The phenomenon of aphthous ulcers.

For such a common ailment among many of our patients, there is little known about aphthous ulcers or how to prevent and alleviate the symptoms they produce. Aphthous ulcers are poorly understood throughout the dental and medical communities and remain a mystery to researchers. (1,2) You will sometimes see aphthous ulcers referred to as canker sores or aphthous stomatitis. The basic definition of an aphthous ulcer is a painful oral lesion that appears round to oval in shape and is yellowish in color surrounded by a halo of erythema, the cause of which is unclear. (3) They are usually painful to the patient and occur in episodes and, many times, in groups. (3) The lesions last about two weeks with the most painful symptoms for the patient being the first four days of the outbreak. (2) The most common demographic affected by these lesions are adult females of middle age (35-50 years old), but the first episode can occur in adolescence. (3) In this article you will learn how to:

* Clinically identify aphthous ulcers.

* Understand the commonly believed pathophysiology and etiology of aphthous ulcers.

* Identify the latest treatment options available on the market today.

* Educate your patients who suffer from these ulcers.

My interest in aphthous ulcers was spurred by a personal experience. About two years ago, my mother came to me in pain and unable to eat due to the discomfort she was having in her mouth. I took one look at her in my private practice dental office in Flower Mound, Texas, and knew there was a serious problem. I immediately identified the sores in her mouth as aphthous ulcers based on the color and content, and my dentist-employer confirmed the diagnosis (See figures 1 and 2). I could not see the actual dorsal surface of her tongue or lower vestibules of her cheeks because they were covered in ulcers. She had a combination of minor and major aphthae growing in her mouth. In all my years of private practice and in dental hygiene school, I had never seen such a thing.

I knew I did not have the education or experience with aphthous ulcers to be able to help my mother, so I sought help from the specialists in my area. I took her to see two oral surgeons, a periodontist and a pathologist at Baylor College of Dentistry. Seeing all these specialists yielded disturbing results. No one could tell us how to definitively treat her infection or how to prevent her outbreaks. All they could do was tell us she had multiple, severe aphthous ulcers of unknown origin and prescribe a palliative mouth-rinse and cream. This is where my journey began to try and find all the information I could about aphthous ulcers and how to better help patients who suffer from them.

It is our responsibility as dental hygienists to be able to recognize, diagnose, treat and educate our patients on this mysterious phenomenon of aphthous ulcers, so let's start with recognition. As stated earlier, an aphthous ulcer has a yellowish floor surrounded by a halo of erythema (figure 3). Their size varies depending on whether the lesion is minor, major or herpetiform. Minor lesions are small, ranging from 3 to 5 millimeters, and major lesions are large, usually anywhere from 5 to 10 millimeters (figure 4). Herpetiform lesions are very small, ranging from 1 to 2 millimeters and occur in coalescing groups. (3) The patient will know they have a lesion because it will be painful. Ulcers can grow large enough to obstruct breathing and prevent the patient from being able to chew or speak, and they can leave permanent indentations and scarring in the area of infection after they have healed. (3,4)

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The location in the oral cavity is an important part of diagnosis as well. Aphthous ulcers never appear on hard tissues like the hard palate and attached gingiva; they will appear on soft tissues like unattached moveable mucosa, the floor of the mouth (figure 5) and the tongue (figure 3). (2) The lesions often appear in groups, but may occur singularly. (2) A minor aphthous ulcer is the most common type and tends to occur on the gingiva not covering bone, labial and buccal mucosas, maxillary and mandibular vestibules (figure 1), the soft palate, the oropharynx and the tongue on ventral and lateral borders. Major aphthae are deeper, can take several weeks to heal and can scar the infected site. They are common in immunodeficient patients. (4) Herpetiform ulcers, so called because they resemble ulcers caused by the herpes simplex virus, can occur anywhere on unattached mucosa and generally occur in coalescing groups. (3) True herpes lesions occur on hard, keratinized tissues, the vermillion border of the lip or the corners of the mouth. Their appearance is extremely different from that of an aphthous ulcer, as well. Herpes lesions are red in color, have an irregular border and lack the halo characteristic of aphthous lesions. Patients often report a tingly feeling before an outbreak of herpetic ulcers. (3,4)

