apthous stomatitis and hypersensitivity reactions

lecture given 10/16/2026

recurrent aptheous stomatitis

most common oral mucosal lesion

cause- different things in different people

T cell mediated immunologic reaction with production of TNF-alpha

etiology of aphthae

still uncertain

different subgroups of pts appear to different causes for the occurance of aphthae

may be multifactorial

immunologic reaction to an oral antigen

allergies, genetic predisposition, hematologic abnormalities, hormonal influences, immmunological factors, infectious agents, nutritional deficiencies, smoking cessation, stress (mental and physical), trauma

factors that increae the frequency of occurrence of aphthae

trauma, nutritional deficiencies, smoking cessation

factors that increae the frequency of occurrence of aphthae

smoking, hormonal changes, attached mucosa

potential antigens of aphthae

sodium lauryl sulphate in tooth paste

systemic medications (NSAIDs, beta blockers)

infectious agents (strep, H. pylori, HSV, VZV, CMV)

foods (cheese, chocolate, coffee, milk, gluten, nuts, strawberries, tomatoes, flavoring agents, preservatives)

recurrent aphthous stomatitis

somtimes associated wtih prior trauma

may be precipitated by psychic stress

may be precipitated by dietary factors

may be associated with hormonal fluctuation

somtimes associated with IBD

uncommon in smokers

clinical variations of apthous stomatitis

minor aphthous ulcerations

major aphthous ulcerations

herpetiform apthous ulcerations

behcet syndrome

minor aphthous ulcerations

children and young adults

fewest recurrences and shortest duration

F>M, frequency declines with age

occur exclusively on non-keratinized mucosa BM, LM, ventral tongue, vestibule, FOM, SP

small, painful, shallow ulcer with red rim

solitary or multiple; <5 at one outbreak

full size within a day; heal within 2 weeks

minor aphthous ulcerations

minor aphthous ulcerations

minor aphthous ulcerations

minor aphthous ulcerations

major aphthous ulcerations

larger ulcerations measuring from 1-3cm in diameter

take from 2-6 weeks to heal

may cause scaring with eventual restriction of oral opening

number of lesions varies from 1-10

present for longer duration

deep ulcerations

common locations: labial mucosa, soft palate, tonsillar fauces

major aphthous ulcerations

major aphthous ulcerations

herpetiform aphthous ulcerations

least common of the aphthous stomatitis conditions

adult onset, mostly movable mucosa, female predominance

greatest number of ulcers and most frequent recurrences

small crops of painful ulcers that come and go

resemble herpes lesions except confined to non-keratinized mucosa

heal in 7 to 10 days but recur more frequently

do not respond to antibiotics/antivirals

herpetiform aphthous ulcerations

treatment for aphthous stomatitis

review diet/nutrition/GI symptoms

symptoms control

OCT preparations

topical anesthesia (elixir of benadryl)

corticosteroids (flucocinomide gel 0.05%, dexamethasone solution 0.5mg/5mL)

antimicrobial (tetracycline/chlorhexidine)

laser/chemical cautery

severe cases: TNF alpha inhibitor (thalidomide)

behcet’s syndrome

affects oral, genital, and ocular regions

multisystem disorder caused by systemic vasculitis

abnormal immune process

triggered by infectious or environmental antigen in a genetically predisposed individual

distinct racial predilection for people of middle east descent

young adults; uncommon in blacks; M>F

oral ulcers resembling minor/major aphthae

genital ulcers

ocular involvement

cutaneous involvment

arthritis

CVS, CNS, pulmonary, renal systems can be involved

behcet’s syndrome

behcet’s syndrome

erythema multiforme

blistering ulcerative mucocutaneous disease

uncertain etiopathogenesis

immunologically mediated process

initiating factors: HSV, mycoplasma pneumoniae, medications

acute onset; young adults; F>M

prodromal symptoms are often present

cutaneous lesions: targetoid or bull’s eye lesions

oral lesions: large, shallow erosions and ulcerations

hemorrhagic crusting of the vermillion zone of the lips

self limiting: lesions heal in 2 to 6 weeks

IV rehydration, symptomatic management, identify initiating factor in recurrent lesions

erythema multiforme

erythema multiforme

erythema multiforme

stevens johnson syndrome (SJS)

toxic epidermal necrolysis (TEN)

hypersensitivity reactions like EM but separate clinically and likely separate etiopathogeneticallu

