Oral mucosal disease: Recurrent aphthous stomatitis
Introduction
Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is typified by recurrent ulceration of the oral mucosa. Whereas patients with RAS have no other clinical abnormalities, people with Behçet disease may also develop a wide spectrum of genital, ocular, cutaneous, neurological, and vascular problems. This article reviews current aspects of RAS – a common oral mucosal disorder that is characterised by multiple, recurrent, small, round, or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors that present first in childhood or adolescence.1, 2
RAS is seen worldwide and may affect up to 25% of the population,3, 4, 5, 6, 7, 8, 9 but may be three times more common in US whites than in African Americans.10
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Aetiology and pathogenesis
The cause of RAS is still unknown. The histopathological changes in the pre-ulcerative stage include infiltration of the epithelium by mononuclear (lymphocytic) cells. Oedema develops, followed by keratinocyte vacuolisation and localised vasculitis causing localised swelling that ulcerates and is infiltrated by neutrophils, lymphocytes, and plasma cells before there is healing and regeneration of the epithelium. There is a cell-mediated immune response that involves T-cells with generation of
Clinical features
RAS comprises recurrent bouts of one or several rounded, shallow, painful ulcers at intervals of a few months to a few days in people who are otherwise well. It has three main presentations – minor (MiRAS), major (MaRAS) or herpetiform (HU) ulcers.
Minor RAS (MiRAS) is the most common,92 and affects about 80% of patients with RAS: ulcers are small (less than 5 mm in diameter), round, or oval, usually with a grey–white pseudomembrane and an erythematous halo (Fig. 1, Fig. 2). It usually occurs on
Diagnosis of RAS
The diagnosis of RAS is based on history and clinical findings. There is no specific diagnostic test, but there is a need to exclude other possible causes of recurrent oral ulceration, such as Behçet disease, PFAPA syndrome, and possible infection by HIV.2 (Table 1, Table 2). The main point is that in Behçet disease there are lesions elsewhere, usually on other mucosa such as genitals or eyes, skin, and organs (Table 2).
Management of RAS
It is important to consider a possible systemic cause, particularly when adults suddenly develop what appears to be RAS (Fig. 4). It is common practice therefore, to assess the full (complete) blood cell count, red cell folate, and serum levels of ferritin (or equivalents) and vitamin B12, which may also show potential gastrointestinal disease, but, in the absence of other manifestations, screening for gluten sensitive enteropathy is usually fruitless.2
There is no curative treatment for RAS.
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