[1] Treating Aphthous Stomatitis

Today I will begin a series reviewing current research and treatments for Aphthous Stomatitis. Future segments in this series will cover specific treatments, effectiveness and sustainability as a long term treatment option.

An article published in 2012 states that...

"Most treatments for RAS are designed to reduce pain and inflammation.[1,2] These palliative treatments do not directly address the underlying cause of this disease, which is unknown. There is a need for targeted treatments that are safer and more effective."

Palliative:  relieving pain or alleviating a problem without dealing with the underlying cause.

This introductory commentary outlines two major issues in the current field of healthcare on treating aphthous stomatitis.

1. The pathology of the disease is unknown.
2. As a result, treatments center around alleviating pain without directly treating the cause of the problem.

From what is currently understood about the disease, it is extremely complex and presentation of the disease may be due to many different factors.  

My friend who suffers from strong outbreaks (approximately 5-10 lesions) about once a month receives palliative treatment in the form of corticosteroids and topical anesthetic in the form of a mouthwash. Some may also know this as Magic Mouthwash. 

The oral steroids are effective in speeding up recovery and the Magic Mouthwash allows him to eat and drink with significantly less pain. As great as steroids are, most physicians seek to avoid long term steroid use as they may cause problems throughout the body. A list of these problems can be found here.

http://dermnetnz.org/treatments/systemic-steroids.html

Bibliography

Topical lavender oil for the treatment of recurrent aphthous ulceration.

Altaei DT.

Am J Dent 2012;25(1):39-43.

Level of Evidence

Level 2: Limited-quality patientoriented evidence

A First Hand Experience of Aphthous Stomatitis

The Case of a 25 Year Old Male

The following interview was conducted with a very close friend of mine who volunteered to share some of his personal experiences with reoccurring oral canker sores.

When did you begin experiencing mouth ulcers?

"I used to get them when I was younger, in about Jr. High but only 1 or 2 [sores], easy to ignore. When I got into senior year of high school I got my first major outbreak."

How often would outbreaks occur?

"Every four months or more frequent, every 1-3 months. I have had consecutive months, and have had 2 months in between."

Would you say outbreaks are more frequent the older you've become?

"Yes."

Are there any particular triggers?

"I find that spicy food, very acidic food, tomatoes, marinara sauce, acidic wines... well dryer wines more than sweet wines, citrus fruits, and pineapples. If I bite my tongue or my cheek it may result in a single/large outbreak. If I am already sick [experiencing an outbreak], it causes a more severe outbreak in the bitten area. Lack of sleep.  Over indulgence in alcohol. Seems to occur in the same places, previously closed sores seem to reopen or new ones open near old ones. It is like they never fully healed. I also avoid carbonated drinks as well."

Can you tell when an outbreak is about to happen? How?

"Yes, it always starts with the back of the tongue near the uvula. It [the uvula] becomes sore and sensitive to food and makes it difficult to swallow food. At that point it spreads to the tongue, my tongue gets sore. It is similar to when you workout, like a muscle soreness, there's a minor discomfort when talking. 

" ...it always starts with the back of the tongue near the uvula."

The first spot that forms bleeds and will be result in mucus with blood. Bloody phlegm forms near the first spots. Uvula gets covered [in sores], by that point, I won't be eating or talking. Even if food can be chewed, one or two big sores ones on the uvula, the sides of the mouth, and the back of tongue makes swallowing very difficult.

It takes about a week after the tongue starts becoming sore for an outbreak to occur. During that week, I will brush teeth more often, use more mouthwash, buy a case of Ensure or make sure that I am taking vitamins more frequently. Sometimes it does help to ward it [an outbreak] off, I might only get 5 ulcers and I can deal with them.  Sometimes it will stop at 5 or other times it doesn't matter what I do, a breakout will still occur.

Ensure is a source of complete, balanced nutrition.
Every ready-to-drink shake is packed with
24 essential vitamins and minerals, including antioxidants
(Vitamins C & E and Selenium).

I changed toothpastes to ProNamel, it doesn't have sodium lauryl sulfate which is a harsh cleaner found in laundry detergeant. It can irritate the mucus lining of your mouth and/or weaken it. I also switched mouthwash from Listerine which contains alcohol because it can irritate the mucus lining as well, these changes have helped a little."

Did you ever receive a diagnosis?

"I have been told canker sores, B-2 deficiency, even herpes."

Really, Herpes!?

"That's what I said, it was silly because herpes forms outside the mouth but I took the test anyways, and the blood test was negative. What I hear most is aphthous ulcers. I have been to hospitals and ERs. Around when it first started in my senior year of HS/freshman year of college is when I went to the ER. They did a throat culture test to see if it was strep throat and it was also negative."

