RECURRENT APHTHOUS ULCER
Recurrent aphthous ulcers (RAUs) have following characteristics:
1. They are recurrent,
painful, superficial oral ulcers that persist 8 to 14 days;
2. They are associated with
a tender regional lymphadenopathv (swelling of lymph nodes in the head and neck
3. They heal spontaneously,
usually without sequelae in healthy patients.
The causes and the course of the disease
Several theories about the cause of recurrent aphthous ulcers have been
proposed; they include psychic, allergic, microbial, endocrine, hereditary,
and autoimmune mechanisms. Many dentists also find mechanical trauma
play a role in the precipitation of these ulcers.
A study reported patients, who
were challenged with certain foods, begins their ulcers. No causative effect
was found on tomatoes, strawberries, or walnuts. Hay and Reade (1984) reported the
results of their study clearly showed that some food ingredients contributed to
the cause of some cases of recurrent aphthous ulcers.
The inheritance of recurrent aphthous ulcers was studied by Miller et al.
(1980). Their results showed the incidence of the disease in children was
significantly higher when RAUs were present in one or both parents. Another
study reported that recurrent aphthous ulcers occurred more commonly in
patients from higher socioeconomic groups.
Studies about the stress-related vitamin B12 and folate levels in recurrent
aphthous ulcers have yielded conflicting results. Some found several RAU
patients with decreased folate levels; others failed to find signilicantly
lower serum levels of yitamin B12 or folate in RAU patients.
Currently it seems likely that the recurrent aphthous ulcers develop because
of several different mechanisms. Studies showing shifts in immune balance
are many. Ferguson et al. (1981) reported the highest incidence occurred
in menstruating women.
The clinical features
The recurrent aphthous
ulcers, in the usual course of events, appear, regress, and heal within 4 to 10
clays. The patients are requested not to brush their teeth in the affected area
until the lesions have completely disappeared.
However, in rare cases, the
lesions may appear without remission for as long as 2 or 3 months. In these
cases the patient has reported the lesions are constantly present but have
shifted location during the disease. Necrotic tissue and uncharacteristic ulceration
are usually present in these cases. Instead of forming on the oral mucosa, the
lesions characteristically occur on the attached gingiva. Typically, the lesions
usually disappear within 2 weeks after starting a regimen of tetracycline
mouthwash, which wipes out the superimposed bacterial infection and allows
The differential diagnosis
The dentists will need to distinguish between recurrent aphthous ulcers
(RAU) and intraoral recurrent herpes simplex (IRHS) ulcers in most cases.
Herpangina and hand-foot-mouth disease are two other conditions that must
The recommended treatment
Most of recurrent aphthous ulcers resolve in 8 to 14 days without treatment.
However, our Houston dentist recommends these:
1. Tetracycline mouthwash
(an oral suspension of uncoated Achromycin crystals 250 mg/tsp in 5 ml water)
to be flushed over the affected region for at least 2 minutes.
2. After cleaning the affected area with the tetracycline mouthwash, the
ulcer is applied with a thick laver of triamcinolone acetonide in emollient
dental paste (Kenalog in Orabase) after meals and before bed. Alternatively,
aloe vera leaves may also be used.
3. Oral and topical
analgesics are administered if necessary.
Our Houston dentist found the above treatment regimen gives satisfactory
results. Other dentists reported that ulcer duration was shortened with
chlorhexidine mouthwash. Recently, a new hvdroxypropyl cellulose
material (Zilactin) has been proposed for the treatment. In addition, various
topical steroids have been promoted, but their benefits have not been consistent.