The term “aphthous” is derived from a Greek word “aphtha” which means ulceration. Recurrent aphthous stomatitis (RAS) is one of the most common painful oral mucosal conditions seen among patients.

1. Recurrent Aphthous
Stomatitis
Presented by
Dr. Rahul Srivastava
Professor
Rama Dental College Hospital
& Research Centre Kanpur

2. Recurrent Aphthous Stomatitis (RAS)
Recurrent aphthous stomatitis is a disorder
characterized by recurring ulcers in the oral
mucosa in the patient with no other signs of
disease.
The term “aphthous” is derived from a Greek word
“aphtha” which means ulceration.

3. Classification of Recurrent Aphthous Stomatitis
(RAS)
Based on nature of recurrence as follows:
1- Simple aphthosis – Here the recurrence occurs
two to four times in a year.
2- Complex aphthosis - Associated with systemic
disease and activity of disease continues
throughout the year and as older lesions heal
newer lesion develops.

4. Classification for determining the management
strategies:
1- Type A: RAS episodes lasting a few days with
tolerable pain and a few occurrences in a year.
2- Type B: Painful RAS lasting 3 to 10 days
recurrence every month.
3- Type C: Chronic painful course with disease
activity almost continuous throughout the year.

5. Recurrent aphthous ulcers can also be divided in
to:
1- Major recurrent aphthous stomatitis.
2- Minor recurrent aphthous stomatitis.
3- Herpetiform ulcers.

6. Etiology of recurrent aphthous stomatitis
1- Local:
Trauma
Smoking
Dysregulated saliva composition
2- Microbial:
Bacterial: Streptococci
Viral: Varicella zoster, Cytomegalovirus

7. 3- Systemic:
Behçet’s disease.
Mouth and genital ulcers with inflamed cartilage
(MAGIC) syndrome.
Crohn’s disease.
Ulcerative colitis.
HIV infection.
Periodic fever, aphthosis, pharyngitis, and
adenitis (PFAPA) or Marshall’s syndrome.
Cyclic neutropenia.

8. 4- Stress:
Psychological imbalance.
Menstrual cycle.
5- Nutritional:
Gluten sensitive enteropathy
Iron, folic acid, zinc deficiencies
Vitamin B1, B2, B6 and B12 deficiencies

9. 6- Genetic:
Ethnicity.
HLA haplotypes: Certain genetically specific
HLAs have been identified in RAS patients as HLA-
A2, HLA-B5, HLA-B12, HLA-B44, HLA-B51, HLA-B52,
HLA-DR2, HLA-DR7 and HLA-DQ series.

10. Allergic/Immunologic:
Local T-lymphocyte cytotoxicity.
Abnormal CD4:CD8 ratio.
Dysregulated cytokine levels.
Microbe-induced hypersensitivity.
Sodium lauryl sulfate (SLS) sensitivity.
Food sensitivity.

11. Others:
Antioxidants.
Non-steroidal anti-inflammatory drugs (NSAIDS).
Beta blockers.
Immunosuppressive drugs.

12. Pathogenesis of RAS
It is cell mediated immune response in which TNF-
alpha plays a major role.
A mononuclear (lymphocyte cell) infiltrate in the
epithelium in pre ulcerative stage followed by a
localized papular swelling due to keratinocyte
vacuolation surrounded by a reactive erythmatous
halo representing vasculitis.

13. The painful papule then turns in to a vesicle which
ulcerates and fibrinous membrane covers the ulcer
that is infiltrated by neutrophils, lymphocytes and
plasma cells.
Finally there is healing with epithelial regeneration.

14. Clinical features of major recurrent aphthous
Also known as Periadenitis mucosa necrotica
recurrens, Sutton’s disease
Rare and severe form.
Sex ratio :M= F
Age of onset (yrs): 10-19
Number of ulcers: 1-10
Size of ulcers: (mm) > 10
Duration (days):> 30

15.  Rate of recurrence (months): < Monthly.
 Sites: lips, cheeks, tongue, palate, pharynx.
 Permanent scarring: Common
 Lesions are oval in shape and painful.

16. Giant aphthae, relapsing aphthae or refractory
aphthae
Rarely major aphthae may present as numerous
ulcers affecting a large area or several giant lesions
that persists for months. These lesions are referred
as giant aphthae, relapsing aphthae or refractory
aphthae.

