Ouch, This Ulcer Hurts! - IneedCE.com

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Ouch, This
Ulcer Hurts!
DEMYSTIFYING THE
PHENOMENON OF APHTHOUS ULCERS
A Peer-Reviewed Publication
Written by Lisa Dowst-Mayo, RDH, BSDH
Abstract
Recurrent aphthous stomatitis (RAS) is the most
common idiopathic ulcerative condition seen
today, affecting over 100 million Americans.
Ulcers can be painful, slow to heal, difficult to
treat, and at worst, cause impairments in eating,
drinking, sleeping, and speaking. This review of
the literature found many different treatment
options whose effectiveness remains inconclusive,
and to date, there is no one definitive treatment
modality for RAS. Even though aphthous ulcers
have been studied extensively, there are still many
unknowns when it comes to their composition,
pathophysiology, and manifestations in the oral
cavity. Research does conclude that RAS may be
the secondary issue of a more serious systemic
infection in patients. This course will provide
the most current research-based tools for for
professionals who are trying to aid their patients
suffering from RAS.
Educational Objectives
1. Proficiently identify clinical traits and
differentiate between the three identified
morphological types of recurrent aphthous
stomatitis.
2. Understand the pathophysiology, etiology, and
microbiology of aphthous ulcers.
3. Be educated on the most current researchbased
treatment options for patients.
4. Possess useful tools to use in the dental office
for the treatment and management of RAS.
Author Profile
Lisa Dowst-Mayo, RDH, BSDH, received her Bachelorette
degree in dental hygiene from Baylor College of
Dentistry in 2002. She has been active member in the
tripartite of the America/Texas/Dallas & San Antonio
dental hygiene associations since graduation and has
held numerous leadership positions both at the state
and local levels. She has worked as a full time clinical
dental hygienist for the past 10 years and is currently
employed at Dominion Dental Spa, the office of Dr.
Tiffini Stratton, DDS. She is a published author and national
lecturer; you can contact her through her website
at lisamayordh.com.
Author Disclosure
Lisa Dowst-Mayo has no affiliations with any company
who would have a gained interest in the material
published in this course. There was no corporate sponsor
in the making of this course and the author is not
employed by a company that would stand to profit off
the publication of this course.
Go Green, Go Online to take your course
Publication date: Mar. 2013
Expiration date: Feb. 2016
Supplement to PennWell Publications
PennWell designates this activity for 1 Continuing Educational Credits Dental Board of
California: Provider 4527, course registration number CA# 01-4527-13007
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Educational Objectives
The overall goal of this course is to review the most current research
surrounding aphthous ulcers or more commonly identified
in the literature as recurrent aphthous stomatitis (RAS), which
can cause significant impairments for patients. After reading this
article the reader should be able to:
1. Proficiently identify clinical traits and differentiate between
the three identified morphological types of recurrent
aphthous stomatitis.
2. Understand the pathophysiology, etiology, and microbiology
of aphthous ulcers.
3. Be educated on the most current research-based treatment
options for patients.
4. Possess beneficial tools to use in the dental office for the
treatment and management of RAS.
Abstract
Recurrent aphthous stomatitis (RAS) is the most common idiopathic
ulcerative condition seen today, affecting over 100 million
Americans. Ulcers can be painful, slow to heal, difficult to treat,
and at worst, cause impairments in eating, drinking, sleeping,
and speaking. This review of the literature found many different
treatment options whose effectiveness remains inconclusive, and
to date, there is no one definitive treatment modality for RAS.
Even though aphthous ulcers have been studied extensively, there
are still many unknowns when it comes to their composition,
pathophysiology, and manifestations in the oral cavity. Research
does conclude that RAS may be the secondary issue of a more
serious systemic infection in patients. This course will provide
the most current research-based tools for for professionals who
are trying to aid their patients suffering from RAS.
Introduction
One in five people in the Unites States are affected by RAS each
year with the highest prevalence rate seen in higher socioeconomic
classes. Females have a slightly higher rate of occurrence than
males due to the perceived link between progesterone and RAS.
Aphthous ulcers are defined as painful oral lesions that appear
round to oval in shape with a yellowish/gray floor surrounded
by a halo of erythema, the cause of which is unknown. The most
common locations for RAS outbreaks are oral soft tissues such
as the moveable mucosa, floor of mouth, and tongue, although
these ulcers can occur virtually anywhere in the mouth, including
the palate and even the throat. RAS side effects can be dramatic
and damaging for patients. Ulcers can grow so large as to obstruct
breathing, prevent an individual from chewing, speaking or swallowing
and may bleed spontaneously while in the active state.
They are frequently accompanied by extreme pain that can last
days or weeks. As in the case with major aphthae, once healed,
ulcer sites can even leave permanent scars or indentations in tissues.
RAS commonly starts in adolescence or childhood, then
reoccurs in later years. Aphthae commonly appear in otherwise
healthy individuals although multiple systemic links are now
being recognized. These systemic links will be discussed in this
article.
