Diagnosis and Treatment of Recurrent Aphthous Ulceration
Brian C. Muzyka, DMD, MS, MBA
Recurrent aphthous ulcerations have been divided into three clinically distinctive categories ( major recurrent aphthous ulceration (MjRAU), minor recurrent aphthous ulceration (MiRAU), and herpetiform ulceration (HU).
Major Recurrent Aphthous Ulcers
Typical MjRAUs are large (10 mm in diameter or more) and craterlike with a deeply eroded base. These ulcers are present for a minimum of three weeks and can be severely debilitating by interfering with normal masticatory and phonetic functions. It is common for patients with MjRAU to become dehydrated and nutritionally depleted due to pain associated with the consumption of foods and liquids. With severe, chronic, nonhealing MjRAU, hospitalization of the patient may be required to ensure adequate nutritional intake by parenteral means. In most cases, therapeutic intervention is necessary to ensure healing. Glucocorticosteroids and antibiotics are often used in conjunction with local anesthetics to reduce discomfort. Due to the infrequent occurrence of this lesion in healthy individuals, no prevalence studies among the general population with MjRAUs have been reported.
Minor Recurrent Aphthous Ulcers and Herpetiform Ulcerations
The more common minor aphthous ulcers, by contrast, are less than 10 mm in diameter and heal spontaneously in seven to ten days. Minor aphthous ulcers are generally found on the less keratinized tissues in the oral cavity, (ie, buccal mucosa, floor of the mouth, and ventral surface of the tongue).
In a study conducted among dental and medical professionals, up to 60% reported the occurrence of MiRAUs, presumably in response to increased stress, while the incidence rate in the general population is approximately 20%.1
Herpetiform ulcerations (HUs) are described as recurrent crops of dozens of small ulcers that appear throughout the oral mucosa. The clinical appearance of HUs is similar to those caused by the herpes simplex virus. Herpetiform ulcerations are more frequently described in women and may account for up to 10% of all RAUs. Herpetiform ulcerations heal spontaneously in seven to ten days without significant scarring of the affected site.
Diagnosis and Treatment of Recurrent Aphthous Ulcerations
A fundamental tenet in the treatment of most diseases or disease entities is to first establish a diagnosis and determine the causative agent. Recurrent aphthous ulcerations, however, are diagnosed by history and clinical presentation, followed by the elimination of known etiologic pathogens. A simple cytological smear from the area surrounding the ulcer is used to determine etiologic agents. Treatment of RAUs must be based on a logarithm of therapies that address known predisposing and local factors.
Since no single causative occurrence is responsible for all RAUs, several different but successful treatment philosophies have been utilized. Glucocorticosteroid and antimicrobial therapy constitute the traditional treatment for MjRAU. These medications are administered in a variety of forms that include topical pastes, mouthrinses, intralesional injections, and systemically by oral route. Varied success has been achieved with alternate therapeutic modalities for RAU, which includes immunomodulators (eg, levamisole).
Preparations of multiple medications in the form of mouthrinses have been beneficial for patients with RAU. One such preparation ( Miles' Mixture ( contains 84,000 µnystatin, 84 mg tetracycline, and 1.04 mg hydrocortisone per 5 cc. Patients are instructed to rinse and expectorate four times per day. Viscous xylocaine (a topical anesthetic agent) may be used concurrently for additional palliative relief.
People with RAUs must be informed of the empirical nature of any proposed treatment. The severe sequellae of MjRAUs in debilitated patients, however, requires immediate and effective therapeutic intervention to prevent further deterioration of the patients' health. It may be wise to consider less toxic treatment at an early stage when the lesions do not exhibit aggressive tissue destruction, although institution of more invasive and potentially cytotoxic therapy may be necessary thereafter.
Many oral lesions are early indicators of immune deterioration. It is imperative for the healthcare team to recognize these manifestations and refer these patients for appropriate treatment. Early detection and successful treatment of these debilitating lesions most certainly increases the patient's quality of life.
Ed. Note: For more information on this topic, we suggest you read our article entitled Recurrent Aphthous Ulcers
*Director of Hospital Dentistry, Division of General Dentistry, East Carolina University School of Dental Medicine, Greenville, NC
- Ship II. Epidemiological aspects of recurrent aphthous ulcerations. Oral Surg 1972;33:400-406.