Aphthae

What are aphthae?

Aphthae are painful, inflamed ulcers in the mouth. Its name says it all, as the word aphtha is derived from the ancient Greek verb “hapto” and means “to make fire”. Aphthae often occur on the inside of the cheeks, on the tongue or on the gums. They can make it difficult to speak, eat and drink. Aphthae can develop again and again. Experts also speak of habitual aphthae, chronic recurrent aphthae and recurrent benign aphthae (RBA). Sometimes up to four aphthae appear at the same time. Although they are usually harmless, aphthae can be very unpleasant for those affected.

What types of aphthae are there?

Aphthae in the mouth occur in various forms. Each of these forms can occur repeatedly and can vary in severity. The three main forms are:

Minor aphthae (Mikulicz aphthae)

• Most common form (approx. 85 percent)
• one to four small, round or oval ulcers (diameter less than 5 millimeters) at the same time
• usually on the inside of the cheeks, the tongue or the lips
• Healing within one to two weeks without scarring

Major aphthae (Sutton’s aphthae, Sutton’s disease, periadenitis mucosae necrotica recurrens)

• less common form (10 percent)
• Larger ulcers (> 10 to 30 millimeters in diameter) in the oral cavity, on the palatal arch or on the tongue
• can penetrate deep into the tissue
• Very painful and protracted (healing often takes several weeks)
• often leave scars

Herpetiform aphthae (stomatitis herpetiformis)

• Rare form (five percent)
• numerous, very small, flat ulcers (one to two millimeters in diameter) that occur in groups
• no vesicle stage
• can grow together to form larger lesions
• occur more frequently on the underside of the tongue or the oral mucosa
• usually heal within one to two weeks

Aphthae: causes and risk factors

The exact causes of aphthae are not yet fully understood. However, there are various factors that can favor their development:

Possible causes of aphthae in the mouth

When aphthae develop, an incorrect reaction of the immune system can trigger the painful blisters. However, genetic predisposition also plays a role in some patients: people with a family history of aphthae have an increased risk (e.g. Fanconi anemia, IL-1 gene polymorphism). In addition, viral or bacterial infections promote the development of aphthae: e.g. infections with Coxsackie virus A16, HIV/AIDS, HHV-8, CMV, EBV, HPV, HSV-1, Rickettsia, Lues, tuberculosis.

Risk factors for the development of aphthae

There are several triggers that can trigger the development of white-red ulcers. These include:

• Mechanical irritation: Injuries caused by braces, dentures or sharp-edged foods
• Stress: psychological stress and emotional strain
• Hormonal changes: Cycle fluctuations, pregnancy or puberty
• Nutrition: a lack of vitamins B1, B2, B6 and B12, iron, folic acid or zinc
• Food intolerances: certain foods such as citrus fruits, tomatoes or nuts
• Autoimmune diseases: Diseases such as Behçet’s disease or Crohn’s disease, ulcerative colitis and celiac disease as triggers of recurrent aphthae
• Medication: some medications, including NSAIDs (e.g. ibuprofen) or beta blockers

Symptoms of aphthae: recognizing signs and warning signals

Aphthae often begin with a slight burning or tingling sensation before a visible sore forms. Small, round or oval ulcers with a white or yellowish coating and inflamed, reddened edges are typical.

The most common symptoms of apthous ulcers are

• Pain and burning: Severe discomfort can occur, especially when eating, drinking and speaking.
• Redness and swelling: The surrounding tissue may be irritated or inflamed.
• Difficulty eating and drinking: Particularly acidic or spicy foods or, for example, hard bread crusts, rusks or crispbread increase the pain. The same applies to carbonated drinks or alcohol.
• Recurrent ulcers: Aphthae can recur at irregular intervals.

Aphthae: diagnosis and examinations

Aphthae are usually diagnosed on the basis of their typical appearance. Experienced (dental) doctors usually recognize aphthae by their appearance. As part of your medical history, the doctor treating you will ask you about the duration, frequency, possible triggers of the aphthae and accompanying symptoms, as well as your age and lifestyle habits. The subsequent clinical examination then focuses on the number, size and localization of the ulcers on the oral mucosa.