Recurrent Aphthous Ulcers
% Cases
Minor
80-90%
Major
10-15%
Site of occurrence Nonkeratinized, moveable mucosa Nonkeratinized mucosa;
some keratinized mucosa
(palate, dorsal tongue)
Color
Red, white
Yellow floor but grays as heals
Erythematous halo
Red, white
Yellow floor but grays as heals
Edematous halo
Raised erythrocyte
Plasma viscosity
Herpetiform
5-10%
Nonkeratinized mucosa, keratinized
mucosa
Begins with vesiculation that passes
rapidly into multiple, coalescing ulcers
Shape Round, oval Round, oval Round, ragged
Size 3-4mm 5mm-1cm 1-2mm (pinhead)
Number of Lesions 1-6 1-6 Coalescing Groups
Generally 10 to 40
Duration 7-14 days 10-40 days 10+ days
Scarring Little to none Yes Not normally
Age 10-40 years 10-40 years Older age groups
Recurrence 2-8 per year Extremely frequently Extreme frequency
Ulceration may be continuous
Other Common in immunodeficient patients Resemble lesions caused by HSV-1 virus
More common in females
56 | rdhmag.com RDH | March 2013

Appearance/Morphological Types
RAS lesions are categorized by their morphological type. There
are three distinct types; they can either be minor, major, or
herpetiform. 11,27 Each type has certain characteristics, different
effects and durations, and therefore different treatment options.
See Figures 1, 2, 3, 4.
Fig 4. Herpetiform Aphthae
Fig1. Major Aphthae
Pathophysiology
The pathophysiology of aphthous ulcers is unclear and poorly
understood by researchers. No one is quite sure of the origin for
RAS; no microorganism or virus to date has been identified as the
sole cause. RAS is commonly thought to have immunological origins
and does not appear to be sexually transmitted or contagious
like herpetic lesions.
‘
Fig 2. Major Aphthae
Fig 3. Major Aphthae
Immunological
While there is no “official” cause of RAS, there are many sound
hypotheses with solid backing in the medical and dental communities.
There has been substantial evidence linking aphthous
ulcers with immunological responses, especially as it relates to T-
lymphocytes, but the precise immunopathogenesis still remains
unclear.
Many studies on recurrent aphthae show altered T and B cell
responses, increased gamma-delta T cells, altered cytokine levels,
and cytotoxic cells. These T-cells may be involved in antibodydependent,
cell-mediated cytotoxicity. 27 Phagocytic and cytotoxic
T cells probably aid in destruction of oral epithelium that is
sustained by local cytokine release. 27
Below is a step-by-step timeline of the immunological
changes that have been seen microscopically with aphthous ulcer
development as reported by Sciubba in 2003. 26
1. Early phase: local lymphocytic infiltrates form within the
submucosa at the site of the future aphthous ulcer.
2. Powerful T-cell-derived cytokines are formed that include
TNF-α, which dominates the immune system dysfunction.
It has been well published that TNF-α exerts a major effect
on endothelial cell adhesion and neutrophil chemotaxis. 21,26
3. This results in the formation of tender tissue alterations
characterized by a circular area of erythema with vascular
dilation.
4. The ulcer will form within 24 hours after this reaction.
5. Neutrophil response and increased patient symptoms
continue.
RDH | March 2013 rdhmag.com | 57

6. Endothelial cell vascularity changes occur. This causes an
up-regulation of adhesion molecule production along the
luminal surface of local blood vessels.
7. The region is affected by leukocyte chemotaxis, which
allows inflammatory responses as well as keratinocyte lysis to
progress.
8. Keratinocyte necrosis occurs. The end result is ulceration
or more specifically, transient superficial pseudomembrane
formation.
9. The healing phase of ulceration shows an influx of CD4+
cells that start to dominate and suppress the CD4+ cytotoxic
and CD8+ lymphocytes. 25
People with RAS can also have raised serum levels of certain
cytokines (interleukin 6/2-R), soluble intercellular adhesion
molecules, vascular cell adhesion molecules, mast cells, macrophages,
and E-selectin. 25,27 Based on a small study done at a dental
school in Brazil, polymorphisms of high IL-1beta and TNF-α
production were associated with an increased risk of RAS development.
Their findings give further support for a genetic basis of
RAS pathogenesis. 15
Genetics
Genetics may play an important role in understanding RAS. A
positive family history is seen in about a third of patients and an
increased frequency of HLA types A2, A11, B12, B51, DR2. 26,27
42% of patients with RAS have a first degree relative with RAS,
90% if both parents are affected, and 20% if neither parent has
RAS. 35 With a positive family history, patients are more likely to
have major aphthae and outbreaks that start at an earlier age. 35
Viral or Bacterial?
Researchers cannot find a specific strain of bacteria or virus to
implicate as being the causative agent in RAS. Cross-reacting
antigens between oral mucosa and microorganisms may be the
initiators but not the sole cause. 10 For many years, because RAS
lesions clinically resemble herpes lesions, it was thought RAS
lesions could be viral related; however, this hypothesis has been
disproven through extensive research. Hypersensitivity to bacterial
antigens such Streptococcus sanguis has also been proposed in
the literature, but again, extensive research has disproven this.
Etiology
What initiates ulcer development remains undefined and unclear.
It could be endogenous, exogenous, or related to nonspecific
factors such as the ones listed below.
1. Stress: Emotional stress can have an effect on a patient’s
overall health and immune system. This can alter the body’s
ability to fight infection.
2. Trauma to oral tissues either through in-office or at-home
incidences.
