From the dentist to the gastroenterologist: aphthous stomatitis.

From this article you will learn:

• how to treat aphthous stomatitis in children,
• symptoms and treatment of aphthous stomatitis in adults,
• list of effective drugs.

The article was written by a dentist with more than 19 years of experience.

Aphthous stomatitis is a disease in which one or more round ulcerations appear on the oral mucosa, which are covered with a necrotic coating of a gray or yellowish tint. Such ulcers (synonymous with aphthae) are not the result of acute infections, and therefore are not contagious, but nevertheless, such damage to the mucous membrane will require specific therapy.

According to statistics, up to 20% of the population suffers from this form of stomatitis. Young children, as well as adults aged 20 to 30 years, are especially susceptible to this disease. In people of more mature age, there is a dependence: the higher the age, the less likely it is to develop. Aphthous stomatitis has a code according to ICD 10 - K12.0. Below you can see what this disease looks like in children and adults.

Aphthous stomatitis in children: photo

Aphthous stomatitis: photos in adults

The most important thing in treating stomatitis is to first correctly determine its form. Indeed, depending on its form, and it can be either herpetic or aphthous stomatitis, treatment for both adults and children will be completely different. Therefore, if you are not very sure of the diagnosis, it is best to familiarize yourself with the symptoms of both forms before starting treatment.

Causes of aphthous stomatitis

The exact cause of this disease remains unclear. It is assumed that HRAS is of an allergic nature; allergens can include: food, medicine, toothpastes, dust, worms.6,7 It is also assumed that the cause of the disease is an autoimmune reaction.8 A hereditary predisposition to this disease can be traced.

Predisposing factors:

• diseases of the digestive system (gastritis, gastric ulcer, cholecystitis, Crohn's disease)
• dysbacteriosis
• stress
• deficiency of iron, vitamins B1, B2, B6, B12, C
• chronic tonsillitis, otitis and rhinitis

Diagnostics

To cure a disease, you need to make a correct diagnosis. This disease usually does not require special research technologies. The doctor will do this during an examination based on the clinical picture and studying the anamnesis after interviewing the patient. If necessary, the doctor prescribes laboratory diagnostics. In some cases, additional examination techniques are used, especially when the disease is severe and the aphthae takes a long time to heal poorly.

Aphthous stomatitis in adults has become increasingly common in our time. This is caused by their constant employment, non-compliance with hygiene rules, excessive consumption of alcoholic beverages, smoking, and chronic diseases. Anomalies appear in women when hormonal levels change. This can happen during pregnancy, during menopause.

HRAS classification:

How to get rid of stomatitis?

Stomatitis is perhaps the most common and unpleasant disease of the oral cavity. When an infection enters the body, ulcers form in the mouth. They cause discomfort and can subsequently lead to serious complications. How to treat stomatitis ?
Treatment of any infectious diseases first of all involves going to the doctor. Antibacterial therapy should be carried out under medical supervision. Bacterial disease most often goes away in 1-2 weeks. If the stage is not advanced, it can be treated independently. How to treat stomatitis at home :

• Rinse your mouth with soda solution. Add 1 spoon of soda to a glass of warm water. You can also use boric acid (1 teaspoon per 150 ml of water) or hydrogen peroxide (1 teaspoon per half a glass of water).
• Chamomile decoction. Heals wounds quickly.
• Sea buckthorn oil has an antibacterial effect. You can use antiseptics: chlorhexidine or miramistin.
• Anesthetic dental gels will help relieve severe pain. They should contain lidocaine.

Soda solution can also be used to treat stomatitis in infants .
Wipe the mouth and tongue with moistened gauze. If signs of stomatitis (bacterial) do not disappear, you should consult a doctor.

In case of aphthous form of the disease, you should urgently go to the clinic. How to determine:

• multiple large and deep ulcers;
• grayish coating in the center;
• red rim around the wound.