What types of doctors did you see?

"I have been to a pediatrician, to regular doctors, walk in clinics. A Chinese herbalists told me it was due to a B-2 deficiency. I have been taking super B complex supplements but I can't say its working or that it isn't working, it seems to be the same. Another factor may be that I seem to also suffer from fatigue a lot."

What treatment have you found to be most useful? if you have found any at all?

"Nothing ever seems to prevent or cause faster healing, the only treatment that helps to soothe the pain is a lot of Advil/Aleve/Tylenol due to fevers and headaches. Magic Wash (viscous lidocaine 1/3, 1/3 Mylanta, 1/3 Benadryll) numbs my mouth for about 30 minutes to eat, it is so numbing that I cannot even feel my tongue.

Herbal medicine/tea helped to soothe me long term. The ulcers didn't hurt as much as they would usually but it is not an immediate solution. The medicine contained mushrooms and other things.

DGL-Liquorice is a supposed natural remedy which seemed to work for a day or two but then things got really bad, I cannot say it made things better or if I just experienced a placebo effect."

What is your longest incidence?

"2 weeks is the longest, the average is 9-10 days."

On a scale of 1-10 how would you rate the pain/discomfort?

"9, it varies actually, during fevers it is very bad, with 101-104 degree fevers. My body is achy as well, with headaches due to lack of nutrition, the outbreaks themselves are a steady pain, contact between food and an ulcer is like getting burned by fire."

How debilitating is it to your daily life? Why?

"I have trouble eating, fevers, hunger headaches, and cannot think clearly due to not eating. I wake up in pools of sweat, my shirts get drenched while trying to sleep.  I cannot talk, it is very uncomfortable, often I don't want to be around people, I gets irritated more easily, much more so than normal. I also lose a lot of weight. During my recent outbreak I lost 10 pounds in a week and a half."

What is your biggest issue regarding this ailment?

"Statistically is seems to be quite frequent among the population yet doctors dont really know much about it and are dismissive about it. I often gets responses like, "It will pass in a few days..." Only 2 doctors have offered something to help make it better for a few days. I have had had this problem for years and didn't learn about the Magic Wash until a year ago.  There are times when my spirit or will to get up and see a doctor does not exist, it seems to be a waste of time or money since nobody knows what's going on. 90% of them say, "It will pass, it happens to a lot of the population and you have to deal with it." It makes me reluctant to seek help."

The 3 Clinical Forms of Aphthous Stomatitis

WARNING: This post contains images of aphthous ulcers that some people may find disturbing. 

The classic categorization of recurrent aphthous ulcer is divided into 3 clinical forms: 

1. Recurrent aphthous ulcer minor
2. Recurrent aphthous ulcer major
3. Herpetiform recurrent aphthous ulcer

Recurrent aphthous ulcer minor:

• Recurrent aphthous ulcer minor is the most common form, accounting for 80% of all cases. 
• Discrete, painful, shallow, recurrent ulcers smaller than 1 cm in diameter characterize this form. 
• At any time, one or more ulcers can be present. 
• Lesions heal without scarring within 7-10 days. 
• The periodicity varies between individuals, with some having longer ulcer-free episodes and some never being free from ulcers.

These ulcers are relatively small and shallow.

Recurrent aphthous ulcer major:

• Recurrent aphthous ulcer is formerly known as periadenitis mucosa necrotica recurrens. 
• This form is less common than the others and is characterized by oval ulcers greater than 1 cm in diameter. 
• In this relatively severe form, many major aphthae may be present simultaneously. 
• Ulcers are large and deep, may have irregular borders, and may coalesce. 
• Upon healing, which may take as long as 6 weeks, ulcers can leave scarring, and severe distortion of oral and pharyngeal mucosa may occur.

Notice the significant difference in depth and irregular shape
of a major ulcer in comparison to a minor ulcer. 

Herpetiform recurrent aphthous ulcer:

• This least common form (5-10% of cases) has the smallest of the aphthae, commonly no larger than 1 mm in diameter. 
• The aphthae tend to occur in clusters that may consist of tens or hundreds of minute ulcers. 
• Clusters may be small and localized, or they may be distributed throughout the soft mucosa of the oral cavity.

It's worse than you imagine it is.

An Introduction to Aphthous Stomatitis

What is Aphthous Stomatitis?

Aphthous: Pertaining to, characterized by, or affected with aphthae.

Aphthae is plural for aphtha which is defined by Mosby's Dental Dictionary as a small ulcer on the mucous membrane.

Stomatitis: Inflammation of the mouth.