3. Sodium lauryl sulfate: A powerful detergent found in
OTC toothpaste that is a wetting, degreasing, and foaming
agent. 11
4. Food sensitivity: Acidic, salty, spicy food/beverages,
caffeine, tomatoes, various fruits, nuts, wheat products or
chocolate. 1,19 This theory has not been widely investigated
as a causative agent of RAS. According to the American
Academy of Oral Medicine (AAOM), two frequent food additives
associated with oral ulcers are cinnamon and benzoic
acid (found in foods and soft drinks). A trial food elimination
or reduction is recommended to aid in identifying potential
food allergens or sensitivity; however, this process can be
challenging.
5. Menstruation: RAS may be related to progesterone levels.
Progesterone will decrease during the luteal phase of
the menstrual cycle, thus activating RAS symptoms. 27
Conversely, ulcers will usually regress during pregnancy
when there is a significant rise in progesterone.
6. Drugs such as NSAIDs, beta-blockers, potassium channel
blockers, alendronate, and nicorandil (used to treat angina)
may produce lesions similar to RAS or increase susceptibility.
26,27
7. Infection: Immune system is compromised.
8. Vitamin deficiencies: Iron, folate, B1, B2, B6, B12, zinc.
These deficiencies account for about 20% of RAS cases. 27
When a patient tests positive for B-12 deficiency, taking
supplemental B-12 has shown positive results in treating
RAS. There is also published research that shows taking
B-12 supplement, even in persons who are not deficient, can
also help with RAS symptoms. 1,3,6,34
9. Altered thyroid levels
10. Smoking cessation: Well documented as being related
to ulcer outbreaks because of oral mucosal changes. The
nicotine does not appear to protect oral mucosal tissues from
ulceration. The more commonly accepted explanation is that
smokers develop mucosal hyperkeratinization, which better
protects the mucosal surface from ulceration. When a patient
ceases smoking and tissues begin to heal, ulceration risk can
increase due to all these mucosal changes. 36
11. Helicobacter pylori: Gram-negative, microaerophilic
bacterium found in the stomach. It was identified in 1982 by
Barry Marshall and Robin Warren, who found that it was
present in patients with chronic gastritis and gastric ulcers. 19
It is also linked to stomach cancer and duodenal ulcers. H.
pylori is the major cause of certain diseases of the upper GI
tract.
12. PFAPA (periodic fever, aphthous stomatitis, pharyngitis,
cervical adenitis) syndrome: Pediatric periodic disease
characterized by recurrent febrile episodes associated with
head and neck symptoms. 4
15. Hand, foot, mouth disease: Commonly caused by
Coxsackie A or Enterovirus 71. Commonly found in infants
and children under 5 years of age. This virus can lead to
ulcer-like lesions in the mouth along with fever and/or
rashes. Mouth ulcers are not RAS-related; the sores just
resemble the appearance of aphthae.
58 | rdhmag.com RDH | March 2013

16. Systemic diseases: Based upon literature searches, there are
several systemic disorders that can present with similar clinical
signs and symptoms of RAS; knowledge of each disease
is necessary for the clinician to provide proper management
and treatment of RAS. There is controversy in the literature
on whether oral ulcerations associated with these systemic
conditions are truly RAS or just oral ulcers similar to or
resembling RAS. 1
17. HIV: Patients can develop ulcers on almost all oral
structures, both keratinized and nonkertanized. Ulcers tend
to be more severe, are slower to heal, and more difficult to
treat due to immunity compromises. Systemic medications
are used more often to treat RAS than with other patients
who are not HIV positive.
18. Epstein-Barr virus: Human Herpes Virus 4 (HHV-4).
There is evidence that infection with the virus is associated
with a higher risk of certain autoimmune diseases. EBV infects
B cells and epithelial cells. Once the virus’s initial lytic
infection is brought under control, EBV latently persists in
the patient’s B cells for the rest of their lives.
19. Neutropenia: Defined as lower than normal numbers of
neutrophils. Patients are more susceptible to bacterial infections
and, without prompt medical attention, the condition
may become life-threatening.
20. Acute febrile neutrophilic dermatosis (Sweet’s syndrome):
A skin disease characterized by the sudden onset of fever,
leukocytosis, and tender, erythematous, well-demarcated
papules and plaques. It is often associated with hematologic
diseases such as leukemia and immunologic diseases such as
rheumatoid arthritis or inflammatory bowel disease.
21. Behcet’s disease: This is a rare immune-mediated systemic
vasculitis that has a triple-symptom complex of RAS,
genital ulcers, and uveitis. This syndrome can be fatal due to
ruptured vascular aneurysms or severe neurological complications.
Aphthae tend to be the major type and patients will
experience frequent episodes and longer healing durations. 27
There was a ground-breaking study done in 2003 by Jorizzo
et al. 18 on the association between Behcet’s and RAS. They
reported the vast majority of patients (90.7%) with RAS
do not have, nor will they develop Behcet’s. 1 This leaves
only a 10% chance that patients with Behcet’s disease will
conjointly be inflicted with RAS.
22. Reiter’s syndrome: A type of reactive arthritis, meaning that
it happens as a reaction to a bacterial infection in the body.
The infection usually occurs in the intestines, genitals, or
urinary tract. This disorder has been associated with oral
ulcers in some studies. 19
23. Gastrointestinal disorders: Account for only 3% of RAS
10, 25, 26
cases.
24. Crohn’s disease: A type of inflammatory bowel disease.
It usually infects the intestines but can cause issues in
the mouth as well. Many people with this condition have
troubles with their immune system.