This type of stomatitis should not be treated at home. It is forbidden to cauterize ulcers with alcohol, iodine, or brilliant green. An advanced disease can lead to suppuration and tissue death.

How to get rid of stomatitis in children?

Basic methods of local therapy:

1. Treating the oral cavity with baking soda. For preparation you will need 1 tablespoon per glass of boiled water. Apply 3-6 times a day.
2. Rinse with Blue solution. Or 2% boric acid.
3. Use of antifungal agents. This includes medicated creams and ointments. For example, Clotrimazole, Pimafucin, Nystatin, Candide.

Symptoms of stomatitis in children and treatment can be determined by a doctor. Treatment is carried out in accordance with the doctor's prescriptions. If the dosage is not followed correctly or the course is interrupted, side effects may occur.

You should not self-medicate, as this can harm the baby.
Only a pediatric dentist will prescribe the correct therapy. He can also advise treating stomatitis in children at home .

Types of stomatitis

Depending on the depth of tissue damage and the cause of inflammation, experts distinguish the following types of stomatitis:

• catarrhal;
• aphthous;
• candida;
• ulcerative;
• herpetic;
• traumatic;
• allergic.

The catarrhal form of stomatitis is the mildest and rarely causes complications. But treatment is still required, mainly local. The most severe course is ulcerative necrotizing stomatitis, which often causes bacterial complications.

The candida type occurs more often in young children.

Each type of disease has its own characteristics, causes of development and symptoms. It is difficult to determine the shape yourself.

Sometimes even specialists do not have enough clinical picture to make an accurate diagnosis. Additional laboratory tests are often required to determine why stomatitis occurs in the mouth and whether it is associated with other diseases.

HRAS as a symptom of the disease

Behçet's disease is a disease of unknown etiology, characterized by vascular damage, the appearance of aphthae in the oral cavity and genitals, damage to the eyes, joints, gastrointestinal tract, central nervous system and other organs. It has a chronic course and, if left untreated, can lead to disability.9

Symptoms:

HRAS

HRAS is the earliest symptom of the disease; aphthae can be of any size, recur at least 3 times a year, and are often located on the mucous membrane of the cheeks, lips, gums, tongue

Eye damage

Uveitis (inflammation of the membrane of the eye), blurred vision, “fog” before the eyes, redness of the eyes (rarely), lacrimation

Genital ulcers

Similar to mouth ulcers, but deeper and more painful

Skin redness

The skin exhibits erythema nodosum (red, painful subcutaneous nodules), rash

Other

• vessels in the form of thrombosis, aneurysms
• Nervous system damage: coma, meningitis, confusion
• joints may also be affected in the form of arthritis

Reiter's disease is a systemic infectious disease characterized by damage to the oral mucosa, genitourinary system, eyes and joints.10 The triggering factor for infection is often chlamydia and gonococci, and there is also a genetic predisposition. The disease has a severe course, and in case of complications it leads to disability (blindness, deforming arthritis) and even death.

It is important to remember that HRAS may indicate the presence of a serious systemic disease.

Systemic pharmacological treatment –

Systemic therapy includes 3 types of drugs - antihistamines, glucocorticoids and immunomodulators. Antihistamines can and should be prescribed to absolutely all patients with aphthous stomatitis (without exception), the cause of which has not been precisely established. As for the drugs of the other 2 groups, they are the second line of defense, after which there are essentially no other treatment options.

1) Antihistamines –

Antihistamines will be an excellent addition to local therapy even for mild cases of aphthous stomatitis. The fact is that aphthous stomatitis can often be caused by unidentified food allergens (or components of hygiene products, for example, parabens). Therefore, it makes sense to start taking 2nd generation antihistamines orally for a course of 7-10 days.

Modern antihistamines are well tolerated and do not have significant side effects, therefore, given the difficulty of identifying the true cause of ulceration, you can start taking them from the first day of the disease, or even better - in the prodromal period, when ulcers have not yet formed, but the patient can already feel at the site of their future occurrence there is a slight burning or itching.