Therefore, Aphthous Stomatitis can be defined as the inflammation of the mouth by small ulcers in the mucous membrane.

An illustration of a patient suffering from Aphthous Ulcers.
Aphthous Ulcers are more commonly referred to as Canker Sores.

According to Medscape,

"Aphthous stomatitis, or recurrent aphthous ulcers (RAUs) or canker sores, are among the most common oral mucosal lesions physicians and dentists observe. Recurrent aphthous ulcer is a disorder of unknown etiology that can cause clinically significant morbidity. One or several discrete, shallow, painful ulcers are visible on the unattached mucous membranes. Individual ulcers typically last 7-10 days. Larger ulcers may last several weeks to months and can scar when healing."

In other words, canker sores are a common phenomena among many members of the population. The condition is relatively easy to diagnose however there is a definitive lack of insight on its cause. As a result, many patients suffering from reoccurring cases face chronic pain within the oral cavity that may last anywhere from weeks to months depending on the severity of their condition. 

The classic categorization of recurrent aphthous ulcer is divided into 3 clinical forms: 

1. Recurrent aphthous ulcer minor
2. Recurrent aphthous ulcer major
3. Herpetiform recurrent aphthous ulcer.

Where does Aphthous Stomatitis affect?

Recurrent aphthous ulcer affects the following nonkeratinized or poorly keratinized surfaces of the oral mucosa:

• Labial and buccal mucosa
• Maxillary and mandibular sulci
• Unattached gingiva
• Soft palate
• Tonsillar fauces
• Floor of the mouth
• Ventral surface of the tongue

The cheeks have been cut and the lips pulled back for an unobstructed view.
Aphthous ulcers have the highest probability of forming anywhere in this diagram except the external portion of the lips and the top of the tongue.

Examples of keratinized surfaces include your skin, the top of your tongue and the external portion of your lips.

This means that a patient suffering from Aphthous Stomatitis may develop ulcers almost anywhere on the inside of their mouth such as the gums, the roof of the mouth, the sides of the mouth, the back of the mouth, the tonsils, the bottom of the mouth and the bottom of the tongue.

Where can cases of Aphthous Stomatitis be found?

In the United States, recurrent aphthouse stomatitis affects 20% of the population. 

That's about 1 in 5 people. 

Recurrent aphthous ulcers occur worldwide and are reported on every populated continent.

Who does Aphthous Stomatitis generally affect?

Farhad Melamed, MD at UCLA's Department of Medicine reports,

"There is a trend found among the population where the condition is more commonly seen in females, with a tendency to be seen in the upper socioeconomic classes."

Why does Aphthous Stomatitis occur?

"...the precise etiology and the pathogenesis of recurrent aphthous ulcer remain unclear. Many possibilities have been investigated. Recurrent aphthous ulcer is a multifactorial condition, and it is likely that immune-mediated destruction of the epithelium is the common factor in recurrent aphthous ulcer pathogenesis. Host risk factors associated with recurrent aphthous ulcer are described below."

Genetics:

A family history of recurrent aphthous ulcers is evident in some patients. A familial connection includes a young age of onset and symptoms of increased severity.

Hematinic deficiency:

In several studies, hematinic (iron, folic acid, vitamins B-6 and B-12) deficiencies were twice as common in patients with recurrent aphthous ulcers than in control subjects. As many as 20% of patients with recurrent aphthous ulcer had a deficiency.

Immune dysregulation:

At present, no unifying theory of the immunopathogenesis of recurrent aphthous ulcer exists, but immune dysregulation may play a significant role. Cytotoxic action of lymphocytes and monocytes on the oral epithelium seems to cause the ulceration, but the trigger remains unclear. Upon histologic analysis, recurrent aphthous ulcer consists of mucosal ulcerations with mixed inflammatory cell infiltrates. T-helper cells predominate in the preulcerative and healing phases, whereas T-suppressor cells predominate in the ulcerative phase.

 Microbial infection:

Researchers disagree about the role of microbes in the development of recurrent aphthous ulcers. Emphasis has been on a microbial agent as a primary pathogen or an antigenic stimulus. Numerous studies have failed to provide strong evidence to support the role of herpes simplex virus, human herpes virus, varicella-zoster virus, or cytomegalovirus in the development of aphthous ulcers.
Recurrent aphthous ulcer formation may be a T-cell–mediated response to antigens of Streptococcus sanguis that cross-react with the mitochondrial heat shock proteins and induce oral mucosa damage.

Believe it or not S. sanguinis is a normal inhabitant of the healthy human mouth where it modifies the environment to make it less hospitable for other strains of Streptococcus that cause cavities.