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Differential Diagnosis of Severe Recurrent Oral Ulceration

Recurrent aphthous ulceration (RAU) also known as aphthous ulceration, recurrent aphthous stomatitis, or in the vernacular as canker sores, is the most common oral ulceration. These ulcers occur several times per year in an otherwise healthy individual. Presently, the cause is unknown although there is reasonable data to suggest an autoimmune etiology. The occurrence of ulcers is believed to be related to stress, trauma, and hormonal or chemical mediators (hypersensitivity). These lesions affect 20% of the population, are painful and appear on the non-keratinized (movable) mucosa including the lips, buccal mucosa, floor of mouth, and soft palate. The lesions are seen more commonly in higher socioeconomic groups, females, children, young adults and non-smokers. There is also a strong familial propensity.

Three types of RAU are recognized, including minor (Mikuliicz aphthae), major (Sutton’s disease or periadenitis mucosa necrotica recurrens), and herpetiform. The minor type, which represents the most common presentation, usually appears as one to four superficial ulcerations that are less than 1 cm in size. They heal in 7 to 10 days without scarring. The major form presents as one or two deep ulcerations that are greater than 1 cm in size. They heal in 2 to 6 weeks with scarring and recur more frequently. In fact, when one ulcer is healing another may appear. Both major and minor aphthae usually present as circular or oblong target lesions with a white pseudomembraneous center surrounded by erythema. The herpetiform type is the least common, and usually appears in crops of 10 to 50 superficial ulcerations that are approximately 1 to 2 mm in size, and heal in 7 to 10 days without scarring. Individual lesions are very small, and may appear similar to herpes lesions (hence the name herpetiform).

There are many vesicular-ulcerative conditions that may appear in the mouth and can be confused with RAU, including primary herpetic gingivostomatitis, Behcet’s syndrome, cyclic neutropenia, pemphigus vulgaris, benign mucous membrane pemphigoid, herpangina, and Crohn’s disease. These conditions should be considered prior to initiating therapy for RAU. Furthermore, oral ulceration may be indicative of underlying or developing systemic disease, the definitive diagnosis of which may not be possible until later in the disease process. In such cases, it is the dentist's responsibility to carefully follow proper differential diagnosis protocol in order to determine the most appropriate working diagnosis. Due to the fact that certain systemic diseases may be in the developing stage, the dentist should continually monitor the patient, and collaborate with medical colleagues to determine if a definitive diagnosis becomes evident.

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