25. Celiac: The connection between celiac and RAS has been
extensively studied in the literature. Ulcers are sometimes
the initial sign of celiac disease and more often of the minor
type. 1, 17, 22, 23 Research has suggested that ulcers associated
with celiac will respond to a gluten-free diet, but if the
infection is classic RAS, then a gluten-free diet may make
no difference. 1 However, there are other studies showing a
gluten-free diet may help RAS sufferers, even those without
celiac.
26. Pernicious anemia: Characterized by a decrease in red blood
cells that occurs when intestines cannot properly absorb
vitamin B12. As previously stated, B12 deficiencies could
contribute to RAS.
27. Dermatitis herpetiformis: Characterized by a chronic,
water-filled, blistering skin condition. Despite its name, DH
is not related to or caused by the herpes virus; the lesions just
share a similar appearance to herpes lesions.
Diagnosis
There are no specific tests to aid in the diagnosis of RAS. Diagnosis
is usually made from clinical features and medical history;
biopsy is almost never necessary. Laboratory investigation is
indicated when a patient has multiple major RAS outbreaks that
cannot be controlled or worsen after the age of 25. 27 Lab tests
may include complete blood cell count, hematological testing to
evaluate for vitamin deficiencies, anti-nuclear antibody titer to
screen for systemic illnesses, or thyroid screening blood work.
Differential Diagnosis
Oral conditions that may resemble RAS and be included in a differential
diagnosis include but are not limited to: herpes lesions,
lichen planus, pemphigus vulgaris, mucous membrane pemphigoid,
ulcers secondary to neutropenia, hand, foot, mouth disease,
syphilis, tuberculosis lesions, or traumatic lesions. It is imperative
that oral health providers learn the clinical presentations of
these lesions to increase their ability in correctly identifying and
accurately treating RAS.
Treatment
Ulcers will heal spontaneously but the patient may have moderate
to severe pain along its course. The magnitude of published studies
on treatment options for RAS is diverse and staggering. This
author could not find research that was categorized as systematic
reviews of randomized controlled clinical trials in her searches,
thus making clinical decision-making that much harder for the
professional. Until the etiology of RAS is known, treatment options
will remain palliative in nature and only partially effective.
The primary goals for RAS therapy are to relieve pain and reduce
ulcer duration and reoccurrence.
Most clinical trials and publications focus on local and topical
treatments rather than systemic as the first line of defense for true
RAS. Systemic treatments can carry greater risks to the patient
RDH | March 2013 rdhmag.com | 59

and should only be explored if local/topical options have been
exhausted in an otherwise healthy individual.
Intensity of treatment will depend on the severity of the case.
The AAOM recommends topical prescription drugs, topical anesthetics,
antihistamines, antimicrobials, and anti-inflammatory
agents. All these drugs will reduce pain and duration but not
always severity or reoccurrence rates.
Topical Corticosteroids
Topical corticosteroids will aid in immediate pain relief but need
to be reapplied frequently throughout the day as their effectiveness
wears off. The side effects of steroids are a concern to doctors
due to the potential adrenal changes that can be seen systemically.
There are two medications on the market that are at lower risk
for adrenal suppression: hydrocortisone hemisuccinate and
triamcinolone. Other popular choices are dexamethasone elixir
(0.5mg per 5mL) or betamethasone sodium phosphate which is
dissolved in water to make a mouth rinse. Betamethasone, fluocinonide,
fluocinolone, fluticasone, and clobetasol are effective in
RAS pain relief but do carry risks for adrenal suppression and a
predisposition to candidiasis.
Antibacterial
Low-dose antibacterial agents in gels and/or rinses also will
reduce RAS pain and possible duration. The current believed
mechanism of action is in the ability of these medications to locally
inhibit collagenases or in their immunomodulatory effects. 1
Side effects can include a predisposition to candidiasis and host
bacterial resistance.
Tetracycline derivatives are not to be used in children younger
than 12 years of age for fear of tooth staining. Tetracycline
(500mg) plus nicotinamide (500mg) or tetracycline suspension
(250mg per 5mL) are prescribed quite often. 19,27 Doxycycline
capsules (100mg in 10mL water) have proven very effective,
especially as a topical gel. 1,24,28 Minocycline (100mg) tablets
dissolved in 180mL water (McBride) is also a popular choice
because it is safe and effective, sometimes more than tetracycline
alone. 1,12,13
Outside the tetracycline family, topical penicillin G potassium
troches, applied 4x/day for four days are also used by some
medical and dental professionals. 11
Anti-Inflammatory/NonSteroidal
Clinicians wishing to avoid steroids, or if their patients have
a contraindication for steroid use in their medical history, may
utilize anti-inflammatory agents. Some of these medications are
taken systemically and have proven extremely effective in the
management of RAS pain and symptoms.
Amlexanox 5% is a popular choice in this category. It is a
topical paste applied 4x/day directly to an ulcer. According to
multiple publications, this seems to be one of the most effective
treatments for RAS. It is the only medicine that has a triple action
in the form of preventing reoccurrences, decreasing healing time,
and accelerating pain resolution. 19 In a comprehensive review of
the literature published by Baccaglini et al. in 2011, it was shown
this medication reduced the median healing time by 1.6 days and
median time for complete pain relief by 1.3 days. 1 Neither result
was considered clinically significant; however, a decrease in time
of pain and healing would be significant for a patient, especially if
the ulcers were preventing someone from eating, drinking, sleeping
or speaking! 11 Amlexanox is particularly effective if started
in the prodromal phase of ulcer outbreak. 1 The exact mechanism
of action is not completely known but is believed to have
anti-inflammatory effects. Other choices in this category are 2%
viscous lidocaine, zinc lozenges, or benzydamine hydrochloride
mouth rinse.
