Clinically, three forms of recurrent aphthous ulceration exist: major, minor, and herpetiform.
Recurrent aphthous stomatitis is distinguished from aphthous-like ulceration by exclusion of underlying systemic conditions (e.g., inflammatory bowel disease, Behcet syndrome, HIV/AIDS, or cyclic neutropenia).
Diagnosis is based on the history and clinical examination with exclusion of a systemic etiology; there are no specific laboratory findings.
Topical corticosteroids and anti-inflammatory agents are the mainstay of treatment. Severe or refractory cases may require systemic therapy.
Recurrent aphthous stomatitis (RAS) is a common condition of the oral mucosa that presents in patients who are otherwise healthy. It is characterized by recurrent episodes of round or ovoid ulcers with circumscribed erythematous margins and a grayish-yellow base. These typically present in childhood or adolescence. Similar presentations of recurrent oral ulceration (aphthous-like ulceration) may occur associated with systemic disease, including autoinflammatory syndromes (e.g., periodic fever with adenitis, pharyngitis, and aphthae [PFAPA syndrome], Behcet syndrome, Crohn disease), and immunodeficiency states (e.g., nutritional defects such as in celiac disease and other gastrointestinal disorders, immune defects such as HIV/AIDS, or neutrophil defects such as cyclic neutropenia); therefore, to avoid confusion, the term RAS should be reserved for ulceration seen in the absence of systemic disease.
Other causes of oral ulceration include trauma, inflammatory conditions such as oral lichen planus or graft versus host disease, medications (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], nicorandil), infections (herpes simplex virus infection, syphilis), and malignancy (i.e. oral squamous cell carcinoma).
History and exam
Key diagnostic factors
- oral ulcers
- absence of genital or ocular ulceration
- no history of immunodeficiency
- absence of pallor
- positive family history
- nonsmoker or cessation of smoking
- age <30 years
- cows' milk-fed children
- female sex
- high stress levels
- food intolerance
- hormonal imbalance
- use of sodium lauryl sulfate-containing toothpaste
Investigations to consider
- serum ferritin
- serum folate
- serum vitamin B12
- serum IgA-tTG
- viral serology (e.g. HIV or Epstein-Barr virus)
- erythrocyte sedimentation rate and CRP
- antinuclear antibody test
- serum HIV test
- Behcet syndrome
- Malignant ulcer
- Folate deficiency
- The diagnosis and management of recurrent aphthous stomatitis: a consensus approach
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