Aphthous stomatitis is a painful recurring condition in the oral cavity that needs professional supervision. Read the article to know more.
"Stomatitis" is the inflammation of the oral mucous membranes. In aphthous stomatitis, the inflammation of oral mucous membranes is recurring and painful. The lesions present as painful large or small ulcers ranging from 1 mm (small canker or aphthous sore) to 2 cms (large canker or aphthous sore). The uncommon clinical feature of this oral condition is not only the ulcerations are pinpointed and varied, but also they are rather reddish like a macule and less like a papule. They do not appear like blisters, but the ulcers have a characteristic erythematous reddish flare with a yellowish-white central covering (called the "pyogenic membrane"). These single or multiple variated ulcers are usually round to oval in shape, and in the region like the oral vestibule, the lesions often appear elongated or stretched.
Not only are canker sores quite common in many patients, but also they represent the most frequently occurring oral lesions in almost 20-60% of the general population. Though all age groups are affected alike, its prevalence is more in the female and young adult populations. If the canker sores are recurrent in nature (as they usually are) and if left untreated, it takes the shape of a continuous pathologic entity or disease process for many years and eventually causes severe pain and large ulcerated bases in the oral cavity.
Canker sores can also be a sign of some serious underlying systemic disease or syndrome, as in the case of Crohn's disease (inflammatory bowel disease), Behcet's syndrome, systemic lupus erythematosus, or inflammatory reactive forms of arthritis. In certain malabsorption syndrome, vitamin deficiencies (vitamin B6, B12), and hematinic iron and folate deficiencies, canker sores or aphthous ulcers are commonly found. Also, in patients with poor or compromised oral hygiene and in smokers alike, the microbiome of the oral cavity that constitutes the oral epithelial defense is severely impacted. Hence in these cases as well, canker sores are a common finding.
Though idiopathic and related to not a single or any specific cause (multifactorial origin), canker sores tend to be noninfectious and localized in the oral mucous membranes. They can be triggered not just by stress and lifestyle disease but can be a result of local irritations, sensitivity, allergies, trauma, excess toxin exposure (like nitrate exposure), or even hormonal fluctuations (like in menstrual cycles).
The pathogenesis of canker sores lies in the T cell-mediated immunity that is dysfunctional because the oral epithelium at the site of ulceration is destroyed or destructed partially because of neutrophils, mast cells, and cell mediators that are responsible for maintaining oral epithelium integrity (like interferon-alpha, TNF (tumor necrosis factor) alpha, interleukins or IL 1, 2 and 5). This destruction or partial destruction when the epithelial immunity of the oral mucosa is breached creates the pseudomembranous manifestation acquired in aphthous ulcerations.
The common misconception the dental surgeon needs to avoid while often diagnosing aphthous ulcers or canker sores is from herpetic ulcers. When several large aphthous ulcers or canker sores form a large irregularly-shaped ulcer with a huge common or central base, it is referred to as a herpetiform pattern ulcer which is a subtype of aphthous stomatitis but is not caused by the herpes virus. Herpetiform ulcerations are less prevalent compared to minor and major aphthous ulcers and heal in a few week's time eventually.
Site of Pathology:
The following sites of the oral cavity are the most affected by aphthous ulcerations:
Marginal or unattached gingiva of the teeth.
Non keratinized oral mucosa or labial and buccal surfaces over the teeth.
Ventral surface of the tongue.
The lateral surface of the tongue.
The floor of the mouth.
On local dental examination or routine dental checkup, the ulcers appear round or oval with a pseudomembranous appearance with a gray exudate.
The erythematous halo is characteristic of these lesions on the non keratinized part of the oral mucous membranes.
The patient may complain of a burning sensation in the mouth (prior to the onset of ulceration) or pain and discomfort while swallowing and chewing food.
Fever or febrility is an uncommon feature of patients having canker sores. The patient will be afebrile, reporting only mild or moderate local irritation in the ulcerated area.
Similarly, rashes, headaches, and lymphadenopathy are also uncommon.
The patient's medical history should be taken regarding the past occurrence of ulcerations, periodic fever, or dehydration, as this would be suggestive in the differential diagnosis with other conditions like herpangina or Behcet's syndrome.
In case of hematinic or specific vitamin deficiencies, if neutropenia (abnormal reduction of the neutrophils - the main type of white blood cells in the body) is observed in the complete blood count, then the diagnosis would be aphthous ulcerations due to cyclic neutropenia.