Systemic medications should not be the first line of treatment
options for patients with RAS due to the risk of adverse side effects.
Systemic medications should be considered only in severe
cases of RAS where topical treatments have not proven effective.
A doctor may also want to consider testing for other systemic
disorders before opting to treat RAS with systemic medications. 29
Pentoxifylline (PTX) is a systemic medication that is a methylxanthine
compound. It is used to treat peripheral vascular diseases
by enhancing blood flow, increasing neutrophil chemotaxis
and motility, and decreasing production of cytokines, thereby
decreasing the effects of cytokines on leukocytes. There is some
research suggesting this drug may aid in the prevention of aphthous
ulcer formation. 29
Colchicine is another systemic medication in the antiinflammatory
family. Its mechanism of action is limiting leukocyte
activity by binding to tubulin, which then inhibits protein
polymerization. This drug inhibits lysosomal degranulation and
increases the level of cyclic AMP, which decreases both the chemotactic
and the phagocytic activity of neutrophils. Colchicine
inhibits cell-mediated immune response, which is why it can be
useful in treating RAS. It is most commonly used in the treatment
of arthritis, psoriasis, and dermatitis herpetiform. However,
this drug carries heavy side effects including teratogenicity,
gastrointestinal issues, and myopathy. 29
Antimicrobial
Chlorhexidine gluconate is a good choice for reducing the bacteria
counts in the mouth. Practitioners need to be sure to specify
the mouth rinse needs to be water-based instead of alcohol-based
for fear of further irritating already tender, swollen tissues.
Systemic Immune Modulators
Thalidomide (50-100mg) is a systemic medication with mixed
and few research studies. It has multiple adverse side effects
such as teratogenicity or neuropathy of the hands and feet.
This medication is usually a “last resort” prescription for RAS
treatment. It is more commonly used in HIV-positive patients
when other local/topical forms of treatment have failed. It suppresses
monocytic synthesis of TNF-α and accelerates TNF-α
messenger ribonucleic acid transcript degradation. 19 This drug
60 | rdhmag.com RDH | March 2013

has anti-inflammatory characteristics as well as anti-angiogenic
properties.
The American Academy of Oral Medicine provides additional
information on its website (www.aaom.com/patients/
treatment-of-canker-sores).
Nonprescription Options/OTC
Vitamin supplements of A, B, C, or lysine have helped some
suffering with chronic RAS although, to date, there is no specific
scientific evidence to support or refute this. 19 Many doctors will
recommend vitamin supplements as a good starting point for ulcer
control or if hematinic deficiencies have been proven through
testing.
Herbal supplements are much the same as vitamin supplements.
One will not find any randomized controlled clinical trials
(McBride) to support this as a definitive treatment option, but
many chronic RAS patients have found some help through herbs,
so it is worth reporting. Echinacea can help activate the body’s
immune system and increase chances of fighting off infection.
Sage and chamomile mouth rinses (mixed with water or tea bags)
used 4-6x/day can help alleviate symptoms. Carrot, celery, or
cantaloupe juice mixed with water can also be helpful complementary
agents.
According to the AAOM, cleansing agents can help decrease
the number of bacteria on the ulcer surface and can help with
healing and pain. Most agents can be found at local grocery stores
or pharmacies. Any product that releases oxygen can be used as
a cleansing agent because the foaming of the oxygen exerts a mechanical
action that loosens debris and cleanses wounds.
OTC anesthetics can provide palliative relief, with most
common agents containing either benzocaine (5-20%), lidocaine,
benzoin, benzoin tincture, or camphor.
In-Office Laser Treatments
With the development and more frequent use of lasers by the
general dental practitioner, some RAS patients are finding new
help when it comes to management of ulcer outbreaks and pain
relief. There are many different dental lasers on the market for
use in a dental office and almost all of them come with clinical trials
on biostimulation of tissues and/or aphthae. Biostimulation is
a process whereby tissues are stimulated, as opposed to cut, with
photon energy from a specific laser wavelength. 7 When biostimulating
tissue, the laser energy is well below the surgical threshold
and takes only one to two minutes to treat. The patient will feel
immediate pain relief and the ulcer and the ulcer will usually
completely heal within one to four days. 9 Biostimulation with
laser energy will increase collagen growth and osteoblastic and
fibroblastic activity in tissues, thereby accelerating healing. 8,23,31
Biostimulation for the purpose of ulcer irradiation is a technique
used by many practicing dentists because it provides instantaneous
pain relief, rapid wound healing, and anti-inflammatory
effects in their patients. Some laser companies claim that if a
laser is used to treat an aphthous ulcer one time, another ulcer
will never appear in that same area again because of the cellular
changes the laser energy induced. However, this is still considered
a theory and not a proven, repeatable result on patients.
When biostimulating with a laser, the clinician does not touch
the tissue with the laser fiber; instead the fiber is held a couple
millimeters away from the lesion and the laser energy is directed
at the ulcerative tissue.
Chemical Cauterizers
Chemical cauterizers are very effective but can have side effects.