17. Clinical features of Minor recurrent aphthous
stomatitis
 Also known as mild aphthae or Mikulicz’s aphthae
 Sex ratio: M= F
 Age of onset (yrs): 5-19
 Number of ulcers: 1-5
 Size of ulcers: (mm) < 10
 Duration (days): 4-14
 Rate of recurrence(months): 1-4
 Permanent scarring: uncommon

18. These ulcers are usually oval or round in shape
enveloped by thin eryhematous halo with grey-white
pseudomembrane.
The labial and buccal mucosa and the floor of the
mouth.
 Gingiva, palate, or dorsum of the tongue is rarely
affected.

19. Prodromal symptoms like localized burning
sensation and pain may occur before the appearance
of ulcers.
Ulceration and pain lasts for about 3 to 4 days, and
then re-epithelialization begins after which pain
starts subsiding.

20. Clinical features of herpetiform ulcers
 Sex ratio : F > M
 Age of onset (yrs): 20-29
 Number of ulcers: 10-100
 Size of ulcers: (mm) > 1-2
 Duration (days): < 30
 Rate of recurrence (months): < Monthly.
 Sites: Lips, cheeks, tongue, palate, pharynx,
palate, gingiva, floor of mouth.
 Permanent scarring: uncommon
 Rare presentation.

21. Accounts for 5 to 10 % of all RAS cases.
Characterized by multiple recurrent crops of small,
painful ulcers (5-100) that are widespread and may
be distributed throughout the oral cavity.
They tend to fuse, producing large irregular
ulcers.
These ulcers have later age of onset with more
predisposition for women.

22. Investigations for RAS
Blood investigations- Serum iron, folate, vitamin
B12 and ferritin levels.
Immuno Histochemistry - The epithelial basalcells in
pre-ulcerative RAS lesions and epithelium at the
ulcer stage contain Class I and Class II MHC
antigens, both being consistent with active cell
mediated inflammation.
RAS biopsy tissue on immunological study reveals
numerous cells with variable ratios of CD4+:CD8+T
lymphocytes depending on ulcer duration.

23. Treatment of RAS
Topical preparation
Topical corticosteroid such as:
1- Clobetasol proprionate 0.05% in Orabase,
Clobetasol proprinate 0.05% or fluocinonide 0.05%
in Orabase (1:1).
2- Hyaluronic acid gel 0.2%.
3- Lidocaine 5% ointment and lidocaine 10% spray
is also effective for temporary analgesia.

24. Systemic Therapy-
Oral antimicrobials, such as penicillin G (50mg
QIDx 4 days), decrease ulcer size and pain.
Clofazimine, an antimicrobial, in combination with
rifampin and dapsone, has been shown to prevent
the formation of new lesions.
Zinc at 50mg/day has also produced beneficial
effects on wound reepitheliazation and healing.

25. Pentoxifylline has shown promising results in
reducing severity of outbreaks, but has little effect
in preventing new outbreaks and has numerous GI
side effects.
Low-dose oral tetracyclines may also be helpful due
to their anti-inflammatory properties.

26. Oral prednisone (initial dose of 25mg/day with
taper) is the first-line systemic therapy and is
typically reserved for the acute treatment of severe
RAS outbreaks.
Steroid-sparing agents, such as colchicine at
starting at 0.5mg/day and gradually increasing to
1.5mg/day or dapsone 25mg/day and gradually
increasing to 100mg/day may also be effective.

28. Thalidomide at a dose of 50 to 100mg/day is
considered the most effective immunomodulator for
RAS, but is obviously limited by its side-effect profile.
Daily ascorbic acid 2000mg/m2/day for minor RAS
shows reduction in oral ulcer outbreaks and a
significant reduction in pain level.
Bioadhesive Patches – Bio-adhesive hydrogel patches.

29. Reference
S.R. Porter C. Scully Recurrent aphthous stomatitis
Crit Rev Oral Biol Med 1998;9:306-321.
S Jurge, R Kuffer, C Scully, SR Recurrent aphthous
stomatitis Porter Oral Diseases 2006;12:1–21.
doi:10.1111/j.1601-0825.2005.01143.x
Edgar NR, Saleh D, Miller R A. Recurrent Aphthous
Stomatitis: A Review. J Clin Aesthet Dermatol
2017;10:26-36.

30. Akintoye SO, Greenberg MS, Recurrent Aphthous
Stomatitis Dent Clin North Am. 2014;58: 281–297.
De Gallo CB, Mimura MA, Sugaya NN.
Psychological stress and recurrent aphthous
stomatitis. Clinics (Sao Paulo) 2009;64:645–648.