The pathophysiology of aphthous ulcers is unclear and poorly understood in the dental and medical communities. Researchers do know that aphthous ulcers are not caused by the herpes simplex virus, but they are not sure whether they are bacterial or viral. (2-4) There has been substantial evidence found in recent years that links aphthous ulcers with immunological responses. It has been found that some patients with recurrent aphthae have altered T-cell and B-cell responses, but the precise immunopathogenesis still remains unclear. (3,4) There has been no microorganism or virus to date that has been identified as the cause of aphthous ulcers. This is the scariest part; because we have no idea what causes these ulcers, we have no idea how to treat them.

Even though researchers are not sure of the exact composition of aphthous ulcers, there are certain etiologic factors that have been identified. Genetics may play a part in recurring aphthous ulcers. (5) Other etiological factors may include stress, trauma, food sensitivity, menstruation, infection, altered vitamin and thyroid levels, smoking cessation, decreased immunity and certain systemic diseases. Aphthous ulcers tend to occur more frequently in persons with HIV, Behcet's syndrome, Crohn's disease, ulcerative colitis, cyclic neutropenia, sprue, intestinal lymphoma, and celiac disease. (2,3) Emotional stress can have an effect on a person's overall health and immune system. Increased stress can alter our abilities to fight infection and can lead a person to be more susceptible to aphthous ulcers. (2,3) For example, students report ulcer infections during exam times when they are experiencing lack of sleep and high stress levels.

Susceptibility to aphthous ulcers is also found in patients with hematinic deficiencies. In 20 percent of patients with recurring aphthae infections, deficiencies such as iron, folate and vitamins B-1, B-2, B-6 and B-12 are being found. (2) Patients with hypothyroidism seem to be more prone to ulcer outbreaks. (2) If you have a patient who suffers from aphthous ulcer issues, they should be referred to their physician, who can check vitamin, iron and thyroid levels.

There are dental considerations to be aware of in treating patients who have frequent aphthous ulcer outbreaks. Dental procedures that can injure or traumatize tissue, such as injections and routine prophylaxes, have been found to predispose a patient to ulcer outbreaks because the tissues are manipulated and possibly lacerated. (1,3) Even simple things done each day in our offices can traumatize tissues, such as taking radiographs. Dental appliances such as partials, dentures, nightguards and orthodontic retainers can injure mucosa as well. Even certain toothpastes can predispose a patient to aphthae outbreaks. Some studies have linked apthous ulcer susceptibility to sodium laurel sulfate, a powerful wetting, degreasing and foaming agent found in some dentifrices. (2)

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These ulcers heal spontaneously, but during their course, the patient can have moderate to severe pain. Treatments options are palliative and symptom-focused and include prescription drugs, over-the-counter analgesics and in-office therapies. There are no preventive options to date.

The American Academy of Oral Medicine (AAOM) has recommended topical prescription drugs for the treatment of aphthous ulcers including topical anesthetics, antihistamines, antimicrobials and anti-inflammatory agents. Popular topical agents on the market today are corticosteroids like Kenalog, Orabase and Lidex; tetracycline mouthrinses; topical anti-inflammatory agents like benzydamine hydrochloride mouthrinses and betamethasone gel; as well as antimicrobial mouthrinses like chlorhexidine gluconate. All of these drugs have been shown to reduce pain and duration, but not severity or recurrence rate. (2,4) To date, the most effective, widely studied and cost-effective topical drug on the market is Amlexanox. (5) It is a paste that is applied four times a day directly to the ulcer. It has been shown to decrease healing time and pain in clinical trials. The most common brand name for this drug in the United States is Aphthasol.

