Aphthae: Causes, Manifestations, Treatment

Aphthae: Causes, Manifestations, Treatment
Photo source: Getty images

Aphthae are among the most common inflammations of the oral mucosa. They affect approximately 20% of the population, both children and adults. Some people develop them only once and others develop them repeatedly throughout their lives. The cause is not yet fully understood.

The oral cavity, like other parts of our body, can be affected by various diseases and have diverse causes.

The most common causes include:

  • viruses
  • bacteria
  • fungi
  • allergy
  • hormones
  • as a consequence of systemic disease
  • genetic predisposition
  • mental disorders
  • oncological diseases

They affect different parts, such as the lips, the oral mucosa, gums, teeth, tongue and salivary glands. They are manifested in different ways, for example by redness, swelling or pain. The pain may be aggravated by eating, talking or persisting without irritants.

Aphthae are just the most commonly occurring problems in the mouth and oral cavity.
They affect up to 20% of the population.

Why do aphthae arise?

In medical terms, aphthae are referred to as recurrent aphthous stomatitis. The cause is not completely clarified even nowadays. It affects mostly the young, but occurs at any age.

In the past, the influence of microorganisms, viruses, was considered. However, this relationship has not been confirmed.

Some presumed causes are:

  • genetic predisposition 
    • associated with HLA antigens
  • a third of people have a confirmed family history
  • vitamin B12 deficiency
  • iron deficiency
  • folic acid deficiency
  • related to conditions and diseases such as:
    • celiac disease
    • Crohn's disease
    • other digestive tract disorders such as irritable bowel syndrome or inflammatory bowel disease
    • inflammations of the stomach
    • ulcer disease
  • allergy to certain foods
  • pernicious anaemia
  • lowered body defences, i.e. immunity
  • hormonal changes in women related to the menstrual cycle
  • smoking and especially the time after quitting
  • stress
  • and the condition after injuries, such as poor brushing technique

The course of aphthous inflammation is aggravated by poor oral hygiene. As the inflammation becomes infected with microorganisms.

What are aphthae and how are they categorised?

Aphthae are small blisters covered with a pale to grey coloured membrane. This membrane often ruptures and a small ulcer forms. Its bottom is slightly below the level of the surrounding healthy mucosa.

The ulcer has sharply demarcated edges with a reddish mucous membrane. Aphthae can occur singly or in clusters. Aphthae are then subdivided according to size.

Aphthae are categorised into three main groups:

  • minor aphthae, also called stomatitis aphtosa minor and Mikulicz's aphthae
  • major aphthae, also called stomatitis aphtosa major and Sutton's ulcers
  • herpetiform types

Table: distribution and description of aphthous inflammations

Type Minor aphthae Major aphthae Herpetiform ulcers
Size up to 4 mm 1 cm on average
sometimes up to 3 cm
smaller ulcers
resemble herpetic inflammation
Count up to 6 do 6 kusov up to 100 ulcers
Frequency most commonly
80 %
about 10 % up to 10 %
Age and sex children, adults children, adults young adults
and in most cases women
Site lips
buccal mucosa
the bottom of the mouth
soft palate
less common:
gums and upper part of the tongue,
i.e. the dorsal part
most commonly:
buccal mucosa
soft palate
most commonly on the tongue
bottom part
Duration up to 10 days about a month about a month
Intensity of difficulties mild
minor issues
higher intensity
may scar
frequent relapsea - return
very painful
ulcers often fuse resemble herpes,
but no viral infection is present

The buccal mucosa is therefore the buccal mucosa.

Aphthae in the mouth can be under the tongue, but also on the tongue or on the gums

The first and most commonly occurring group are small aphthae. They have a mild course, although it is inconvenienced by soreness. They usually disappear within 10 days. It can be complicated by poor oral hygiene and infection with microorganisms.

They occur mostly on the mucous membrane of the cheeks and the base of the mouth. The bottom of the mouth is the area under the tongue. To a lesser extent, they may appear on the gums and upper part of the tongue. The palate is affected only in its soft part.

Large aphthae can occur in these places and virtually anywhere in the mouth. Their course is characterized by a higher intensity and a longer period of occurrence. They are also characterised by a tendency to recurrence, i.e. recurrence.

