INTRODUCTION:

Recurrent apthous stomatitis is one of the most common painful oral mucosal conditions seen among patients. These present as recurrent, multiple, small, round, or ovoid ulcers, with cirucumscribed margins, having yellow or gray floors and are surrounded by erythematous haloes, present in childhood or adolescence.¹

Because of the similarity between this disease and herpes simplex infection, with respect to precipitating factors, certain aspects of the clinical appearance of lesions, duration of lesions, recurrence and general failure of response to any form of therapy, the two diseases have been generally confused. A series of intense investigations have established the fact that there is no etiologic relationship between recurrent aphthous stomatitis and herpes simplex infection.

The clinical features of RAS comprise recurrent bouts of one or several rounded, shallow, painful ulcer at intervals of a few months to a few days; RAS has three main presentations: minor, major, or herpetiform ulcers.

Minor recurrent apthous stomatitis, the most common variety, affects about 80% of RAS adult and child patients, and is characterized by round or oval shallow ulcers usually less than 5 mm in diameter with a gray-white pseudomembrane enveloped by a thin erythematous halo. Usually, it occurs on the nonkeratinized mobile surface such as the labial and buccal mucosa and floor of the mouth and is uncommon on the gingival, palate, or dorsum of the tongue. These lesions heal within 1 or 2 weeks without scarring. ²

Clinical Features:

Major recurrent apthous stomatitis is an uncommon and severe form of RAS, comprising oval or irregular ulcers that may exceed 1 cm in diameter. These ulcers have a predilection for the lips, soft palate, and fauces, persist for up to 6 weeks, and often heals with scarring.

Herpetiform is very uncommon, being characterized by multiple recurrent crops of small, painful ulcers that may be distributed throughout the oral cavity. As many as 100 ulcers may be present at a given time, although they tend to fuse, producing large irregular ulcers. It has been suggested that herpetiform ulcer might have a female predisposition and also a later age of onset than other RAS types or represents a spectrum of oral disorders manifesting as recurring ulcers.³

Etiopathogenesis:

Family history:

There often is a genetic basis for RAS. More than 42 percent of patients with RAS have first-degree relatives with RAS.⁴ The likelihood of RAS is 90 percent when both parents are affected, but only 20 percent when neither parent has RAS.⁵

Immunopathogenesis:

The pathogenesis of RAS involves a predominantly cell-mediated immune response in which tumor necrosis factor α plays a major role. A mononuclear cell infiltrate in the preulcerative stage is followed by a localized popular swelling due to keratinocyte vacuolation surrounded by a reactive erythematous halo representing vasculitis. The painful papule then ulcerates and a fibrinous membrane covers the ulcer, which is infiltrated mainly by neutrophils, lymphocytes and plasma cells. Finally, there is healing with epithelial regeneration. The immunopathogenesis probably involves cell-mediated responses, involving T cells and TNF-α production by these and other leukocytes.⁶

Predisposing Factors:

Classic RAS is a localized condition representing a relatively simple disease, although a minority of patients may be predisposed to it by systemic conditions or diseases. The etiology probably is multifactorial, with various predisposing factors and immunological changes provoked by a range of factors.

Trauma:

Trauma may provoke ulcers in patients with RAS.

Stress:

Stress can provoke episodes of RAS, but the association is not invariable.⁷

Foods:

Foods such as chocolate, coffee, peanuts, cereals, almonds, strawberries, cheese, tomatoes and wheat flour may be implicated in some patients.^8,9

Hormonal imbalance:

There are a few patients whose RAS remits with oral contraceptives or during pregnancy.¹⁰

Tobacoo smoking:

Patients suffering from RAS usually are nonsmokers,¹¹ and there is a lower prevalence and severity of RAS among heavy smokers as opposed to moderate smokers.¹²The use of smokeless tobacco also is associated with a significantly lower prevalence of RAS.¹³Nicotine- containing tablets also appears to control the frequency of RAS.¹⁴

Diagnosis:

A complete blood cell count, hematinic estimation and test for anti-endomysial antibodies are indicated to rule out immune disturbances, vitamin and iron deficiencies, and malabsorption (such as in celiac disease).¹⁵

Histopathology of RAS:

The microscopic picture of aphthous ulcer is non-specific, and diagnosis must be based on history and careful clinical examination. The mucous membrane of aphthous ulcer shows superficial tissue necrosis with a fibrinopurulent membrane covering the ulcerated area. The necrosis is covered by tissue debris and neutrophils. Epithelium is infiltrated by lymphocytes and few neutrophils. Intense inflammatory cell infiltration, predominantly neutrophils present immediately below the ulcer, mononuclear lymphocytes are seen in adjacent areas. Minor salivary glands commonly present in areas of aphthae exhibit focal periductal and perialveolar fibrosis and chronic inflammation.^16,17

Management of RAS:

A systematic review of the management of RAS is available.¹⁸Patients with oral ulceration possibly associated with systemic disease require referral to an appropriate specialist.²

CONCLUSION:

Recurrent apthous stomatitis remains a common oral mucosal disorder in most communities of the world; however, as its precise etiology remains unknown, therapy is nonspecific and often of limited efficacy. Fortunately, patients with RAS are generally otherwise quite well.

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Received on 13.01.2015 Modified on 04.02.2015

Research J. Pharm. and Tech. 8(11): Nov., 2015; Page 1580-1581

DOI: 10.5958/0974-360X.2015.00281.4