SJS typically associated with medication usage or mycoplasma pneumoniae infection and rarely HSV

SJS considered less severe variant of TEN

flu-like prodromal signs and symptoms

skin lesions always present with predominant involvement of the chest

like EM, both TEN and SJS present with labial crusting, oral bullae/ulcers/erosions

eye and genital involvement in addition to oral lesions

discontinue drug; skin lesions heal in 3 to 5 weeks

stevens johnson syndrome (SJS)

toxic epidermal necrolysis (TEN)

transient lingual papillitis

one to several painful enlarged fungiform papillae

unknown pathogenesis

may represent a hypersensitivity rxn however, the underlying etiology has not been fully elucidated

typically involves the anterior dorsal tongue

red papules with yellow ulcerated cap

no treatment necessary

resolve spontaneously within several hours to several days

transient lingual papillitis

erythema migrans (geographic tongue)

common benign condition predominantly involving the tongue

asymptomatic; occasionally causes mild burning discomfort

etiology unknown; atopic individuals?

multiple well-demarcated erythematous patches; yellow-white scalloped border

filiform papillary atrophy which migrates from one area to the next

often seen in association with fissured tongue

may occasionally occur on other mucosal sites

treatment rarely indicated

erythema migrans (geographic tongue)

erythema migrans (geographic tongue)

erythema migrans (geographic tongue)

allergic mucosal reaction to systemic medication

stomatitis medicamentosa

several different patterns of oral mucosal lesions- anaphylactic stomatitis, intraoral fixed drug eruptions, lichenoid drug reactions, lupus erythematosus-like eruptions, pemphigus-like drug reactions, pemphigoid like drug reactions, non-specific erosive/ulcerative/aphthous-like lesions

medication associated mucositis

no clinically consistent features- may mimic various other disorders

index of suspicion needed for unusual presentations

may take weeks to improve on withdrawl of stimulus

palliated with topic steroids if the offending medication cannot be discontinued

medication associated mucositis

medication associated mucositis

medication associated mucositis

medication associated mucositis

medication associated mucositis

medication associated mucositis

allergic contact stomatitis from dental restorative materials

may involve buccal mucosa, tongue, and gingiva in intimate contact with restoration

typically solitary red/white lesion; may exhibit peripheral striae

cutaneous allergy patch testing may be helpful to identify appropriate choice of material for future restorations

allergic contact stomatitis from dental restorative materials

allergic contact stomatitis to oral hygiene products

wispy strips of epithelium lying on surface

no erythema or pain

caused by use of strong dentifrices

treat via discontinuation of inciting agent

allergic contact stomatitis to oral hygiene products

allergic contact stomatitis to oral hygiene products

allergic contact stomatitis to oral hygiene products

allergic contact stomatitis from artificial cinnamon flavoring

cinnamon oil (used as a flavoring agent) is used in concentrations 100x that found in natural spice

reaction typically seen in candy, chewing gum, and toothpaste

toothpaste reactions show changes ranging from diffuse erythema to superficial sloughing; may be associated with exfoliative cheilitis/circumoral dermatitis

candy/gum reactions on buccal mucosa and lateral tongue at level of occlusion; typically white, irregular patches

pain and burning sensation

allergic contact stomatitis from artificial cinnamon flavoring

allergic contact stomatitis from artificial cinnamon flavoring

angioedema

mast cell degranulation

IgE- mediated hypersensitivity reactions

allergic contact reaction

physical stimuli

physical stimuli

ACE inhibitiors

activation of the complement pathway: herediatry/acquired

high levels of antigen / antibody complexes

elevated peripheral blood eosinophil counts

angioedema

angioedema