APHTHAS AND APHTOSIS
Etymologically, the term “aphte”; deriving from the Greek “aptein” meaning to burn, described by Hippocrates in 400 BC .
Isolated aphthous ulcer (banal, vulgar or simple) constitutes the basic common lesion of all aphthous lesions whatever their clinical form. It is a painful and superficial ulceration of the oral mucosa evolving spontaneously towards healing without scarring sequelae . It remains the key symptom, found both in chronic recurrent oral aphthosis ABR and in Behçet ‘s disease .
Oral aphthosis is classically a recurrent condition of the oral mucosa that evolves in flare-ups (recurrent oral aphthosis ABR) and generally does not leave scarring sequelae. The repetition of aphthous lesions within a year leads to the diagnosis of ABR .
Classically, ABR aphthae are most often superficial , isolated (vulgar-looking aphthae) or multiple, or even in a “bouquet”, or are sometimes deep (necrotizing aphthae). This ABR is described as simple or minor in the usual cases (spaced and few lesions), and complex when recurrences occur even before the healing of the previous lesion , or when associated with a systemic condition ( AIDS ). Associated with genital aphthosis, it is called bipolar aphthosis, isolated ( Neumann bipolar aphthosis) or in the context of Behçet ‘s disease which is serious, disabling and multipolar (oral, genital, ocular, etc.).
I. EPIDEMIOLOGY OF APHTHOSES : These lesions affect to varying degrees 6 to 66% of the population, depending on the groups studied. A certain predominance seems to exist for women and girls. Recurrent oral aphthosis begins during childhood or adolescence, with a peak frequency between 10 and 19 years of age. It can affect children under 5 years of age .
The frequency and severity of flare-ups decrease with age. Giant or necrotizing canker sores may begin after puberty. Miliary canker sores tend to affect older people.
II. GENERAL CLINICAL MANIFESTATIONS:
1. Isolated aphtha, elementary lesion: whatever the clinical form, the elementary lesion is the same. Ulceration sometimes preceded by a burning sensation; the initial lesion is an erythematous macule, a papule or even a vesicular one on which the classic ulceration occurs: round or oval, with regular edges, surrounded by a red halo, with a flat, flexible, yellow or grayish fibrinous base.
All sites of the oral cavity can be affected, especially the non-keratinized mucosa.
The lesions are painful, non-infiltrated, without satellite adenopathies.
1.1. Differential diagnosis of isolated aphtha:
The diagnosis of isolated simple common aphthae is purely clinical and easy to make, but this diagnosis will only be made after a complete examination to eliminate any lesions whose clinical appearance is similar to that of aphthae (traumatic, tuberculous, syphilitic, cancerous ulcers, etc.)
1.2. Anatomopathology :
This is a non-specific ulceration; the center of the lesion is characterized by ischemic necrosis by vascular obliteration, with disappearance of the Malpighian mucosal body.
At the periphery of the necrosis, the vessels are dilated. This microscopic appearance corresponds to vasculitis.
The course of a mouth ulcer can be schematically divided into four successive phases, according to Stanley:
* phase 1 or prodromal phase : it is painful, characterized by a tingling and burning sensation lasting less than 24 hours .
* phase 2 or preulcerative phase : it lasts 18 to 72 hours during which one or more erythematous, macular or papular lesions develop, or even vesicular ones with increasing pain.
* phase 3 or ulcerative : this is the appearance of ulceration that never bleeds and persists for a few days to a few weeks (case of giant necrotizing canker sore ). It is very painful; but the latter gradually diminishes. This phase can last 4 days.
* phase 4 or re-epithelialization period : this is the healing phase; it is painless and lasts a few days to a few weeks.
These ulcers ( phase 3 ) are locally painful , uncomfortable, and interfere with speech and eating. They are typically 2 to 10 mm in diameter, with a yellowish necrotic base, “fresh butter”, then become grayish (phase 4 ). Their edge is clear, surrounded by a bright red inflammatory peripheral border (halo). The base of the ulceration remains flexible and not indurated, except in necrotic varieties (giant necrotizing aphtha). The aphthae appear isolated or grouped in a “cluster or bouquet”. The pain persists for 3 to 4 days , until the formation of a thick fibrinous layer or re-epithelialization. Three main presentations of ABR were initially described by Cooke, and which always remain benign:
APHTHAS AND APHTOSIS
2. Aphthous ulcers : Aphthous ulcers generally begin in childhood ( 80% before the age of 30 ) and tend to regress in number of outbreaks and severity over the years. It is characterized by the multiplicity of lesions ( 2 to 10 ) or more and frequent recurrences (several times per year).
Minor form
Major form
Cooke ‘s herpetiform or miliary form
2.1. The minor form of ABR
The minor or simple form of ABR is the most common variety, simply disturbing affecting 80% of patients with aphthosis. The age of onset is 5 – 19 years ; it preferentially affects the subject between 10 and 40 years .
Symptoms are generally minor. It is characterized by the presence of classic (common) oral ulcers. These ulcers are isolated or multiple ( 2 to 6 ulcers ). These minor lesions occur mainly on the labial and jugal mucosa as well as the floor of the mouth. They heal in 7 to 14 days without leaving scars. They recur after an interval of 1 to 4 months and this is the most frequently encountered form in children. Recurrences only occur after the complete healing of the lesions that precede them. Its diagnosis is clinical and is based on the history. No additional examination is necessary for the diagnosis if the lesion is isolated.
It is necessary to look for the circumstances that trigger flare-ups in order to avoid them (foods).
