What is Recurrent Aphthous Stomatitis?
Recurrent aphthous stomatitis (RAS), or recurring mouth ulcers, is a long-term problem where the inside of the mouth becomes inflamed, though it’s unclear why this happens. Doctors usually identify this problem by looking at your medical history and doing a physical check-up.
There seems to be a genetic influence because nearly half of the people with this problem have family members who also have it. Some other factors that might make you more likely to get RAS include injury to the inside of your mouth, being under stress, stopping smoking, having low levels of iron (anemia), or other vitamin deficiencies.
Some digestive problems like Crohn’s disease, ulcerative colitis, or celiac disease (where your body can’t properly digest certain foods) can also make you more likely to get mouth ulcers. RAS is also a feature of Behçet’s disease, and if your RAS is particularly bad, it might be a sign of an HIV infection.
A topical corticosteroid (a medication that you apply directly to the inside of your mouth) is usually the first treatment that doctors will try. For more serious cases, doctors might give you systemic steroids (medications that you take by mouth or injection that affect your whole body) for a short time. In some scenarios, medications that lessen your body’s immune response might be needed to stop new ulcers from forming and to reduce the possible side effects from systemic steroids.
What Causes Recurrent Aphthous Stomatitis?
Aphthous stomatitis, commonly known as mouth ulcers, happen for complex reasons that researchers don’t fully understand. However, it is believed to involve an immune response and potential genetic factors.
Before an ulcer forms, certain immune cells called lymphocytes invade the lining of the mouth. This causes swelling, and the cells lining the mouth start to break down, which might cause damage to the small blood vessels in the area. This leads ultimately to localized swelling and eventually ulceration or formation of an open sore. This process triggers more immune cells to infiltrate the area before it eventually heals.
Recurrent mouth ulcers, known as RAS, is thought to be associated with an immune response that involves specific proteins, including one called tumor necrosis factor-alpha. This protein helps call more immune cells to the area thereby causing more inflammation.
This immune response seems to attack the cells lining the mouth, leading to their destruction. It’s suggested that this response might be a reaction to specific bacteria that can harm the lining of the mouth.
Having family members with recurrent mouth ulcers could possibly increase the likelihood of someone developing the condition. Those with a family history might also have ulcers that appear faster and are more severe. Certain genes may also play a role in the development of this condition.
There are factors that might help determine who gets recurrent mouth ulcers. Local factors include mouth injuries. People who smoke tend to get these ulcers less frequently. Systemic factors, which relate to the whole body, include diseases like Behçet disease, nutritional deficiencies, gastrointestinal disorders, and immune deficiencies, such as HIV.
Behçet disease which can cause inflammation in several parts of the body, including the mouth, is one condition diagnosed using recurrent mouth ulcers as a criterion.
Some patients with recurrent mouth ulcers have shown deficiencies of certain nutrients needed by the body, like iron, folic acid, vitamin B12, and zinc. Lack of these nutrients might lead to conditions like anemia and reduced capacity of blood to carry oxygen to the mouth leading to damaging effect. However, supplementing these nutrients does not always result in healing of the ulcers.
Recurrent mouth ulcers could signify bowel diseases like Chron’s disease and ulcerative colitis. The ulcers in these cases might result from malabsorption i.e., the body’s difficulty in absorbing certain nutrients.
Women during their menstrual periods or menopause are more likely to develop recurrent mouth ulcers. On the other hand, pregnant women or those taking contraceptive pills frequently may experience a decrease in ulcers, suggesting hormones might impact the prevalence of ulcers.
Patients with HIV, who have altered levels of certain immune cells, may also have a higher likelihood of developing recurrent mouth ulcers.
Risk Factors and Frequency for Recurrent Aphthous Stomatitis
Recurrent aphthous stomatitis, also known as canker sores, is fairly common, impacting around 25% of people around the world. It typically first shows up in childhood or teenage years. Sometimes, it might appear on its own, or it can be part of a larger health issue, like Behçet’s disease. There are three different types of canker sores:
- The minor type is the most common, accounting for more than 70% of cases.
- The major and herpetiform types are less common, each making up about 10% of cases.
Signs and Symptoms of Recurrent Aphthous Stomatitis
Recurrent Aphthous Stomatitis (RAS), a condition where painful mouth ulcers keep coming back, typically lasting several days to a few months. This condition can be broken down into three main types: minor aphthous ulcers, major aphthous ulcers, and herpetiform aphthous ulcers.
