Oral thrush: the clinical problem
Canker sores are ulcers that are located on the oral mucosa. They can be very painful and sometimes prevent food intake. It should be taken into account that there are systemic diseases that manifest with thrush, such as celiac disease, Crohn’s disease, Beh?eth’s disease and immunodeficiencies, which include that caused by HIV.
In this chapter we will basically refer to recurrent aphthous stomatitis (RAS) limited to the oral mucosa and in the absence of systemic disease, that is, idiopathic.
This disorder is the most frequently found among the conditions of the oral mucosa and affects up to 25 percent of the population at some point in life.
It is characterized by recurrent outbreaks of variable duration depending on the clinical form. While the episode lasts, the patient finds it difficult to speak, eat and clean his mouth.
Although it has been widely studied, knowledge about its etiology is limited and treatment is currently symptomatic.
Clinical forms: three fundamental clinical forms are described:
- Type 1 or minor RAS: it is the most common and patients usually have a family history with this pathology. It reaches 80 percent of those affected by EAR. Ulcers typically appear for the first time in childhood and their observation decreases after the third decade of life.
The ulcers are flat, have a rounded shape with a yellowish or grayish base and are surrounded by an inflammatory halo. They have a diameter of 2 to 8 mm and predominantly affect the labial mucosa, the floor of the mouth and the ventral surface of the tongue. They are rarely found on the back of the tongue or hard palate.
After a couple of weeks they heal spontaneously without leaving scars.
- Type 2 or major EAR: it is much less frequent than the previous one, reaching 10% of those affected by EAR.
It is also called “recurrent necrotic mucosal periadenitis” . The ulcers are larger: 1 cm or more, are accompanied by gray pseudomembranes and have a broader distribution, extending to the hard palate and the back of the tongue.
The outbreak can last up to 6 weeks or more and the risk of scarring is also higher
- Type 3 or herpetiform EAR: it is the least common of the three. Although it receives this name, it is not caused by the herpes simplex virus. It is characterized by a large number of deep ulcers (up to 100) that often converge. Flare-ups typically resolve within a month without scarring.
Table 1: findings in the different clinical forms *
Minor EAR Major EAR Herpetiform EAR
According to sex, the same predominates in women
Morphology
round lesions round lesions ulcers small
or oval, pseudo- or oval, pseudo-deep usually
white membranes white membranes converge
grayish, grayish halo, halo irregular contour
erythematous erythematous
Distribution
lips, cheeks lips lips, cheeks,
tongue, floor of soft palate tongue floor of
mouth pharynx mouth, gums
Number of
ulcers 1 - 5 1 - 10 10 to 100
Ulcer size < 10mm > 10mm 2 to 3 mm
Prognosis
lesions heal lesions persist lesions heal in
4 -14 days > 6 weeks < 30 days; not usually
without scars there are usually scars left
scars
*From Edgar NR, Saleh D, Miller, RA Recurrent Aphthous Stomatitis. A Review. J Clin Aesthet Dermatol 2017 Mar, 10 (3) 26-36
Treatment
Topical therapy: aimed at preventing superinfection of existing ulcers, analgesia and reducing inflammation. To prevent infection of the lesions, swishing with 0.2% chlorhexidine (Cyteal diluted to 10%) with subsequent rinsing is suggested.
Topical corticosteroids are useful in treatment. (Oralsone with hydrocortisone, Fluticasone spray). In long-term treatment they are sometimes administered with antifungals to reduce the risk of secondary candidiasis.
Systemic therapy: prednisone is recommended in the initial dose of 20 mg with gradual decrease. In those cases where they are contraindicated, the leukotriene antagonist Montelukast can be used at a dose of 10 mg daily.
Thalidomide at a dose of 50 to 100 mg daily is considered the most effective immunomodulator in RAS. Obviously, its teratogenic effects should not be lost sight of, so in principle its use in women of childbearing age is discouraged.
Ascorbic acid at a dose of 2,000 mg/m2/day has been reported to be of value in minor RAS.
Laser therapy: laser therapy at low levels, with wavelengths of 658 nm, can be beneficial as an adjuvant and results equal to or superior to pharmacological treatment have been reported.
Recommended readings
- Edgar NR, Saleh D, Miller, RA Recurrent Aphthous Stomatitis. A Review. J Clin Aesthet Dermatol 2017 Mar, 10 (3) 26-36
- Crispian Scully, Aphthous Ulceration, N Eng J Med 2006. 355 165-172
DISORDERS THAT DISORDER US IN GASTRENTEROLOGY
We chose this title to define a particular set of conditions that are difficult to manage. According to the Dictionary of the Royal Academy, a disorder is defined as a “mild alteration in health” and the verb to upset means “to disturb or remove tranquility or peace.” Doctors are often disturbed by these conditions that, although not serious, greatly upset the patient and represent a frequent reason for consultation. In many cases we lack an effective treatment and the literature is insufficient to help us. The purpose of this guide is to know how far we have come in the study and treatment of these disorders, what experts think and what evidence-based medicine contributes.
Series index
- oral thrush
- burning mouth
- In each of them we will make an introduction where we will summarize the basics of current medical knowledge and the treatments usually recommended. Below, we will refer in more depth to the recommended literature and what informs evidence-based medicine when it is available.
- Functional anorectal pain.
- Belching
- balloon
- Halitosis
- Prolonged hiccups
- anal itching
