Aphthae habituelle K12.0

Authors: Prof. Dr. med. Peter Altmeyer, Prof. Dr. med. Martina Bacharach-Buhles

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Last updated on: 29.10.2020

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Synonym(s)

Chronic recurrent aphthae; Habitat Aphthae; Periadenitis mucosae necrotica recurrens; Recurrent aphthae; Recurrent benign aphthosis

History
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Heberden, 1802; by Mikulicz-Radecki and Caraway, 1898; Sutton, 1911

Definition
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Extremely frequent, mostly harmless disease with the appearance of superficial, painful ulcers on the mucous membrane.

Occurrence/Epidemiology
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In 10-50% of the population, mostly minor type.

Etiopathogenesis
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Unexplained, probably multifactorial triggering with corresponding disposition. Possible triggers are trauma, gastrointestinal disorders, hormonal influence (paramenstrual occurrence), infections, stress and food intolerances (nuts, more rarely tomatoes). One thinks of an immunological or autoimmunological malfunction with subsequent destruction of the epithelial cells. Familial accumulation.

Manifestation
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Usually begins between the ages of 20 and 30, but also in childhood (mean age of onset of the disease in children 9.6 years); the prevalence decreases with increasing age. Gynaecotropia exists.

Localization
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Oral mucosa (preferably fold in the vestibulum oris) and lateral edges of the tongue, especially the front third of the oral cavity.

Clinical features
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Typical is the recurrent occurrence over years (average duration of the disease is 3.6 years) (frequency of recurrences fluctuating between weeks and months) of single or several pinheads, rarely lenticular, or even 3.0-5.0 cm large, usually very painful erosions or ulcerations with a highly red rim in the area of the mucosa. More rarely, a small, quickly eroded, painful blister can be observed initially. The painfulness makes eating and drinking difficult (especially acidic fruit juices). Accompanying symptoms are increased salivation and foetuses ex ore.

A distinction is made between 3 types:

  • Minor type (80%): Few erosions or flat ulcers; size: <0.3-05 cm; general symptoms.
  • Major type (Type Sutton; 10%): Few, deep ulcers up to 3 cm in diameter, often regional lymphadenitis, moderate to high fever; general feeling of illness.
  • Herpetiform aphthae (10%): Very numerous; size: &lt; 0.3 cm; disseminated, erosions or flat ulcers; entire oral mucosa, similar to gingivostomatitis herpetica. Periodic course for years to decades. Short intervals without appearance.

Histology
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Not meaningful. Biopsy not recommended.

General therapy
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The majority of aphthae do not require treatment. Educate patients about the harmlessness of the lesions. Symptomatic therapy is only indicated for more severe subjective complaints. Clarification and elimination of possible causal intestinal disorders.

Notice! In case of large, constantly recurring aphthae, think of M. Behçet or M. Crohn

! Foods or substances which intensify the symptoms should be avoided, especially foods which cause burning, such as spices, acids, fruit juices, alcohol. Foods that irritate the mucous membrane mechanically, such as hard rusks, rolls, etc., should also be handled with care. Sparing use or avoidance of mouthwashes and toothpastes.

External therapy
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  • Disinfection: Mouth rinses initially with disinfecting solutions such as chlorhexidine R045, hexetidine (e.g. Hexoral solution), ethacridine lactate (e.g. 0.25% ethacridine lactate monohydrate solution with lidocaine 0.5%, dequalinium chloride (e.g. Maltyl solution).
  • Pain relief: In case of severe pain, mouth rinses with aqueous solutions containing benzocaine (e.g. Dolo-Dobendan solution) can be used. Combination preparations of 0.1% benzalkonium chloride/2% lidocaine (e.g. Dynexan A gel), which is applied several times to the painful lesions, or ethacridine lactate/lidocaine solutions (e.g. 0.25% ethacridine lactate monohydrate solution with lidocaine 0.5%) show good results.
  • In addition, glucocorticoid adhesive pastes or gels are indicated for extensive aphthae, which are applied to the lesion after dry swabbing with a cotton swab.
  • Alternatively, "mice" (gauze swabs) with medium to highly potent topical glucocorticoids (e.g. Clobegal cream) can be applied to the aphthae for about 30 minutes. Due to the longer retention time at the lesion, betamethasone valerate adhesive paste 0.1% R031 or prednisolone paste (e.g. Dontisolon D oral healing paste) are most suitable.
  • Alternatively, oral gels whose vehicle systems act as adhesive ointments can be used, e.g. 0.1% triamcinolone acetonide gel(e.g. Volon A adhesive ointment). Irrigation with glucocorticoids (e.g. 1 tbl. of prednisone 50 mg dissolved in 20 ml of aqua purificata; rinse the mouth with the solution for 5 minutes, do not swallow!) are common but not very effective (dilution effect by saliva, short retention time at the lesion). In the further course of treatment, mouthwashes that promote healing, such as dexpanthenol solution, can be applied to support the healing process. See also Dental products.
  • Alternatively: local tetracycline therapy (e.g. mouth rinses 4 times/day for 3-5 minutes with a solution of 300 mg doxycycline in 30 ml distilled water). In the case of deep, very painful aphthae, a glucocorticoid can be added (e.g. 20 mg prednisolone).

Internal therapy
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  • In the case of menstruation-dependent aphthosis, an estrogen-emphasized contraception can be useful.
  • Interval-type therapy with glucocorticoids (20-50 mg/day prednisolone p.o. in the acute phase)
  • Long-term therapy with DADPS (50 mg/day p.o.) shows an improvement in symptoms in individual cases.
  • The use of colchicine should be considered for the major type in exceptional cases (1-2 times/day 0.6 mg p.o.).
  • Thalidomide (non-approved experimental approach) shows (as in Behçet's disease) good efficacy in some patients (100-300 mg/day p.o.).

Naturopathy
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  • Tannin drugs: Tannin drugs have anti-inflammatory, weakly antimicrobial and wound healing promoting effects. The lesions can be brushed several times a day with an undiluted sage or tormentil tincture. Alternatively, a tincture of rhatania roots is suitable.
  • Essential oil drugs: the essential oil drugs such as clove oil, camomile flowers (camillosan solution), myrrh (10% myrrh tincture), sage leaves (aqueous solution with 1-5% sage leaf oil) and thyme herb (10% thyme tincture) have antibacterial, virustatic, antifungal and sometimes local antiphlogistic effects. They are well suited as "alternative therapy" for habitual aphthae.
  • Alternatively, combinations are also suitable: (see below tormentil-myrrh astringent (NRF 7.1.)

Literature
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  1. Belenguer-Guallar I et al (2014)Treatment of recurrent aphthous stomatitis. A literature review. J Clin Exp Dent 6e:168-174

  2. Gürkan A et al (2015) Recurrent Aphthous Stomatitis in Childhood and Adolescence: A Single-Center Experience.
    Pediatric Dermatol doi: 10.1111/pde.12577
  3. Heberden W (1802) Commentaries on the History and Cure of Diseases. T. Payne (ed.), London
  4. Sutton RL (1911) Pariadenitis mucosa necrotica recurrens. J Cutan Dis 29: 65-71
  5. by Mikulicz-Radecki J, Caraway WF (1898) The diseases of the mouth. In: The diseases of the mouth. Gustav Fischer, Jena

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.