Aphthous ulcer, one of the very common oral diseases, is frequently reported to clinics. A wide range of group of people suffer from this disease . It is also called Recurrent Aphthous Ulcer(RAS) due to its recurring nature. It is characterized by recurring ulcers of the oral mucosa usually manifesting first in childhood or adolescence in patients with no other systemic diseases. RAS may present in four main forms based on its clinical appearance: minor, major, herpetiform, and severe.
In this article we are presenting a detailed case of aphthous ulcer presented in the clinic with complete detailed history, signs, symptoms, clinical examinations and treatment procedures along with rationale after every examination and treatment methodology.
A patient of age 25 reported to the clinic with a chief complaint of wound in the inner side of lower lip since 4 days.
He says “ there was a small blister like lesion initially which was whitish in colour, appeared in the inner mucosa of the lower lip 4 days back which was slightly painful initially. But the wound was increasing its size resulting in a large flat wound and very painful. The pain aggravates during eating food and drinking water. The pain is so severe that sometime i even have problem in speaking”
I asked whether he had any fever or tingling sensation 4-5 days back? He responded negatively.
(History of fever and tingling sensation is quite important in such case since it can differentiate the lesion from apthous ulcer to oral herpetic ulcer)
(For detail of difference between apthous ulcer and herpetic ulcer with figures and flashcards CLICK HERE)
On intraoral Examination, there was
- An ulcerative lesion on mucosal surface of lower lip of size approx 1cm * 1 cm in size with ERYTHEMATOUS HALO around it
- Similarly another small lesion was present about 2-3 mm in diameter on left labial mucosa.
- No any signs of bleeding, pus discharge.
- No any lesions visible on gingiva, palate and vermillion border.
- Minor Aphthous Ulcer
- Herpetiform type aphthous ulcer
- Major Apthous Ulcer
- Recurrent intraoral herpetic stomatitis
Laboratory Findings in aphthous ulcer:
In this case Laboratory investigation is not ordered since the lesion seemed to be mild.
Condition when the Laboratory investigations are required:
- Severe RAS begin after the age of 40
- HIV infected patients with CD4 count less than 100/mm cube
Tests that can be performed under these conditions:
- Hematological tests(serum iron level,folate level, vit B12, ferritin)
- Biopsy to rule out Crohn’s disease, sarcoidosis, pemphigus, pemphigoid)
Recurrent Apthous Stomatitis
Since in this case the severity is mild with only 2-3 lesions:
- Gel Mucopain– Local application- BD for 7 days .( for pain relief)
- Tab multivitamin with zinc – PO- BD for 10 days ( For facilitating healing)
In severe case:
Use of high Topical steroid preparation like betamethasone or Clobetasol placed directly on the lesion, shortens healing time and reduces size of ulcer)
The steroid gel should be applied directly to the lesion after meals and at the bedtime 2-3 times a day mixed with adhesives such as Orabase.
For more detail management of Recurrent aphthous stomatitis CLICK HERE)
NEVER PRESCRIBE CHX TO A PATIENT WITH ULCER CAUSE IT MAY AGGRAVATE IT. ENCOURAGE PATIENT TO RINSE MOUTH WITH LUKEWARM SALINE WATER.
Home remedy: RAS is an immune mediated disease so it can be managed in home also only if the case is Minor Aphthous Ulcer and severity is mild. There is pain for an initial 3-4 days severely but slowly the pain will decrease and at 10-14th day the lesion will heal without scarring.
Patients can get mucopain gel Over the counter and apply topically on the lesion for 5-6 days until the pain persists. The key is to make the lesion clean by frequently rinsing the mouth with lukewarm saline water.
Conclusion: RAS is one of the most common diseases to be reported in the clinic. The clinical history and intra oral examination is the key to proper diagnosis of this disease. The clinical judgement of the clinician on different parameters like location, numbers, size and association of the lesion leads to proper diagnosis. Also other similar lesions should be kept in mind. If the lesion is severe then the disease should be referred to specialists and consultants.