2.2. Major form of ABR
The major or complex form of ABR is severe but rarer ( 10 to 15% of ABRs ), more painful than the minor form. The aphthous ulcer is generally described under the term “necrotizing aphthous ulcer”, formerly called “periadenitis” of Sutton . These lesions usually begin after puberty. They are usually deeper, oval, single or multiple ( 2 to 10 ulcerations ) and can exceed 1 cm in diameter up to 3 cm and they often leave a scar. These necrotizing aphthous ulcers have a predilection for the lips, the soft palate and the tonsillar pillar, but can affect any site, including the dorsal surface of the tongue. The aphthous lesion can last 30 days or even 45 days , new lesions appear during the healing of the previous ones (overlapping lesions), or in the event of association with genital aphthosis or perianal lesions, in the absence of Behçet’s disease, or in association with a systemic condition ( AIDS for example). This form can occur when taking Nicorandil ( antianginal).
The differential diagnosis can be made with:
herpes
lichen planus in its erosive form
bullous stomatitis
pemphigus
2.3. Herpetiform or miliary form of ABR
It is also described under the terms of miliary aphthae or Cooke ‘s herpetiform ulcers . It may have a predilection for women, and begins later than the other forms. It is characterized by the recurrent occurrence and in “bouquet” of multiple small ulcers ( 10 to 100 ), each measuring 1 to 3 mm, extremely painful, disseminated, and which can be distributed throughout the oral cavity. These ulcers are grouped and tend to merge, to produce large superficial and irregular ulcers which then resemble major “necrotizing” aphthae. They heal in 7 to 30 days.
Herpetiform ABR is not of viral origin
III. ETIOLOGY OR CAUSES
The etiology of canker sores is not yet well understood, however there are factors that may be incriminated.
1. Genetic bases
More than 40% of patients with ABR may report a vague notion of familial oral aphthosis.
2. Local predisposing factors
* local trauma: tooth brushing, dental prostheses, etc.
* non-keratinized mucous membranes;
* poor oral hygiene;
* some toothpastes;
3. Predisposing systemic factors
Most patients with ABR are otherwise in excellent general condition.
* stress, anxiety;
* atopy or allergy;
* food additives and certain foods: chocolate, cheese (Gruyere), dried fruits, etc.
* a minority of women have cyclical oral aphthosis related to the luteal phase
of the menstrual cycle;
* certain medications: NSAIDs ( Non- Steroidal Anti – Inflammatory Drugs ) ; Nicorandil (anti-anginal drugs).
IV. TREATMENT
There is no specific effective treatment for ABR . Mild forms of oral aphthosis justify the use of non-aggressive and symptomatic therapies (topical or local treatment). Symptoms can be reduced, but it is difficult to prevent recurrences.
Before prescribing treatment for ABR , it is important to look for causes that may contribute to this disease. Patients who present with a potentially causative systemic condition should be referred to the appropriate specialists.
The search for food allergens is useful, and dietary measures are proposed, when certain foods seem to be correlated with aphthous outbreaks. Hematological tests are carried out in the case of ABR of more than 6 months , in search of a hematinic deficiency (iron, folic acid, vitamin B 12).
1. Topical treatments
These treatments concern the first aim of the overall treatment, the pain and the duration of the attacks, but have no effect on the prevention of recurrences.
* topical application of local anesthetics gel or solution ( Xylocaine ) provides temporary relief, applied especially before meals. Thus, local applications (in the case of isolated canker sores) of Lidocaine gel at 2% and mouthwashes (in the case of multiple or miliary canker sores) with viscous Lidocaine at 2%
( 1 teaspoon of the product in 1 or 2 teaspoons of water helps relieve pain before meals.
* the use of local corticosteroids constitutes, along with local anesthetics, one of the essential components of the treatment of recurrent aphthous ulcers. They reduce the duration of the ulcers as well as the pain, they do not prevent recurrences.
_ Hydrocortisone H emisuccinate (lozenges) 2 to 4 times / day;
_ B etamethasone (mouthwash) …
* in clinical practice , products can be combined in magistral preparation:
_ Molar sodium bicarbonate 8.4 %: 60 ml ;
_ Chlorhexidine gluconate: 60 to 120 ml;
_ Lidocaine hydrochloride: 120 to 240 mg;
_ Dexamethasone (corticosteroid): 4 to 20 mg ;
_ H 2 O: 300 ml.
* to obtain immediate and generally definitive neutralization of the pain, cauterization of the lesion can be performed, for example with 30% trichloroacetic acid applied with a cotton swab, or with chromic acid or silver nitrate.
2. Systemic treatment
Several systemic immunomodulatory treatments have been proposed, such as their trial or use in Behçet’s disease . Among these, the efficacy of Levamisol , oral corticosteroids, Colchicine and Thalidomide should be noted in the treatment of disabling ABR .
V. APHTHAS IN THE CONTEXT OF PATHOLOGIES
1. Behçet’s disease
It is a recurrent inflammatory multisystem disease, with a chronic course and unknown cause. Its clinical expression is dominated by oral, genital, ocular (uveitis) and even cutaneous and articular aphthous ulcers. Arteries and veins, the central nervous system and the digestive tract can also be affected.
2. Aphthosis and AIDS
A particular form of associated aphthosis, a common aphthosis can be encountered during AIDS , as in non-immunocompromised patients; but a severe form of oral aphthosis , made up of giant, often necrotic or hollowing aphthae , is encountered quite frequently during AIDS.
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APHTHAS AND APHTOSIS
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