They are semiviscous liquids applied directly to an ulcer. Researchers
have noted that these products can cause destruction
of local nerve endings and their use should be limited to professional
application only. Other side effects noted in the literature
are argyria, mucocutaneous reactions, or permanent tattooing of
the mucosa. 11
Dental Considerations
Be cognizant of procedures that could traumatize or injure tissues
such as injections, taking X-rays, routine prophylaxis, scaling and
root planing, crowns, any surgical procedure, etc. Removable
appliances such as ill-fitting mouth guards, partials, dentures,
retainers, or snore guards can injure or lacerate tissues.
Reminders for Dental Professionals
1. RAS lesions are not thought to be contagious.
2. The exact cause is not known.
3. Ulcers can be controlled but there is no known cure.
4. The long-term consequences are unknown.
5. Children may inherit RAS from their parents.
6. Have patients make small changes to daily routines when RAS
is first reported, such as eliminating sodium lauryl sulfate
toothpastes. 10,25 Maybe try diet modification, eliminating certain
foods/drinks that are known to contribute to RAS. Patients, for
example, can keep track of offensive foods through a diary. Suggest
a multivitamin, educate them on minimizing oral trauma
(foods that can cause tissue laceration such as tortilla chips),
make sure oral appliances are fitting well and do not need
adjustments, and try to stop oral habits such biting cheeks, lips,
etc. Stress reduction techniques can also be considered.
7. Patients should have good oral hygiene; chlorhexidine gluconate
or sodium bicarbonate rinses may be useful.
8. Attain the ability to differentiate between RAS and other oral
lesions so appropriate diagnosis can be made.
9. Gluten-free diets have shown success in some trials in reducing
reoccurrence rates of RAS even in the absence of celiac disease
10. Inform patients that RAS can be controlled but not necessarily
eliminated or cured. Tell patients that you will try your best to
help them eliminate future outbreaks. Be sure to set realistic
goals with patients from the get-go.
Patient Education
Many patients do not understand what ulcers are, what causes
them, or how to alleviate symptoms. Most think all ulcers are
herpes related. Patient education is the key to proper control and
maintenance of RAS. Try asking patients your leading questions
to get to the root of the problem. For example:
RDH | March 2013 rdhmag.com | 61

• Has anyone else in your family had troubles with mouth
ulcers?
• Do you take a multivitamin?
• When was the last time you saw your physician for a checkup?
• Could you have thyroid issues or a systemic problem your
primary care physician is not aware of?
• Do you have any GI issues?
• Tell me about your stress levels.
• Have you had changes to your lifestyle recently?
After this Q&A or failed treatment attempts, you may find
the need to refer the patient to a medical doctor or oral surgeon for
further testing. Remember, RAS may be the first sign of a more
serious systemic problem.
Conclusion
RAS still remains a mystery to most researchers in regards to its
pathophysiology, etiology, and microbiology. Treatment options
are mainly palliative in nature unless a more serious systemic
condition is co-occurring. In cases of non-resolving RAS, a referral
to a medical doctor is indicated, since RAS could be the first
sign of a more serious health condition. By presenting the most
current research-based conclusions; the reader now possesses the
correct tools, education, and confidence to start helping patients
suffering from this disorder.
References
1. Baccaglini L, Lalla RV, Bruce AJ, Sartori-Valinotti JC, Latortue MC,
Carrozzo M, Rogers RS 3rd. Urban Legends: Recurrent Aphthous
Stomatitis. Oral Dis. Nov 2011; 17(8):755-70.
2. Barrons RW. Treatment Strategies for Recurrent Oral Aphthous Ulcers.
Am J Health System Pharmacy. 2001;58(1):41-53.
3. Biedowa J, Knychalska-Karwan Z. Submucous injections of vitamin
B12 and hydrocortisone in cases of recurrent aphthae. Czasopismo
stomatologiczne. 1983; 36:565–67.
4. Berlucchi M, Nicolai P. Marshall’s Syndrome or PFAPA (periodic
fever, aphthous stomatitis, pharyngitis, cervical adenitis) Syndrome.
January 2004. https://www.orpha.net/data/patho/GB/uk-PFAPA.
pdf. Accessed Nov 2012.
5. Brocklehurst P, Tickle M, Glenny AM, Lewis MA, Pemberton MN,
Taylor J, Walsh T, Riley P, Yates JM. Systemic interventions for recurrent
aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. Sept
2012; 12:6:CD005411.
6. Carrozzo M. Vitamin B12 for the treatment of recurrent aphthous
stomatitis. Evid Based Dent. 2009; 10:114–15.
7. Cobb C. Lasers in Periodontics: A Review of the Literature. Periodontol.
Apr 2006; 77(4):544-564.
8. Coluzzi D. Fundamentals of Lasers in Dentistry: Basic Science, Tissue
Interaction and Instrumentation. J Laser Dent, Compendium of Laser
Dentistry. 2008; 16(Spec Issue):4-10.
9. De Souza TO, Martins MA, Bussadori SK, Fernandes KP, Tanji EY,
Mesquita-Ferrari RA, Martins MD. Clinical Evaluation of Low-Level
Laser Treatment for Recurring Aphthous Stomatitis. Photomed Laser
Surg. Oct 2010; 28(Suppl 2):S85-8.
10. Felix D, Luker J, Scully C. Oral Medicine: 1. Ulcers: Aphthous and
Other Common Ulcers. Dental Update. Sept 2012; 39(7):512-520.
