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Story 13 July 2006
Clinical review - aphthous ulceration
This week's clinical review from the NEJM covers what the author notes to be one of the commonest oral conditions, which may affect up to 25% of people at some time. As usual in this series, the review starts by presenting a typical case: a woman aged 20 who has had recurrent painful mouth ulcers for the past ten years, with no other mucous membrane ulceration or other signs of systemic illness.
Aphthous ulcers - or recurrent aphthous stomatitis - is characterised by round or oval, painful, recurring ulcers in the mouth. In distinction from oral ulceration associated with other, more serious, conditions (e.g. Behçet's syndrome, inflammatory bowel disease, celiac disease, HIV infection), ulceration is limited to the mouth and there are no systemic signs. It tends to start in childhood, and there is often a family history; it is less common after the age of 30. Most patients have minor aphthous ulcers, which are generally less than 8mm in diameter and heal spontaneously in around 10-14 days; a smaller proportion have major ulcers, which are larger, and other more serious variants. The epidemiology and pathophysiology are briefly covered - although various precipitating factors and causes have been suggested, most have little reliable evidence in their support.
The author describes steps in the diagnosis of aphthous ulceration - diagnosis is primarily on history and symptoms: a careful history and examination are necessary to rule out any underlying cause. Further investigation is also necessary in cases where ulcers do not heal within three weeks, but are probably not necessary if the history and examination are characteristic of aphthous ulceration and there are no indications of other disorders. Some cases can be drug-induced, so a drug history is important.
Treatment is aimed mainly at relief of pain and inflammation, unless an underlying cause has been identified, and patients should be advised to avoid oral trauma and acidic foods or drinks that may exacerbate pain. Evidence supports a number of treatments for aphthous ulcers, although much is from trials that have been small and incompletely blinded. Efficacy for most treatments is modest. Among those for which some efficacy has been demonstrated are topical protective pastes, topical corticosteroids (including hydrocortisone oral pellets), antimicrobial mouthwashes containing chlorhexidine or triclosan, and amlexanox paste (Aphtheal, not yet available in UK). Doxycycline mouth rinse (mix the contents of a 100mg capsule with 10ml water) may also be helpful, but oral candidiasis may be a problem with prolonged use. There are few head-to-head comparisons of different agents.
The author notes that there are still areas of uncertainty over the causes of the condition, and over the effectiveness of some of the treatments suggested for more severe cases. Available guidelines include those from PRODIGY, with which the management strategy suggested is consistent. (50 references)
NEJM 2006; 355: 165-72 (link to abstract)