When the formation of an ulcer is on the mucous membranes, it is an aphthous ulcer. They are also referred to as aphthosis, canker sores, aphthae and aphthous stomatitis. This is usually an oval or round sore in the mouth where the skin is not bound tightly to the bone. This includes beneath the tongue and inside the lips. In most cases, aphthous ulcers are minor. They have also been linked to serious health issues for certain individuals. An aphthous ulcer can be developed by anyone. They generally appear first in adolescence or childhood. Females are affected more than males.
The Causes
The specific reason for the development of an aphthous ulcer has no clear definition. There is a family history for roughly forty percent of all individuals developing an aphthous ulcer. The current belief is an external factor disrupts the immune system. This triggers an abnormal reaction regarding a protein found in the mucosal tissue. The potential factors triggering outbreaks include:
• Lack of sleep
• Viral infections
• Nutritional deficiency including folic acid, iron and vitamin B
• Certain kinds of toothpaste containing sodium laureth sulfate
• Emotional stress
• Menstruation
• Specific foods such as chocolate
• Mechanical trauma such as a self-inflicted bite
• Certain medications such as nicorandil for angina
The potential causes of mouth ulcers include:
• Herpangina
• Fixed drug eruption
• Herpes simplex
• Erythema multiforme
The Signs and Symptoms
A current aphthous ulcer generally starts as an elevated, yellowish round spot with a red halo. This becomes a punched-out ulcer. This has a loosely attached covering with a greyish, yellow or white membrane. The surrounding tissue remains unaffected and healthy. The ulcer can cause pain when irritated by eating specific foods like citrus fruits or by movement. The individual may have multiple ulcers or just one. There is usually a wide distribution of multiple ulcers throughout the mouth.
The three types of aphthous ulcers are:
•Recurrent Minor Aphthous Ulcer: The diameter is less than five mm. This ulcer heals in one to two weeks.
•Herpetiform ulcers: These are numerous pinpoint ulcers requiring one month to heal. This type of ulcer is most commonly located on the tongue.
•Major Aphthous Ulcer: This ulcer is large, often exceeding ten mm. This ulcer requires weeks to months for healing and will scar.
If the case is extremely severe, an aphthous ulcer can cause the lymph nodes to swell, lethargy, fatigue and fever. This type of reaction is rare. By the time the lymph nodes start to swell, the aphthous ulcer is already advanced. The best option is seeking medical attention before the ulcers become any worse.
The Testing
Most individuals do not need tests. Testing is only necessary for consistent attacks of complex aphthosis or severe oral ulcers. The blood tests often include:
• Iron, blood count, B12 and folate studies
• Fecal calprotectin testing for Crohn disease
• Testing of gluten antibodies for coeliac disease
• Swabs for Candida albicans, Vincent's organisms and Herpes simplex virus
The Treatment
There is currently no cure for aphthous ulcers. The recurrence of minor aphthous ulcers will heal with no treatment in one to two weeks. The key goals of treatments are enhancing healing and decreasing discomfort and pain. Treatments include:
• Decreasing secondary infection with an antibacterial mouthwash
• Using lidocaine and benzocaine to decrease pain levels
• Dietary mineral or vitamin supplements for deficient diets
• Cauterizing superficial tissues with a silver nitrate stick
• Prescribing medications
• Eliminating foods exacerbating or triggering ulcers
• Medicated toothpaste not containing sodium laureth sulfate
• Decreasing stress
• Forming a barrier over the ulcer using protective pastes to decrease irritation
Topical Prescription Medication
Possible prescribed medication may be:
• Dapsone
• Tetracycline suspension mouthwash
• Apremilast for treating oral ulcers resulting from Behcet disease
• Colchicine
• Systemic steroids
• Topical corticosteroids as paste, creams, lotions or dental paste
• Tetracycline (doxycycline) for a minimum of three to six months
• Calcineurin inhibitors including topical tacrolimus or pimecrolimus
• Immunosuppressive agents including ciclosporin, methotrexate and azathioprine
• (TNF) Tumor necrosis factor antagonists including infliximab, etanercept and adalimumab and Thalidomide
Severe cases with systemic symptoms may require the use of anti-inflammatory oral medications. If you believe that you may have an aphthous ulcer, visit us at the Upper Hunt Club Dental Centre in South Ottawa to learn more about the potential treatment options for you. Contact us today to book an appointment or have any of your questions answered.