If the aphthae occur particularly frequently or in a severe form, further diagnostics may be necessary. This includes blood tests for possible deficiency symptoms such as vitamin B12, iron or folic acid deficiency. Autoimmune diseases such as coeliac disease or Behçet’s disease can also be diagnosed by blood tests. If a connection with certain foods is suspected, allergy tests are also helpful. In rare cases, especially if the wounds have persisted for an unusually long time or look conspicuously altered, a tissue sample (biopsy) may be necessary to rule out more serious diseases such as oral cancer.

In most cases, however, no extensive examinations are necessary, as aphthae are harmless and heal on their own after a short time.

Aphthae: prevention, early detection, prognosis

Aphthae can be unpleasant and painful, but with the right measures they can often be avoided or treated at an early stage. Conscious oral hygiene, a balanced diet and dealing with stress play an important role in this. How to recognize the first signs and what you should know about the healing process.

How can I prevent aphthae?

As the exact causes of aphthae are not yet fully understood, there is no certain method to completely prevent the development of aphthae. However, certain measures can help to reduce the risk. Gentle oral hygiene, which includes a soft toothbrush and mild, alcohol-free mouthwashes, can prevent mechanical irritation. A balanced diet with sufficient vitamin B12, iron and folic acid also protects against deficiency symptoms as a possible trigger. Stress is considered a common risk factor, so relaxation techniques such as yoga or meditation can help to reduce the occurrence of aphthae. If you are sensitive to certain foods, you should avoid potential irritants such as citrus fruits, nuts or spicy foods.

Aphthae early detection

Aphthae often announce themselves with a slight burning or tingling sensation before they become visible as painful changes to the mucous membrane. If you pay attention to these first signs at an early stage, you can react quickly with soothing measures. Special gels or solutions with anti-inflammatory agents alleviate the symptoms from the outset and support the healing process.

Aphthae prognosis

In most cases, aphthae are harmless and heal on their own within one to two weeks without leaving any scars. However, major aphthae or herpetiform aphthae can be larger, last longer and, in rare cases, leave scars. Recurrent aphthae are annoying, but do not usually pose a serious health risk. However, if they occur unusually frequently or do not improve despite treatment, you should seek medical advice to rule out possible underlying illnesses.

Aphthae treatment: What helps with aphthae?

As long as the symptoms are bearable, aphthae do not need to be treated. However, if they make speaking, eating and drinking very uncomfortable, there are various treatment options to promote healing and alleviate the discomfort:

• Topical treatments: You can apply special ointments or gels with anti-inflammatory and pain-relieving agents to the affected areas. In severe cases, your doctor may also prescribe cortisone tablets. Further treatments such as laser therapy or anti-inflammatory tablets are only useful in severe cases.
• Mouthwashes: Antiseptic mouthwashes or those containing chamomile or sage can help reduce inflammation and promote healing.
• Painkillers: Severe pain can be relieved with over-the-counter painkillers or sprays.

The right diet for aphthae

With aphthae in the mouth, it is important to choose foods that do not irritate the wounds and at the same time promote healing. Avoid spicy, acidic, salty or highly seasoned foods, as these can aggravate aphthae. Soft, mild foods such as rice, porridge, yogurt or cooked vegetables are better. A balanced diet rich in vitamins – especially vitamin B12, folic acid and iron – can help to strengthen the immune system and promote healing. Drink plenty of water to keep the mouth moist and support healing.

Aphthae – when to see a doctor?

In most cases, aphthae heal on their own within one to two weeks and do not require medical treatment. However, there are situations in which it is advisable to consult a doctor or dentist:

• Frequent or recurring aphthae: If aphthae occur repeatedly, this may indicate an underlying disease such as a weakened immune system or a chronic illness.
• Severe pain or discomfort: If the pain is so severe that it significantly interferes with speaking, eating or drinking, you should consult a doctor to obtain appropriate pain medication or other treatment.
• Aphthae that persist for more than two weeks: An aphthous focus that does not heal or worsens for more than two weeks may indicate an infection or other illness.
• Large or unusually numerous aphthae: If the aphthae are unusually large or occur in large numbers at the same time, this may indicate an autoimmune disease or a viral infection.
• Additional symptoms: If you experience additional symptoms such as fever, tiredness or swollen lymph nodes, you should consult a doctor to rule out serious illnesses.

A doctor can make an accurate diagnosis and, if necessary, arrange suitable treatment.