The third group resembles a herpetic infection, hence its name. Herpetiform aphthae are characterized by a size of about 3 mm. The number of ulcers is higher. The ulceration goes deeper.

Although this form is similar to herpetic infection, the presence of herpes virus has not been proven.

Most often they occur on the lower part of the tongue. They have a high intensity of pain. Although the boils are small, they often merge. They can take up to a month to heal and often recur.

In their case, it is important to distinguish whether they are really aphthae or whether another disease is the cause. An example would be herpetic tonsillitis or another herpetic infection in the oral cavity.

They occur frequently in children and young adults

The most affected population is children, adolescents and young adults. Women as well as men are affected, with people aged 11 to 35 years being most commonly affected.

Herpetiform boils that are more prominent in women.

Of course, aphthae also occur in adulthood.

In women in pregnancy and with hormonal changes

They can also bother expectant mothers. And this is not at all an isolated phenomenon. Pregnancy is an extremely demanding condition for a woman's organism.

The mother's body nourishes the fetus, and a decrease in iron or folic acid is a prerequisite for the formation of aphthous inflammation. Another cause may be a weakened immune system. The immune system is affected by pregnancy. However, they do not have a negative effect on pregnancy.

Aphthae and pregnancy
Aphthae can also afflict pregnant women. Photo: Getty Images

By improving lifestyle or diet, a pregnant woman can prevent aphthae. It is very important to take a diet rich in vitamins and minerals. Vegetables, fruits and foods that supply the body with B complex vitamins, folic acid or iron.

Also during pregnancy, aphthae can be treated with the help of topical disinfectants. Which should prevent their subsequent infection.

Behçet's disease

It is a disease whose cause is unknown. It may be due to genetic predisposition, autoimmune disease or infection with a virus. A combination of these may be considered. It may also occur familially.

The manifestation is a triad of symptoms, namely:

  1. numerous aphthae in the oral cavity
  2. aphthous ulcers in the genital area
  3. hypopyon - an eye disease

The disease is rare and mainly affects populations in areas of the world such as Japan, China, Korea, Turkey, Tunisia. It is most common between the ages of 20 and 35, especially in men.

The manifestation is the appearance of aphthae in the oral cavity and on the genitals. In men, mainly on the scrotum, or scrotum. Less often on the penis. In women, the labia are affected.

Both eyes are usually affected, in most cases within three years of the onset of the disease.

Consequently, it also has a negative signature on other organ systems. And this is, for example, the skin, blood vessels, neurological and digestive system or joints.

Learn more about the disease: Recurrent aphthae and Behcet's disease.

Is transfer of aphthae possible?

In aphthae, an infectious cause is not assumed. So no. Aphthae are not an infectious disease.

But, a complication of aphthous inflammation can be infection with a microorganism. Therefore, at the time of occurrence, oral hygiene is all the more important. 

How to prevent them?

One should take care to maintain sufficient oral hygiene. Use a proper toothbrush and brushing technique when brushing teeth.

Read also:
How to choose a suitable toothbrush?
How to get and keep healthy teeth

Aphthae occur most often in the child population and therefore care must be taken to prevent them. Mechanical damage is prevented by proper technique, which needs to be taught to the child.

Mechanical damage can also be caused by dental braces.

If hypovitaminosis, i.e. a lack of vitamins or minerals, is behind the occurrence of aphthae, they need to be replenished in the form of an appropriate diet or nutritional supplements and by strengthening immunity.

Aphthae after injection at the dentist
The occurrence of aphthae is also common after dental procedures. Source.

How to get rid of them? The best treatment treats the causes

In most cases, the aphthae disappear by themselves after some time. If their occurrence is prolonged or recurrent, it is necessary to seek professional help. A general practitioner can refer you to a dentist.

Diagnosis is important. This is based on the medical history and clinical picture.

Differential diagnosis, i.e. ruling out another cause, is very important. Blood sampling and laboratory tests are also used. A blood count or analysis of minerals, vitamins or antibodies. Even a biopsy.

If the course is more severe, it is also necessary to perform some tests, such as allergological, immunological genetic or microbiological.

Treatment is mainly local and symptomatic, i.e. symptoms are alleviated.

An oral anaesthetic is administered to numb the mouth and relieve pain, or painkillers - analgesics. Vitamin preparations, various ointments, gels, solutions or some types of teas help.