Minor aphthous ulcers are the most common form of RAS and affect about 80% of patients. These small (less than 5mm), oval or round ulcers pop up in clusters of 1 to 6 at a time, usually every 1 to 4 months. They’re distinguished by their grey-white coating and the red swollen halo that surrounds them. Normally they appear on the soft tissues within the mouth (buccal and labial mucosa), and the floor of the mouth, and heal within two weeks without leaving any scars. In some cases, discomfort in the mouth may come before the appearance of these ulcers.
Major aphthous ulcers are a more severe variety of the disease and affect about 10% of RAS patients. Unlike minor ulcers, these are larger (over 10mm), last longer (5 to 10 weeks), and leave scarring. They can appear in any area of the mouth, including the throat (oropharynx). Major aphthous ulcers are frequently seen in AIDS patients and are loosely associated with conditions affecting the digestive system and blood. Unlike other types, they don’t occur in a regular, predicted cycle.
Herpetiform ulcers are the least common type of RAS, occurring in about 1% to 10% of patients. This type got its name because it resembles a viral condition called primary herpetic stomatitis, but isn’t caused by a herpes virus. They’re more likely to affect older women. Typically, up to 100 small (2-3mm), painful ulcers can appear at once and last for about one to two weeks. These are commonly seen on the floor of the mouth and the tongue’s tip and edges. They may appear on any type of mouth tissue, whether it’s keratinized or non-keratinized. If several small ulcers join together, they can form a larger, irregular ulcer that heals with scarring.
Testing for Recurrent Aphthous Stomatitis
Recurrent aphthous stomatitis, a condition causing repeated mouth ulcers, doesn’t require specific lab tests for diagnosis. The doctors can usually identify it based on your symptoms. However, other health conditions can cause similar symptoms, such as Behçet’s disease, nutritional deficiencies, or inflammatory bowel disease. This is particularly true if the mouth ulcers occur suddenly in adults.
Some people with recurrent aphthous stomatitis may have anemia, meaning they have lower than normal red blood cells, or nutritional or dietary deficiencies. Therefore, it’s common for doctors to run a complete blood count, which measures the number of blood cells in your body. Other tests may include checks for red cell folate, which helps your body make DNA, as well as ferritin and vitamin B12, which help with body function and energy production. These tests can also detect issues related to your stomach and intestines.
Treatment Options for Recurrent Aphthous Stomatitis
Recurrent aphthous stomatitis, commonly known as mouth ulcers, can often be a challenging condition to manage. The best course of action is to find a treatment that can control the ulcers for the longest period while causing the fewest side effects. The treatment will depend on how much pain you feel, how often you get ulcers, and your medical history, including your ability to tolerate medication.
Before starting any treatment, it is vital to determine if any factors are triggering the ulcers, like stress or certain foods, so these can be managed.
The objective of treating mouth ulcers is not only to ease the symptoms but also to reduce the number and size of the ulcers, promote healing, and extend the periods of being ulcer-free. For milder episodes, painkillers like nonsteroidal anti-inflammatory drugs (NSAIDs) and local treatments with steroids can be managers. In particular, benzydamine mouthwash and chlorhexidine mouthwash are sometimes used to prevent added infections caused by bacteria. In some cases, a combination of local tetracycline (an antibiotic) and steroids may be helpful. For severe major mouth ulcers, a short course of oral steroids, like prednisone, might be recommended. It’s important to note that long-term use of steroids is usually avoided due to potential serious side effects. Herpetiform ulcers, tiny multiple ulcers, are usually treated similarly to minor mouth ulcers.
Research has shown that using chlorhexidine gluconate mouthwash and local steroids can decrease the severity of mouth ulcers and shorten their duration. The mouthwash helps by reducing the amount of bacteria, which promotes healing. Topical steroids can be beneficial when used in the early stages of ulcers when you start to feel a tingling or burning sensation.
It’s important to remember that the severity and frequency of ulcers vary greatly between individuals, and each person’s treatment needs to be tailored to their needs. Classifying patients into three categories, A, B, or C, can be helpful in determining the right treatment approach.
