Recurrent Apthous Ulcers: A Review of Diagnosis and Treatment

Department of Pediatric Dentistry
Resident’s Name: Murphy Program: Lutheran Medical Center - Providence
Article title: Recurrent Apthous Ulcers: A Review of Diagnosis and Treatment
Author(s): Sook- Bin Woo DMD, MMSC. Stephen Sonis DMD DMSC
Journal: JADA
Year. Volume (number). Page #’s: 1996. Vol. 127 1202-1213
Major topic: Recurrent Apthous Ulcers (RAU)
Overview of method of research: Clinical Review

Findings:
RAU, or canker sores, are oral mucosal conditions commonly seen by both dentists and physicians. Almost 20% of the population are affected by RAU in some way. RAU occur only on non-keratinized mucosa. While patients may demonstrate lymphadenopathy, fever is rare. RAU can be broken down into three categories: minor, major, and herpetiform.
RAU Minor- Composes 70-87% of all RAU forms. Appears as discrete, painful, shallow, recurrent ulcers covered by a yellow-gray pseudomembrane and surrounded by an erythematous halo. There are usually 1-5 ulcers at any one time, each measuring <1 cm.
RAU Major- Coalescent ulcers 1-10 at a time, usually >1cm and persists for weeks to months.
Herpetiform RAU- Occurs in crops of 10-100 at a time usually in the posterior of the mouth.

There are numerous factors that can play a role in a patient having RAU.

Genetics
About 50% of first degree relatives of patients with RAU also suffer from the condition.

Food Hypersensitivity
Strict elimination diets resulted in improvement/resolution of otherwise persistent RAU’s. A double blind study showed people eating a gluten free diet made a significant difference in ameliorating their symptoms.

Stress and Menses
May or may not play a significant role. Studies are fairly split on this, with some saying it matters, others saying it doesn’t.

Trauma
Pts affected with RAU are predisposed to have ulcers at sites of trauma.

Smoking
Several reports have documented the negative association between smoking and the occurrence of RAU. An absorbed substance such as nicotine may play a role in preventing the occurrence of RAU. Also, tobacco may increase keratinized gingival, thus rendering the tissue less susceptible to RAU.

Infection
Researchers are torn on the role microorganisms play in RAU. Strep ‘may’ play a role, and Varicella zoster virus has been linked to RAU. Pts treated with large doses of acyclovir, 800mg twice a day for 10 weeks seemed to help 66% of the pts studied.

Immune Dysregulation
Studies have found expressions of class 1 and class 2 major histocompatibility complex antigens in the epithelium during all stages of RAU ulcer development. These antigens cause the epithelial cell to be seen as foreign by T cells, which then kill it. This expression fails to cease after the ulcers have healed. However, RAU is not an autoimmune phenomenon, and these findings are described as non specific.

Management
The first step in RAU management is to rule it out as an oral manifestation of systemic disease. Blood tests should be done to rule out iron, b12, or folate deficiency as well as CBC. With that said, most pts with RAU are healthy. Management should be focused on control of the disease in order to reduce pain while maintaining function and reducing frequency and severity with a goal of prolonged remission.

Topical Meds
Variably successful. Do not prevent occurrence. Strictly palliative. Meds such as benzocaine, diclonine hydrocloride, benzy-damine hydrochloride, and magic mouthwash.
Other topical txs work via antimicrobial or anti inflammatory agents. Tetracycline or chlortetracycline rinses and topical cyclosporine may reduce lesion size, duration and pain. Chlorhexidine gluconate may also work.
Immunomodulating agents have been the mainstay of tx of RAU. Pain is reduced, but not frequency. Topical triamcinolone and clobetasol are the usual suspects used.

Systemic Meds
Prednisone works well, however once the pt is off the cycle the ulcers return. Other meds used are azathioprine, colchicines, and levamisole hydrochloride, and azelastine. Thalidomide seems to work best overall.

Systemic Conditions Assoc w/ RAU
Behcet’s
Multisystem disorder seen mostly in Mediterranean, Middle Eastern, and Japanese men.

Hemantinic Def.
Pts w/ Iron, folate, or any vitamin B def. are more affected by RAU. Vitamin replacement therapy works well.

GI disorders
Pts w/ Celiac and Crohn’s can present with RAU.

HIV
Ulcers assoc. w/ RAU tend to follow the traits of RA minor, however the are often larger, usually >1cm.

Neutropenic Ulcers
Ulcers are often assoc. w/ fever, malaise, furunculosis, and cellulitis.

FAPA syndrome
Syndrome of periodic fever, apthous ulcers, pharyngitis and cervical adenitis. Ulcers look like RAU minor, and usually affect children by age 5.

HSV infection in immunocompromised pts
Commonly mistaken for RAU

Key points/Summary: RAU takes many forms, can be caused by/assoc w/ many things, and tx is essentially palliative. Know the difference between the 3 forms. A good history is key in proper diagnosis.

Assessment of Article: Good review. Boring as hell. Worst/longest lit review I’ve had to write up since I’ve been here. I pray that this is on the board reading list.