11. Fernandes R, Tuckey T, Lam P. The best treatment for aphthous ulcers.
Available at www.utoronto.ca/dentistry/newsresources/evidence_
based/apthousulcers.pdf. Accessed June 2006.
12. Gorsky M, Epstein J, Rabenstein S, Elishoov H, Yarom N. Topical
minocycline and tetracycline rinses in treatment of recurrent aphthous
stomatitis: a randomized cross-over study. Dermatology online journal.
2007; 13:1.
13. Gorsky M, Epstein J, Raviv A, Yaniv R, Truelove E. Topical minocycline
for managing symptoms of recurrent aphthous stomatitis. Spec Care
Dentist. 2008; 28:27-31.
14. Gregg R., McCarthy D. Eight Year Retrospective Review of Laser
Periodontal Therapy in Private Practice. Dentistry Today. Feb. 2003;
22(2):1-4.
15. Guimarães AL, Correia-Silva Jde F, Sá AR, Victória JM, Diniz
MG, Costa Fde O, Gomez RS. Investigation of functional gene
polymorphisms IL-1beta, IL-6, IL-10 and TNF-α in individuals with
recurrent aphthous stomatitis. Arch Oral Biol. Mar 2007; 52(3):268-72.
16. Ibsen OAC, Phelan J. Oral pathology for the dental hygienist. 3rd
edition. Philadelphia:Saunders, 2000; P113-114.
17. Jokinen J, Peters U, Maki M, Miettinen A, Collin P. Celiac sprue in
patients with chronic oral mucosal symptoms. Journal of Clinical
Gastroenterology. 1998; 26:23–26.
18. Jorizzo JL, Taylor RS, Schmalstieg FC, Solomon AR, Jr, Daniels JC,
Rudloff HE, Cavallo T. Complex aphthosis: a forme fruste of Behcet’s
syndrome? Journal of the American Academy of Dermatology. 1985;
13:80–84.
19. McBride D. Management of aphthous ulcers. Am Family Physician.
July 1,2000; Available at www.aafp.org/afp/20000701/149.html.
Accessed June 2007.
20. Messadi DV, Younai F. Aphthous ulcers. Dermatol Ther. May-June
2010; 23(3):281-90.
21. Natah SS, Hayrinen-Immonen R, Hietanen J, Malmstrom M,
Konttinen YT. Immunolocalization of tumor necrosis factor-alpha
expressing cells in recurrent aphthous ulcer lesions. J Oral Pathol Med.
2000; 29:19-25.
22. Olszewska M, Sulej J, Kotowski B. Frequency and prognostic value of
IgA and IgG endomysial antibodies in recurrent aphthous stomatitis.
Acta dermato-venereologica. 2006; 86:332–334.
23. Pereira AN, Eduardo Cde P, Matson E, Marques MM. Effect of lowpower
laser irradiation on cell growth and procollagen synthesis of
cultured fibroblasts. Lasers Surg Med. 2002; 31(4):263-7.
24. Preshaw PM, Grainger P, Bradshaw MH, Mohammad AR, Powala
CV, Nolan A. Subantimicrobial dose doxycycline in the treatment of
recurrent oral aphthous ulceration: a pilot study. J Oral Pathol Med.
2007; 36:236–240.
25. Sciubba J. Oral Mucosal Diseases in the Office Setting. Gen Dent. July/
Aug 2007; 55(4):346-54.
26. Sciubba J. Herpes Simplex and Aphthous Ulcerations: Presentation,
Diagnosis, and Management – An Update. Gent Dent. Nov-Dec 2003;
51(6): 509-16.
27. Scully C. Aphthous Ulcers. Emedicaine from WebMD. Oct 28,2005.
Available at www.emedicine.com/ent/topic700.htm. Accessed June
2006.
28. Skulason S, Holbrook WP, Kristmundsdottir T. Clinical assessment of
the effect of a matrix metalloproteinase inhibitor on aphthous ulcers.
Acta Odontologica Scandinavica. 2009; 67:25–29.
29. Stoopler E, Sollectio T. Recurrent Aphthous Stomatitis. NYSDJ. Feb
2003; 69(2): 26-29.
30. Tezel A, Kara C, Balkaya V, Orbak R. An evaluation of different
treatments for recurrent aphthous stomatitis and patient perceptions:
Nd:YAG laser versus medication. Photomedicine and laser surgery.
2009; 27:101–106.
31. Todea C. Laser Applications in Conservative Dentistry. www.tmj.ro/
pdf/2004_number_4_7623644694124490.pdf. Accessed Nov 28,2012.
32. Van A. The Diode in Treating Ulcerative Oral Lesions. Dent Today. Dec
2011; 30(12):112.
33. Veloso FT, Saleiro JV. Small-bowel changes in recurrent ulceration of
the mouth. Hepato-gastroenterology. 1987; 34:36–37.
34. Volkov I, Rudoy I, Abu-Rabia U, Masalha T, Masalha R. Case report:
62 | rdhmag.com RDH | March 2013

Recurrent aphthous stomatitis responds to vitamin B12 treatment.
Canadian family physician. 2005; 51:844–845.
35. Wardhana, Datau EA. Recurrent Aphthous Stomatitis caused by Food
Allergy. Acta Med Indones. Oct 2010; 42(4):236-40.
36. Winn D. tobacco Use and Oral Disease. Journal of Dental Education.
April 2001. 65(4): 306-312.