Aphthae can be treated with topical disinfection. If necessary, also with antibiotics, if there is an infection with a bacterium, such as streptococcus. 

But the most important thing is to focus on a known cause that may have caused the aphthae.

And this is more complicated with aphthae. Because their cause may not be obvious.

Known causes include, for example:

  • traumatic injury in the oral cavity caused by
    • toothbrush
    • braces
    • injection at the dentist
    • biting the inside of the lip
    • tongue bite
  • mineral and vitamin deficiencies
    • iron
    • vitamin B6
    • folic acid, i.e. vitamin B9
    • vitamin B12
  • food allergies - for example to apples, pears, peas or carrots

Aphthae may only be the beginning

Underestimating aphthae means ignoring not only the symptom and manifestation itself, but especially ignoring the cause.

Aphthae can also sometimes very easily be mistaken for, or prevented by, some very serious oral diseases or be their first and warning sign.

Unfortunately, it is not only about diseases in the mouth, because aphthae are also a sign of immunological diseases, diseases of infectious origin and some systemic diseases.

It is therefore ideal to see a doctor as soon as aphthae appear, e.g. your GP, dentist, dental surgeon or an immunologist.

First and foremost, it is advisable to focus on prevention as part of oral hygiene, which means, for example, removing plaque and tartar, which can harbour micro-organisms.

Children should also avoid chewing gum, spices and irritating foods.

White Coated Tongue vs. Oral Thrush

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Interesting resources

  • Bruch JM, Treister N (2009). Clinical Oral Medicine and Pathology. Springer Science & Business Media. p. 53. ISBN 9781603275200.
  • Scully C (2013). Oral and maxillofacial medicine: the basis of diagnosis and treatment (3rd ed.). Edinburgh: Churchill Livingstone. pp. 226–34. ISBN 978-0-7020-4948-4.
  • Treister JM, Bruch NS (2010). Clinical oral medicine and pathology. New York: Humana Press. pp. 53–56. ISBN 978-1-60327-519-4.
  • Altenburg A, Zouboulis CC (September 2008). "Current concepts in the treatment of recurrent aphthous stomatitis". Skin Therapy Letter13 (7): 1–4. PMID 18839042.
  • Neville BW, Damm DD, Allen CM, Bouquot JE (2008). Oral & maxillofacial pathology (3rd ed.). Philadelphia: W.B. Saunders. pp. 331–36. ISBN 978-1-4160-3435-3.
  • Brocklehurst P, Tickle M, Glenny AM, Lewis MA, Pemberton MN, Taylor J, Walsh T, Riley P, Yates JM (September 2012). "Systemic interventions for recurrent aphthous stomatitis (mouth ulcers)". The Cochrane Database of Systematic Reviews
  • Millet D, Welbury R (2004). Clinical problem solving in orthodontics and paediatric dentistry. Edinburgh: Churchill Livingstone. pp. 143–44. ISBN 978-0-443-07265-9.
  • Preeti L, Magesh K, Rajkumar K, Karthik R (September 2011). "Recurrent aphthous stomatitis". Journal of Oral and Maxillofacial Pathology
  • Souza PR, Duquia RP, Breunig JA, Almeida HL (September 2017). "Recurrent aphthous stomatitis in 18-year-old adolescents – Prevalence and associated factors: a population-based study". Anais Brasileiros de Dermatologia92 (5): 626–629. 
  • Slebioda Z, Szponar E, Kowalska A (June 2014). "Etiopathogenesis of recurrent aphthous stomatitis and the role of immunologic aspects: literature review". Archivum Immunologiae et Therapiae Experimentalis62 (3): 205–15. 
  • Odell W (2010). Clinical problem solving in dentistry (3rd ed.). Edinburgh: Churchill Livingstone. pp. 87–90. ISBN 978-0-443-06784-6.
  • Riera Matute G, Riera Alonso E (September–October 2011). "[Recurrent aphthous stomatitis in Rheumatology]". Reumatologia Clinica7 (5): 323–8
  • Scully C, Porter S (April 2008). "Oral mucosal disease: recurrent aphthous stomatitis". The British Journal of Oral & Maxillofacial Surgery46 (3): 198–206.
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