Oral Ulcerative Lesions
Ulcers are the most common lesions affecting the oral mucosa, and they can be ascribed to a plethora of local or systemic conditions, making differential diagnosis pivotal and often difficult. As oral ulcers dŁ can be a manifestation of local or systemic conditions of very different nature and severity, including trauma (mechanical, chemical, thermal), drug reactions, immune-mediated diseases, infections, and neoplasms; a careful differential diagnosis is mandatory. Recurrent aphthous stomatitis (RAS) is the most frequent ulcerative disorder of the oral cavity, affecting 10–20% of the general population. RAS lesions typically present as round or oval shallow ulcers of the nonkeratinized mucosa, with a yellow-grayish fibrin pseudomembrane and a characteristic erythematous halo. They usually appear first in childhood or adolescence, in subjects without other systemic signs. RAS may present in four main forms based on its clinical appearance (minor, major, herpetiform, and severe), and its management depends on the frequency and severity of the lesions. RAS episodes are self-limiting and in most cases do not need treatment. For severe and painful cases, the aim of therapy is to control pain and to reduce the frequency of episodes. Topical corticosteroids are typically first-line treatment, but they do not affect the rate of recurrence. Less frequently, aphthous stomatitis can be associated with a number of systemic conditions, including gastrointestinal disorders, in particular inflammatory bowel diseases and celiac disease, Behçet syndrome, food allergy, and deficiencies of micronutrients, mainly vitamin B12, folate, ferritin, and iron. In all these cases, the detection of oral lesions can lead to an early diagnosis of the underlying condition, the management of which requires a multi-specialist approach.
KeywordsOral ulcer Oral ulcerative disease Oral ulcerative conditions Recurrent aphthous ulceration Recurrent aphthous stomatitis Aphthous-like ulcers Crohn’s disease Celiac disease Inflammatory bowel disease Behçet syndrome Food allergy Micronutrient deficiency
- Babaee N, Hosseinkazemi H, Pouramir M, Khakbaz Baboli O, Salehi M, Khadir F, Bijani A, Mehryari M. Salivary oxidant/antioxidant status and haematological parameters in patients with recurrent aphthous stomatitis. Caspian J Int Med. 2016;7(1):13–8.Google Scholar
- Barker JM, Liu E. Celiac disease: pathophysiology, clinical manifestations, and associated autoimmune conditions. Adv Pediatr Infect Dis. 2008;55:349–65.Google Scholar
- Behçet H. Uber rezidivierende aphthöse, durch ein Virus verursachte Geschwure, am Mund, am Auge, und an den Genitalien. Dermatol Wochenschr. 1937;36:1152–7.Google Scholar
- Brocklehurst P, Tickle M, Glenny AM, Lewis MA, Pemberton MN, Taylor J, Walsh T, Riley P, Yates JM. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012;9:CD005411.Google Scholar
- de Carvalho FK, de Queiroz AM, Bezerra da Silva RA, Sawamura R, Bachmann L, Bezerra da Silva LA, Nelson-Filho P. Oral aspects in celiac disease children: clinical and dental enamel chemical evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119(6):636–43.PubMedCrossRefPubMedCentralGoogle Scholar
- International Study Group for Behçet Disease. Criteria for diagnosis of Behçet disease. Lancet. 1990;335(8697):1078–80.Google Scholar
- International Team for the Revision of the International Criteria for Behçet Disease (ITR-ICBD). The international criteria for Behçet disease (ICBD): a collaborative study of 27 countries on the sensitivity and specificity of the new criteria. J Eur Acad Dermatol Venereol. 2014;28(3):338–47.CrossRefGoogle Scholar
- Lionetti E, Castellaneta S, Francavilla R, Pulvirenti A, Tonutti E, Amarri S, Barbato M, Barbera C, Barera G, Bellantoni A, Castellano E, Guariso G, Limongelli MG, Pellegrino S, Polloni C, Ughi C, Zuin G, Fasano A, Catassi C, SIGENP (Italian Society of Pediatric Gastroenterology, Hepatology, and Nutrition) Working Group on Weaning and CD Risk. Introduction of gluten, HLA status, and the risk of celiac disease in children. N Engl J Med. 2014;371(14):1295–303.PubMedCrossRefPubMedCentralGoogle Scholar
- McMillan R, Taylor J, Shephard M, Ahmed R, Carrozzo M, Setterfield J, Grando S, Mignogna M, Kuten-Shorrer M, Musbah T, Elia A, McGowan R, Kerr AR, Greenberg MS, Hodgson T, Sirois D. World workshop on oral medicine VI: a systematic review of the treatment of mucocutaneous pemphigus vulgaris. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;120(2):132–42.PubMedPubMedCentralCrossRefGoogle Scholar
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention – Epidemiology of the IBD – Inflammatory Bowel Disease. [Internet] 2015 [page last updated: March 31, 2015]. Available from: www.cdc.gov/ibd/ibd-epidemiology.htm. Accessed 19 Aug 2016.
- Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Boston: Little, Brown; 1991.Google Scholar
- Shah D, Sachdev HS, Gera T, De-Regil LM, Peña-Rosas JP. Fortification of staple foods with zinc for improving zinc status and other health outcomes in the general population. Cochrane Database Syst Rev. 2016;6:CD010697.Google Scholar
- Singh B, Kedia S, Konijeti G, Mouli VP, Dhingra R, Kurrey L, Srivastava S, Pradhan R, Makharia G, Ahuja V. Extra-intestinal manifestations of inflammatory bowel disease and intestinal tuberculosis: frequency and relation with disease phenotype. Indian J Gastroenterol. 2015;34:43–50.PubMedCrossRefPubMedCentralGoogle Scholar
- Sun A, Chu CT, Liu BY, Wang JT, Leu JS, Chiang CP. Expression of interleukin-2 receptor by activated peripheral blood lymphocytes upregulated by the plasma level of interleukin-2 in patients with recurrent aphthous ulcers. Proc Natl Sci Counc Repub China B. 2000;24(3):116–22.PubMedPubMedCentralGoogle Scholar
- Taylor J, Glenny AM, Walsh T, et al. Interventions for the management of oral ulcers in Behcet’s disease. Cochrane Database Syst Rev. 2014;9:CD011018.Google Scholar
- Taylor J, McMillan R, Shephard M, Setterfield J, Ahmed R, Carrozzo M, Grando S, Mignogna M, Kuten-Shorrer M, Musbah T, Elia A, McGowan R, Kerr AR, Greenberg MS, Hodgson T, Sirois D. World workshop on oral medicine VI: a systematic review of the treatment of mucous membrane pemphigoid. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;120(2):161–71.PubMedCrossRefGoogle Scholar
- Vidal-Alaball J, Butler CC, Cannings-John R, Goringe A, Hood K, McCaddon A, McDowell I, Papaioannou A. Oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency. Cochrane Database Syst Rev. 2005;3:CD004655.Google Scholar
- World Health Organization. Nutrition. Micronutrients. [Internet] 2016. Available from: www.who.int/nutrition/topics/micronutrients/en/#. Accessed 19 Aug 2016.