Table No. 1 (examples of 2nd generation antihistamines)

Means for nonspecific hyposensitization - for moderate and severe forms of aphthous stomatitis, when we need to quickly reduce the patient's body's sensitivity to allergens - in this case, the use of drugs for nonspecific hyposensitization is indicated. For example, these could be subcutaneous injections of histoglobulin - 2 ml 2 times a week with an interval of 2-3 days (a total of 10-12 injections per course). Or we can prescribe intravenously - a 30% solution of sodium thiosulfate, 10 ml daily, for a total of 6-8 injections for a course. These are all prescription drugs!

2) Systemic glucocorticoids –

These drugs are a second line of defense and are a lifesaver for patients with acute severe outbreaks of canker sores, but these drugs can only be used as directed by a doctor. Typically, prednisolone tablets are used in adults at an initial dose of 25 mg/day for the first 7 days (followed by a gradual dose reduction). The total duration of the course of therapy is usually 15 days, but in severe cases it can even reach 1-2 months.

However, in a clinical study by Pakfetrat et al. (source) – good results of treatment with prednisolone were achieved when used at a dosage of only 5 mg/day. Prednisolone is an extremely effective drug for the treatment of severe forms of aphthous stomatitis, but its dosage must be selected individually for each patient (taking into account the severity and severity of the disease, as well as the patient’s health condition). Be aware that prednisone may cause long-term side effects.

The search for alternative, safer drugs made it possible to find that the drug "Montelukast" (usually used as an anti-asthmatic drug) - at a dose of 10 mg per day, like prednisolone, reduced the number of lesions, relieved pain and accelerated the healing of ulcers, but at the same time it caused significantly fewer side effects (clinical study - Femiano et al.). It is important that Montelukast can be used even when systemic glucocorticoids are contraindicated.

3) Immunomodulators –

Immunomodulators are also a second line of defense, as are glucocorticoids. Their use is especially indicated in patients who are diagnosed with chronic recurrent aphthous stomatitis (with frequent relapses and an aggressive course of the disease). For children over 1 year of age, this could be, for example, in the form of Thymogen nasal spray, but keep in mind that this is a prescription drug.

For children over 3 years old, the over-the-counter drug “Likopid” 1 mg is suitable, which is taken 1 tablet 3 times a day, for a total of 10 days (for resorption under the tongue or orally). However, despite the over-the-counter availability of this drug, we, in principle, recommend taking drugs from the group of systemic immunomodulators - only after consulting an immunologist.

For adults - in adults, for immunocorrection with recurrent aphthous stomatitis, it is optimal to use either the drug "Timogen" (in the form of intramuscular injections of 100 mg daily for 10 days), or "Levamisole", which restores normal phagocytic activity among macrophages and neutrophils and modulates T-lymphocyte-mediated immunity. It is prescribed - 150 mg 3 times a week (for 6 months).

You can also use the drug "Methyluracil" (1 tablet 0.5 g - 3 times a day, for 1 month). For the most severe outbreaks of aphthous stomatitis, you can use Thalidomide at a dose of 50-100 mg/day, but keep in mind that although with the use of this drug 85% of patients experience complete remission of severe lesions (already in the first 14 days) - it has very strong side effects. Keep in mind that all of the above medications can only be used as prescribed by a doctor!

Both children and adults can also use the over-the-counter drug "Imudon", which is available in the form of tablets for resorption in the oral cavity. But this drug affects only the local immunity of the oral mucosa, without affecting the immune system as a whole. The course of treatment is 6-8 tablets per day for resorption (course duration is from 10 to 20 days - depending on the severity and frequency of relapses of aphthous stomatitis).

4) Means for restoring intestinal microflora –

We have already said above that there is a clear correlation between gastrointestinal diseases and repeated outbreaks of aphthous stomatitis, which is explained by the significant influence of intestinal pathology on the state of the immune system. Therefore, such patients are always advised to take medications (probiotics) that normalize the intestinal microflora. This could be Linex or Bifiform, as well as Hilak-Forte or other similar drugs.

