Quality Resource Guide –

Oral Ulcerative and Vesiculobullous Diseases Part 1 - 4th Edition

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Table 1 - Clinical Features of Aphthous Ulcerations

Minor Aphthae

Major Aphthae

Herpetiform Aphthae

Size

<0.5 cm

>1.0 cm

<0.5 cm

Shape

Oval

Ragged, oval, crateriform

Oval

Number

1-5

Usually solitary

10-100

Location

Nonkeratinized mucosa

Any intraoral site

Treatment

Topical corticosteroids,

tetracycline mouthrinse,

immunosuppressives,

topical anesthetics

(lidocaine, benzocaine)

Topical/systemic/intra

lesional, corticosteroids,

thalidomide

Topical/systemic

corticosteroids,

tetracycline mouthrinse

Deficiencies of vitamin B12, folic acid, and iron

as measured in serum have been found in only a

small percentage of patients with aphthous ulcers.

Correction of these deficiencies has produced

improvement or cures in this small group. Patients

with malabsorption conditions such as celiac

disease and Crohn’s disease may also develop

aphthous-type oral ulcers.

Other causes or alternate etiologies of aphthous

ulcers that have been investigated include family

history, hormonal alterations, stress, trauma, and

food hypersensitivity including nuts, chocolate, and

gluten, among others, though only anecdotally,

such as tomatoes and spicy foods. None of these

is seriously regarded as being important in the

primary causation of aphthous ulcers, although

any of them may have a modifying or triggering

role. Although HIV-positive patients may have

more severe and protracted aphthous-like ulcers,

the role of HIV and other agents is unknown.

The degree of immunosuppression appears to

be more related to the major form of aphthous

ulceration as measured by both peripheral blood

CD4+ T-cell subsets and neutrophils within this

population. More recently,

it has been proposed

that gamma/delta - T-lymphocytes may have a role

in an antibody-dependent cell-mediated cytotoxicity

reaction toward oral epithelium. Systemic diseases

or conditions may also influence development

of or be associated with aphthous ulcers. These

include celiac disease, inflammatory bowel disease,

neutropenia and use of certain drugs such as

methotrexate. Of note is the recent hypothesis that

aphthous type ulcerations may be associated with

an autoinflammatory disease group of conditions

or periodic syndromes, including Behcet’s disease.

Clinical Features

Three forms of aphthous ulcers have been

recognized: minor, major, and herpetiform aphthous

ulcers (Table 1). All forms present as painful

recurrent ulcers that heal within 10 to 14 days.

Patients occasionally have prodromal symptoms

of tingling or burning before the appearance

of the lesions. Importantly, the ulcers are not

preceded by vesicles and characteristically appear

on the vestibular and buccal mucosa, tongue,

soft palate, fauces, and floor of the mouth (non-

keratinized sites). These lesions rarely occur on the

attached gingiva and hard palate, thus providing

an important clinical sign for the separation of

aphthous ulcers from secondary recurrent herpetic

ulcers. In the patient with AIDS or HIV disease,

however, aphthous-like ulcers may involve any

mucosal site.

Minor Aphthous Ulcers

Minor aphthous ulcers are the most commonly

encountered form of aphthous ulceration

(Figures 1, 2) and affect about 80% of those with

RAS. This type usually appears as a single to a

few painful, well defined oval or round ulcers, less

than 0.5 cm in diameter. They are covered by a

yellow fibrinous membrane and surrounded by

an erythematous halo. When the lateral or ventral

surfaces of the tongue are affected, pain tends to

be out of proportion to the size of the lesion. Minor

aphthous ulcers generally last 7 to 10 days and

heal without scar formation. Recurrence patterns

vary across patients; individuals may not have

clinical lesions for periods ranging from weeks to

years, while in others, recurrences on a regular and

frequent basis are the rule.

Major Aphthous Ulcers

This form of aphthous ulceration is regarded

as the most severe expression of aphthous

stomatitis (Figure 3), affecting about 10% of

those with aphthous ulcers. Lesions are larger

A small, solitary minor aphthous ulcer involving

the lower labial mucosa demonstrates a yellow-

ish fibrinous base with a well defined periphery.

This is representative of a later, less symptomatic

phase of the condition as healing progresses.

Figure 2

A slightly irregularly marginated aphthous

ulceration over the anterior floor of the mouth

with a characteristic fibrinous base located and

a brisk peripheral inflammatory reaction as

representative of an early acute phase lesion.

Figure 1

Figure 3

This major aphthous ulcer of several weeks

duration measures over 2 cm in diameter with

a cratered periphery and fibrinous surface. A

thin circumferential inflammatory rim is pres-

ent. Management strategies may include those

aimed at transitory symptomatic relief with

topical anesthetics, topical, systemic and intra-

lesional steroids, and in severe or recalcitrant

cases, thalidomide may be considered.