In less than 5% of the cases with aphthous ulceration, underlying celiac disease or gluten-enteropathy is often possible. In such cases, a transglutaminase assay has to be performed to confirm the underlying disease.
The dental surgeon should also carefully observe if the recurrent or herpetiform ulceration has involved the hard palate or the dorsal surface of the tongue or any keratinized part of oral mucosa would indicate an underlying HIV infection that needs to be confirmed by HIV test.
Minor aphthous ulcers are self-healing within 1 to 2 weeks, but recurrently minor and major aphthous ulcers may take months to heal, often with the pronounced impact of scarring on the oral mucosal tissues.
The first line of treatment in small ulcerations is to always prescribe a topical anti-inflammatory and antiseptic gel for application to the affected area that contains an anesthetic component (Benzocaine or lidocaine), antiseptic component (Triamcinolone or Dexamethasone), anti-inflammatory component (chlorhexidine gluconate, hydrogen peroxide).
Withdrawal of certain foods like gluten and tomato and discontinuing toothpaste with sodium lauryl sulfate has also proved effective in some cases. In severe cases, systemic administration of Prednisone or local steroid injection with Triamcinolone can be effective in preventing severity and recurrence. Similarly, for long-term therapeutic purposes, laser therapy and dietary vitamin supplementation will reduce the recurrence rates of canker sores.
To conclude, good oral hygiene, regular dental checkups for diagnosing oral ulcerations are effective in the prevention of aphthous ulcers or canker sores. Often they indicate a systemic component that needs to be diagnosed by the physician and cross-checked for differential diagnosis by the dental surgeon to appropriately treat the inflammatory ulceration in the oral mucous membranes.
Stomatitis is most commonly caused by local trauma to the oral tissues due to ill-fitting dentures, accidentally biting the cheek, tongue, or lip, microbial infections like herpes and thrush, smoking, using smokeless tobacco, poor nutrition, stress, and reduced immunity.
Streptococcus sanguis and Helicobacter pylori bacteria are frequently associated with aphthous stomatitis, especially in the case of recurrent lesions.
- Vitamin B2 (riboflavin).
- Vitamin B3 (niacin).
- Vitamin B6 (pyridoxine).
- Vitamin B9 (folic acid).
- Vitamin B12 (cobalamin).
Canker sores are ulcerated lesions of the oral tissues meaning an injury to the oral tissues leading to an open wound that constantly gets exposed to saliva and food items. This makes them more painful.
Canker sores usually appear yellow to white with red borders. This is probably due to bacterial activity and the body’s immune response.
There are three stages of a canker sore.
- The Prodromal Stage - This stage comprises the first three days before the sores appear.
- Ulcer Stage - This stage lasts from the third day to the sixth day, during which the ulcer has formed.
- Healing Stage - From the seventh day, the healing stage starts. It can last up to 7 to 10 days based on the extent of sores.
Both aphthous ulcer and stomatitis are the same. They are also known as aphthae, aphthosis, and canker sores.
Persistent canker sores can be indicative of any underlying medical conditions like nutritional deficiencies, celiac disease, Crohn’s disease, and other gastrointestinal disorders. Sometimes it can even be oral cancer.
Persistent canker sores that do not heal and are accompanied by fatigue, fever, abdominal pain, rash and soreness in other body parts, and eye problems definitely cause a concern. These can be the signs of systemic problems.
It nearly takes 1 to 2 weeks for aphthous stomatitis to heal. They get better on their own. However, supportive treatment might be needed to relieve its symptoms.
Salt water gargling definitely helps relieve the symptoms of canker sores. It raises the mouth’s alkalinity and aids in healing, reducing the swelling and drying out the canker sores.
Stomatitis is often self-limited, and treatments can only lessen the symptoms of stomatitis.
- Application of numbing ointments like Lidocaine and Benzocaine.
- Antibacterial mouthwashes.
- Avoiding citrusy and acidic foods.
- Treating nutritional deficiencies (if any).
- Stress management.
- Saltwater gargle.
Stomatitis often heals on its own within two weeks without any treatment. However, preventing the sores from getting exposed to triggering food items like hot and spicy foods, citrusy foods, etc., protecting the sores from manual injury, adding nutritional supplements, and managing stress hastens the healing process.
Information on the internet about overnight healing of canker sores is misleading. There is no permanent and instant cure for canker sores. Symptomatic treatment helps ease the sores’ symptoms. Whether you treat it or not, minor canker sores of local cause resolve automatically after a week or two. If it does not, reach your physician to get your overall health condition checked.
Last reviewed at:
17 Sep 2021 - 4 min read
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