Type A patients only experience episodes a few times a year, with outbreaks lasting only a few days and mild pain. For these patients, discovering and eliminating any trigger factors and using a softer toothbrush to avoid trauma might be enough, and further medication may not be needed.
Type B patients experience painful ulcers monthly, lasting from 3 to 10 days. They may find it difficult to eat or brush their teeth due to pain. Their treatment includes using chlorhexidine mouthwash and a short course of local steroids as soon as ulcers appear. They generally need ongoing treatment to prevent the return of the ulcers. If oral hygiene is affected due to pain, professional cleaning from a dental hygienist may be considered once the ulcers have healed.
Type C patients suffer from severe mouth ulcers with constant new eruptions whenever one ulcer heals. These patients are managed with a combination of local and systemic steroids and immunosuppressant medications like pentoxifylline, dapsone, and thalidomide to prevent the formation of new ulcers and lessen the adverse effects caused by systemic steroids.
What else can Recurrent Aphthous Stomatitis be?
Some systemic diseases can mimic the symptoms of recurrent aphthous stomatitis, which is commonly known as canker sores. These include the following conditions:
- Behçet disease: In this, patients also suffer from repeated ulcers in their genitals, skin disorders like erythema nodosum or papulopustular lesions, eye disease (commonly posterior uveitis), and a range of nerve, stomach, kidney, blood, or joint disorders.
- MAGIC syndrome or Sweet syndrome: Patients with this disease suddenly get a fever, increased white blood cells, and skin lesions which look like plum-colored bumps or patches. About half of the patients with this syndrome also have some sort of a cancer disease.
- PFAPA syndrome: This includes periodic fever, throat infection, canker sores, and swelling of the glands in the neck. Mostly young children get this, and two-thirds of them get better after having their tonsils removed.
- Cyclic neutropenia: People with this disease get fever, skin abscesses, swollen lymph nodes, and infections in their respiratory tract. In addition to canker sores, they may also get severe gum disease and aggressive periodontitis.
- HIV disease: People with HIV can also exhibit symptoms resembling recurrent canker sores.
What to expect with Recurrent Aphthous Stomatitis
Recurrent aphthous stomatitis, often called canker sores, is a condition where painful sores keep appearing in the mouth and typically follow a pattern of return. The severity of these sores hinges on the type of canker sores one has. Minor canker sores usually heal in two weeks on their own without leaving a scar, whereas major canker sores take longer to heal – up to six weeks, and can leave a scar behind. A specific variety called Herpetiform ulcers, which aren’t related to herpes, also tend to heal within a month and rarely leave a scar.
Possible Complications When Diagnosed with Recurrent Aphthous Stomatitis
The level of pain from these sores can vary. When the pain is severe, it can make eating and drinking difficult, increasing the likelihood of dehydration and nutritional deficiencies. The pain might also make it harder to maintain good oral hygiene. If the sores get infected with bacteria, they become even more painful, but this can be prevented by using chlorhexidine mouthwash. Additionally, long-term use of topical corticosteroids, which can help with the maintenance of these sores, may increase the risk of fungal infections in the mouth. To counteract this, a topical antifungal medication should be used for at least two weeks.
Common Symptoms & Precautions:
- Variable pain intensity
- Potential difficulty eating or drinking
- Risk of dehydration and nutritional deficiencies
- Possible impairment of oral hygiene
- Risk of bacterial infections in the sores; preventable by chlorhexidine mouthwash usage
- Possible fungal infections with long-term use of topical corticosteroids; preventable by topical antifungal medication use for at least two weeks
Preventing Recurrent Aphthous Stomatitis
If you have RAS (Recurrent Aphthous Stomatitis), a condition that causes recurring mouth sores, it’s important to figure out what triggers your symptoms and try to avoid these things. Triggers could include physical damage or stress on your mouth.
Keeping your mouth clean is important to help your sores heal. You might need to avoid eating hot, spicy, acidic or salty foods and avoid overworking yourself to exhaustion or not getting enough sleep when you have active sores.
Leading a healthier lifestyle, which includes eating right, exercising regularly, and getting enough rest, can reduce how often you get sores. Also, if you’re not getting enough of certain nutrients, taking supplements might help to lessen or even stop the sores from coming back.
If you have RAS, your doctor will ask to see you every 3 to 6 months. This is to make sure that there are no sores for at least a year, which means that your condition is under control.