Probiotic Bifiform –

Prevention of HRAS

Prevention should be aimed at monitoring the state of health in general, treating chronic diseases, and it is necessary to undergo regular examinations regarding the existing disease. Hardening and strengthening the immune system have a good effect. You need to visit the dentist to monitor your oral health once every 3-4 months to ensure timely detection of relapses. You should avoid using toothpastes, hygiene products with dyes or identified allergens. Taking antibiotics should only be done under the supervision of a doctor. It is recommended to avoid strong psycho-emotional stress and regularly carry out wet cleaning of the premises.

It is worth paying attention to Tantum® Propolis .

Tantum® Propolis

Propolis has an immunostimulating effect, promotes healing, vitamin C, which is part of it, is responsible for regeneration, participating in the synthesis of collagen.
Propolis also has antiviral and antifungal effects. Therefore, vitamin therapy Tantum® Propolis is an effective means of preventing stomatitis12 Find out more

Diagnosis of the disease and its differences from other pathologies

The doctor receives the first data after examining the patient’s mouth. Next, the doctor collects an anamnesis of the disease and the patient must answer when the first symptoms appeared, how quickly the disease developed, whether there were injuries (including burns) to the oral cavity, allergies to foods and medications, whether close relatives suffered from stomatitis.

To identify the causative agent of the disease, you will need to take a smear on the flora and exclude manifestations of herpes and candidiasis. For this purpose, laboratory tests are used - bacterial culture and PCR smear.

For persistent stomatitis, you should check your blood glucose level.

Forms of the disease

Aphthous stomatitis can occur in two forms: chronic and acute. Each form of pathology has its own characteristics of symptoms, which help establish the clinical picture during diagnosis.

Acute form of aphthous stomatitis

The pathological condition is accompanied by puffiness and swelling of the mucous membrane, on which aphthae of gray or white color and round shape are formed. With timely initiation of treatment, acute stomatitis lasts up to 10 days. After therapy, the mucous membrane is completely restored.

Chronic form of aphthous stomatitis

It develops in the absence of treatment for acute stomatitis, hereditary predisposition or the presence of chronic diseases that affect the immune system. The peculiarity of the pathology is the occurrence of periodic relapses. The duration of the disease is up to 14–30 days.

What systemic diseases can manifest as aphthae?

• Reiter's syndrome
• Behçet's disease
• AIDS
• cyclic neutropenia
• PFAPA syndrome

The gastroenterologist is especially interested in the connection between recurrent ulcers and specialized systemic diseases.

Celiac disease is found in 5% , and for a long time canker sores may be the only manifestation of a reaction to gluten.

Let me remind you that the estimated prevalence of celiac disease in the general population is about 1%.

Enamel defects and aphthous stomatitis in celiac and healthy subjects: Systematic review and meta-analysis of controlled studies

Other important conditions that manifest as canker sores are inflammatory bowel diseases: Crohn's disease and ulcerative colitis.

Extraintestinal Manifestations of Pediatric Inflammatory Bowel Disease: Prevalence, Presentation, and Anti-TNF Treatment

Dentists' recommendations

Prevention of aphthous stomatitis is the surest way to prevent the disease in children. Parents of children with a hereditary predisposition, chronic diseases or weakened immunity should pay the greatest attention to preventive measures.

To reduce the risk of developing aphthous stomatitis, dentists recommend:

• monitoring the child's nutrition;
• exclusion of allergenic products (if indicated);
• periodic intake of vitamin complexes;
• maintaining oral hygiene at home;
• professional teeth cleaning every 6 months;
• timely treatment of dental diseases;
• treatment of any provoking diseases;
• contact your dentist at the first symptoms of aphthae.