There are also over-the-counter medications for pain relief available to patients. Any medication that contains lidocaine, benzoin, benzonin tincture, camphor or 20 percent benzocaine is effective in pain reduction. There are studies that suggest vitamin supplements like lysine and vitamins A, B and C can help alleviate ulcer outbreaks, but no scientific studies have been done on these agents to date. Some physicians are also recommending herbal supplements like echinacea because it activates the body's immune system, increasing the chances of fighting off infection. (2,4)

In-office treatment options are very helpful for providing fast pain relief that permits a more comfortable prophylaxis appointment for your patients. The medication I use quite frequently is Debacterol, which can be used only under the direct supervision of an oral health provider and is not available for home use. It is a semi-viscous liquid agent that is applied directly onto an ulcer for 10 seconds, then rinsed away. Debacterol will seal damaged oral mucosal tissues and forms a protective barrier after just one application. Since it provides relief to the patient immediately after application, I am able to access all areas of their mouth during a routine prophylaxis without causing them any pain by touching and manipulating their ulcerated tissue.

I have many patients come into my dental practice with ulcers in their mouths. Usually, I will apply Debacterol to the area and their pain is gone. The next goal I have is to educate the patient on aphthous ulcers, because I have found that most people have no clue what they are. Most people tell me they think they have a herpes lesion, and when I tell them it is an aphthous ulcer, they do not recognize that term. I look for risk factors that may be present in their medical history as described above. I look for thyroid problems or any immunodeficiency problems. I ask if they are having high levels of stress, if they take a multivitamin daily and if their parents or grandparents suffer from ulcer outbreaks. I try to ask the right questions to see if I can identify a risk factor.

If the patient has a high frequency of outbreaks, and I cannot identify any risk factor on my own, I will refer them to their primary care physician and possibly one of our local oral surgeons for further investigation. Usually a blood sample is needed to rule out systemic predisposing factors that may be contributing to ulcer problems. I treat reported ulcer outbreaks the same way I treat oral cancer screening issues. If I see something suspicious intraorally during my screening, I immediately refer my patient to their physician or to an oral surgeon for further evaluation. Aphthous ulcers can be the first sign or symptom of a more serious systemic problem and should not be overlooked.

From this article, you should better be able to discuss aphthous ulcers with your patients and provide treatment options or referrals as needed. Due to the mysterious nature of aphthous ulcers, it is hard for health care professionals to provide our patients with definitive answers. However, we can try to alleviate their pain and offer education that may help improve their understanding of their own condition. Until researchers have more answers for us on the composition and etiology of aphthous ulcers, we are forced to treat out patients palliatively. Hopefully, answers to all our questions are just around the corner.

References

(1.) Barrons RW. Treatment strategies for recurrent oral aphthous ulcers. Am J Health System Pharmacy 2001; 58(1): 41-53. Available at www.medscape.com/medline/abstract/11194135. Accessed June 2006.

(2.) Scully C. Aphthous ulcers. Emedicine from WebMD, October 28, 2005. Available at www.emedicine.com/ent/topic700.htm. Accessed June 2006.

(3.) Ibsen OAC, Phelan J. Oral pathology for the dental hygienist, 3rd ed. Philadelphia: Saunders, 2000: 113-114.

(4.) McBride D. Management of aphthous ulcers. Am Family Physician, July 1, 2000. Available at www.aafp.org/afp/20000701/149.html. Accessed June 2007.

(5.) Fernandes R, Tuckey T, Lam P, et al. The best treatment for aphthous ulcers. Available at www.utoronto.ca/dentistry/newsresources/ evidence_based/aphthousulcers.pdf. Accessed June 2006.

By Lisa Dowst-Mayo, RDH, BS

Lisa Dowst-Mayo holds a Bachelor's Degree in dental hygiene from Baylor College of Dentistry, where she graduated in 2002 with highest honors and received numerous scholarships. She has held many leadership positions including president of her dental hygiene class and the current first vice president of the Dallas Dental Hygiene Society. An active member of the Texas and American Dental Hygienists' Associations, she works as a full-time clinical dental hygienist in Flower Mound, Texas at Cross Timbers Dental, the office of Brad Revering, DDS.