RECURRENT ORAL ULCERATION

Oral ulceration
Ulceration is defined as a break in the continuity of an epithelial lining. Causes are
summarized in Table 15.4.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is a common oral condition of unknown aetiology
affecting approximately 20% of the population. Three types are recognized, although it is
unclear if they represent variants of the same disease or are distinct entities: minor, 80
85% major, 1015% herpetiform, 5%.

Clinical features are shown in Table 15.5.

Aetiological factors Can be considered as host or environmental factors. Evidence for
aetiological factors can be summarized as:

Genetic Family history in up to 45% cases. High concordance rate among identical twins.
Several HLA associations reported.
Nutritional deficiencies Haematological deficiencies (most commonly iron, although may
also be associated with vitamin B12 and folic acid). Found in approximately 2030% of
patients with RAS. Some reports also suggest increased incidence of vitamin B1 and B6
deficiencies.

Systemic diseases RAS may occur in association with a variety of systemic disorders, e.g.
coeliac disease, Crohns disease, ulcerative colitis and cyclic neutropenia.

Endocrine In a small proportion of female patients RAS may be more severe during the
luteal phase of the menstrual cycle, related to the increased levels of progestogens and
decreased oestrogens. Remissions often occur during pregnancy.

Stress/anxiety Conflicting reports in the literature; this issue remains unresolved.

Trauma Minor trauma may initiate ulceration in susceptible patients. Influences the site of
ulceration.

Allergy Some reports suggest associations between RAS and exposure to dietary allergens,
although further study is required in this area.
Infection Conflicting data on the role of oral streptococci as direct pathogens or antigenic
stimuli for production of antibodies that cross-react with keratinocyte determinants.
Similarly, some
investigators have suggested a role for VSV and HSV although the results require
confirmation.

Smoking Negative association between RAS and cigarette smoking. Onset of RAS in some
patients may coincide with cessation of smoking.

Investigation and diagnosis Full blood count, assays of ferritin, vitamin B12 and folate to
exclude nutritional deficiency. In areas where there is a high prevalence of coeliac disease,
or if the patient has features suggestive of malabsorption, coeliac serology (antiendomysial
antibody or tissue transglutaminase antibodies) is appropriate as a screen to exclude coeliac
disease. No specific diagnostic tests. In patients who are rarely free of ulcers, allergy may be
a contributing factor and patch testing can identify dietary and/or environmental allergens.
449
Treatment No specific management available for the majority of patients. Correct
haematinic deficiencies. In general, symptoms can be reduced although no treatment
consistently prevents recurrences (Table 15.6).

Behets syndrome
Comprises a triad of:
recurrent aphthous stomatitis
genital ulceration
posterior uveitis.

Only about 42% of cases show the classic triad although >90% have oral ulceration.
Diagnosis is usually made if two of these features are present. Any of the three variants of
aphthous stomatitis may occur although there is an increased prevalence of herpetiform and
major aphthae. Other manifestations, occurring with varying frequency, now recognized as
components of the syndrome include:
cutaneous lesions
neurological problems
joint lesions
intestinal lesions
haematological abnormalities
vascular lesions.
Age of onset mainly third decade. Male preponderance (M :F,2.3 : 1). There is a significant
geographic variation, with the syndrome being more common in the Eastern Mediterranean
and Japan.
Clinical features are shown in Table 15.7.

Investigations and diagnosis No universally agreed diagnostic criteria. Diagnosis is

essentially clinical. Exclude nutritional deficiency as a contributing factor. Strong
association with HLA B51 may support the diagnosis.

Treatment Overall treatment with immunosuppressive agents, e.g. steroids, azathioprine,

colchicine, tacrolimus, thalidomide. Oral ulceration can be managed as for RAS.
Ophthalmological opinion to exclude ocular involvement should be sought as this may lead
to
visual impairment or blindness.