Author Profile
Lisa Dowst-Mayo received her Bachelorette degree
in dental hygiene from Baylor College of Dentistry
in 2002. She has been active member in the tripartite
of the America/Texas/Dallas & San Antonio dental
hygiene associations since graduation and has held
numerous leadership positions both at the state and
local levels. She has worked as a full time clinical dental
hygienist for the past 10 years and is currently employed at Dominion
Dental Spa, the office of Dr. Tiffini Stratton, DDS. She is a published
author and national lecturer; you can contact her through her website at
lisamayordh.com.
Disclaimer
This author has no affiliations with any company who would have a gained interest
in the material published in this course. There was no corporate sponsor in the
making of this course and the author is not employed by a company that would
stand to profit off the publication of this course. All the research is presented in
an unbiased manner.
Reader Feedback
We encourage your comments on this or any PennWell course. For your convenience,
an online feedback form is available at www.ineedce.com.
Notes
RDH | March 2013 rdhmag.com | 63

Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the online purchase.
Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete all the program questions and submit your answers. An immediate grade
report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for viewing and/or printing. Verification Forms can be viewed and/or printed anytime in the future by
returning to the site, sign in and return to your Archives Page.
1. Which lesions can cause scarring in the site
of infection?
a. Minor
b. Major
c. Herpetiform
2. RAS lesions occur more frequently in:
a. Lower socioeconomic classes
b. Higher socioeconomic classes
c. Males
d. Females
e. Both B & D
3. In the immunological theories of RAS
formation, which structures are most often
associated with RAS formation?
a. Altered T and B cells responses
b. Increased gamma-delta T cells
c. Macrophages and mast cells
d. TNF-α
e. All of the above
4. In the etiology of RAS, menstruation has
been linked as a positive causative agent
when:
a. Progesterone levels decrease
b. Progesterone levels increase
c. Estrogen levels decrease
d. Estrogen levels increase
5. According to the reported literature findings,
systemic medications for the treatment
of RAS:
a. Should be used as the first line of treatment
b. Should be used when topical medications have proven
ineffective
c. Have no teratogenic effects
6. Systemic conditions related to RAS include:
a. Celiac
b. Cystic fibrosis
c. HIV
d. Both A & C
Questions
8. Vitamin deficiencies associated with RAS
include,
a. B12
b. Folate
c. Iron
d. All of the above
e. None of the above
9. Differential diagnosis of RAS could also
include,
a. Pemphigus
b. Gonorrhea
c. Lichen planus
d. Herpes lesion
e. A,C & D
f. All of the above
10. Goals of RAS therapy are to:
a. Relieve pain
b. Decrease ulcer duration
c. Cure RAS
d. A & B
11. Antibacterial agents used to treat RAS
could include which of the following?
a. Tetracycline and erythromycin
b. Minocycline and penicillin G
c. Tetracycline and clindamycin
12. Chlorhexidine gluconate should be:
a. Water-based for treatment of RAS
b. Alcohol-based for treatment of RAS
c. Not used at all in the treatment of RAS
13. When using a dental laser in the treatment
of ulcerative lesions associated with RAS
through biostimulation, the operator
should:
a. Touch the ulcer with the laser fiber so as to cut the lesion
b. Hold the laser fiber a few millimeters away from the
lesion
c. Tell the patient laser treatment will completely prevent
another ulcer from ever forming in that treatment area
again
15. Topical medications used to treat RAS can
include,
a. Amlexanox
b. Triamcinolone
c. Lidocaine
d. Hydrocortisone
e. All of the above
16. Which of the following herbal supplements
has been proposed to help alleviate
symptoms of RAS?
a. Lavender
b. Echinacea
c. Ginger
d. Jasmine
17. The most common type of RAS ulcer is:
a. Minor
b. Major
c. Herpetiform
18. Which type of ulcer could take up to six
weeks to heal?
a. Minor
b. Major
c. Herpetiform
19. The morphological shape of RAS ulcers
can be:
a. Round
b. Oval
c. Coalescing
d. All the above
20. Which is true in the dental considerations
of RAS?
a. RAS lesions are thought to be contagious
b. RAS lesions are not common and professionals will
rarely see them in private practice
c. RAS lesions can be caused by trauma during dental
procedures such as a prophylaxis or scaling and root
planing
7. Which is true of the relationship between
RAS and Behcet’s disease?
a. 90% of patients with Behcet’s also suffer from RAS
b. Aphthae tend to be characterized as major type
c. Diagnosis of RAS increases the likelihood a patient has
Behcet’s disease
14. In the general clinical appearance of RAS
ulcers, they are surrounded by a ______
halo.
a. Red
b. White
c. Yellow
21. ___% of Amlexanox is useful in treating
RAS topically:
a. 5%
b. 10%
c. 15%
d. 50%
64 | rdhmag.com RDH | March 2013

ANSWER SHEET
OUCH, THIS ULCER HURTS!
Name: Title: Specialty:
Address:
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Telephone: Home ( ) Office ( ) Lic. Renewal Date:
Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
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you 1 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
Educational Objectives
1. Proficiently identify clinical traits and differentiate between the three identified morphological types of recurrent
aphthous stomatitis.
2. Understand the pathophysiology, etiology, and microbiology of aphthous ulcers.
3. Be educated on the most current research-based treatment options for patients.
4. Possess useful tools to use in the dental office for the treatment and management of RAS.
Course Evaluation
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OUCH313RDH