Minor Aphthous Ulceration

Discussion of the etiology, pathogenesis, presentation and management of minor aphthous ulceration

Aphthous ulcers are a common but painful problem in the general population. There are three general classificatory categories of this condition: minor, major and herpetiform. [1] Minor aphthae are commonly located on the labial or buccal mucosa, the soft palate and the floor of the mouth. [1]

In essence aphthous ulceration or canker sores are ulcers that "...form on the mucous membranes of the mouth or genitals" [2]. The most common type of an aphthous ulcer is the recurrent minor aphthous ulcer or recurrent aphthous stomatitis. These sores can be singular or multiple and also tends to be less than one centimeter in size. The major form of this condition is usually much larger (more than 10mm) and can involve much deer ulceration. Herpetiform ulcers are multiple pinpoint ulcers usually found on the tongue. [2]

The incidence of minor aphthous ulceration varies in different populations and has been documented as 5-66% and 50% world-wide. Studies also show that Minor Aphthae is particularly common in the United States. [3] There is also certain comorbidity present and the conditions tend to occur or are associated with chronic gastrointestinal malabsorption disturbances such as Crohn's disease and celiac disease. [3]

2. Etiology and Pathogenesis

While Aphthous ulcers are of the most commonly found human oral mucosal disease, the cause or causes of this condition are not clearly understood and are described as "indeterminate" [3]. Another important aspect is that aphthous is not preventable, although treatment of the symptoms of the ulcers is possible. This has meant that contemporary research has focused largely on the various factors and health conditions that are considered to precipitate the condition. Since the etiology of aphthous ulcers is indeterminate, "...research has focused upon a variety of potentiating factors" [3]. These factors include the following.

A stress, nutritional deficiencies, trauma, hormonal changes, diet, immunologic disorders.

A foods, allergies, progesterone levels, psychologic factors, and a familial history. [3]

Among the factors that are often related to the emergence of minor aphthous ulceration are emotional stress and the accompanying lack of sleep. Nutritional deficiencies that can contribute to the development of these ulcers include a lack of vitamins B, iron, and folic acid. [2] There have also been studies which indicate that certain toothpastes can provoke this condition as well as menstrual cycles. [2]

Previous research was of the view that the cause of aphthous ulcerations was due to an L-form of Streptococcus since this organism was often isolated from the lesions. However, "A more common belief is that the lesions may become secondarily infected with streptococci." [3] the consensus in modern research is that this condition is an idiopathic disorder with an unclear etiology. What is also agreed upon by medical researchers in that aphthous ulcerations are related to and mediated by immunological determinants.

The pathophysiology of aphthous ulcers also not clearly understood. McBride state that, "Histologically, aphthae contain a mononuclear infiltrate with a fibrin coating. Patients with recurrent aphthae may have alteration of local cellmediated immunity. Systemic T- and B-cell responses have also been reported as altered in patients with recurrent aphthae" [1].

3. Treatment and management

There are conventionally five types of treatment and management for oral aphthae. These are: antibiotic, anti-inflammatory, immune modulatory, symptomatic and alternative. [1] the use of antibiotic treatment is empiric and is based on the assumption that some infectious agent is the underlying cause of the ulcer or…