Aphthous stomatitis is a complex dental disease caused by infection. Treatment of infectious pathology at home often only helps to eliminate symptoms and transition of the disease to a chronic form. Contacting a qualified dentist will allow you to individually select treatment tactics for complete recovery or achieve long-term remission with subsequent “attenuation” of the infection.

Symptoms

The disease has rather sparse symptoms. Visually, it is easy to identify by the presence of characteristic ulcers on the inside of the lips, cheeks, soft palate and tongue (rarely). Keratinized (fixed) gums are not affected by aphthous stomatitis, which is another difference between aphthous stomatitis and herpetic stomatitis. At the initial stage of aphthae, the patient usually feels discomfort and burning, and the temperature may rise slightly. Diagnosis involves a visual examination, as well as taking blood tests and mucosal smears if the doctor suspects the presence of concomitant diseases.

The causative agent of the disease

Aphthous stomatitis is an infectious disease that develops after penetration of a pathogen into the body. The mucous membrane protects the tissues of the oral cavity from pathogenic microorganisms, but if damaged, the infection can penetrate inside. The causative agent of aphthous stomatitis does not immediately become active. If the patient has a strong immune system, then the incubation period begins. But when the immune system is weakened under the influence of any factors, the disease begins to progress.

There are several ways of contracting aphthous stomatitis.

1. Contact and household. The infection enters the oral cavity from dirty hands, objects, products, etc.
2. Interior. Every person’s body contains not only “good” bacteria, but also “bad” bacteria. When the immune system is weakened, pathogenic microorganisms begin to manifest themselves. These bacteria also include the causative agent of stomatitis.
3. Pathological. The cause of the disease may be another disease of a bacterial or viral nature. Stomatitis is mainly observed against the background of measles, smallpox and herpes.

Most people suffer from stomatitis in childhood, which has a simple explanation - the immunity of children is much weaker than that of an adult. Even with the chronic form of the disease, as the child grows older, relapses occur less and less frequently.

Conclusions:

Aphthae in the mouth recur at some point in life in almost 20% of all people, most often in the second decade of life.

It is difficult to establish a clear and unambiguous reason.

If recurrent aphthae occurs, the pediatrician, physician, or dentist should consider the possibility that rare aphthae are a manifestation of a serious systemic disease.

In such situations, the gastroenterologist must exclude celiac disease, Crohn's disease and ulcerative colitis.

4, total, today

Types of aft.

Small aphthae is the most common type of aphthae (80-85%). Their size ranges from 1 to 10 mm. Ulcers can appear singly or several at a time (up to five).

Usually heal in 7-10 days.

Large aphthae (10-15%) - more than 10 mm in diameter, can even be up to 3 cm, deeper, take longer to heal (10-30 days).

They may leave scars behind. Very rare in children.

Herpetiform aphthae (5-10%) are small, from 1 to 3 mm, located in groups like herpetic vesicles. They heal quickly, within 10 days. They are not typical for children; they usually occur in the elderly.

The rest of the oral cavity looks normal - there is no inflammation of the gums, redness of the tonsils and pharynx, enlarged and painful cervical lymph nodes.

There is no fever or other general manifestations.

Aphthae in children is manifested primarily by refusal to eat and drink due to pain in the mouth.

The reasons for the recurrence of aphthae are not completely clear; the most popular theory is related to errors in the immune system.

Doctors most often do not find a specific cause of the failure; most likely it is a combination of several factors.

But doctors still have assumptions about some factors.

Ways of transmission of stomatitis

Let's summarize. Viral, bacterial and herpetic forms of stomatitis are contagious. Knowing how the disease is transmitted, you can protect yourself and your loved ones. Ways of transmission of infection:

• airborne - sneezing, coughing;
• household items - common dishes, linen, personal items;
• toys, raw pacifiers, rattles;
• dirty hands;
• unwashed food;
• biological fluids - through saliva, blood, breast milk;
• Pets can carry the virus.

It is possible to catch the infection anywhere – from the street to your own home. You can get infected from both a child and an adult.