patient

Biopsy may be required for histopathological diagnosis.

Prevention

• Maintain oral hygiene

• Avoid mucosal trauma

• Nutritional supplementation when deficient

• Stress management

• Regular dental review

• Early treatment during prodromal phase

Patients with frequent recurrence benefit from trigger identification.

Complications

• Dehydration

• Malnutrition

• Secondary infection

• Chronic pain

• Reduced quality of life