Studies on Recurrent Oral Aphthae

STUDIES ON RECURRENT ORAL
APHTHAE
I. Clinical and Laboratory Comparisons
HARVEY A. BRODY, D.D.S.
and
SOL SILVERMAN, JR., M.A., D.D.S.
San Francisco, Calif.
School of Dentistry, University of California,
San Francisco Medical Center
Reprinted from
ORAL SURGERY, ORAL MEDICINE AND
ORAL PATHOLOGY
St. Louis
Vol. 27, No. 1, Pages 27-34, January, 1969
(Copyright © 1969 by The C. V. Mosby Company)
(Printed in the U. S. A.)
Reprintetl from ORAL S RGERY, ORAL MEDICINE AND ORAL PATHOLOGY, St. Louis
Vol. 27, No. 1, Pages 27-34, January, 1969. (Printed in the U.S. A.)
(Copyright © 1969 by The C. V. Mosby Company)
Studies on recurrent oral aphthae
I. Clinical and laboratory comparisons
Harvey A. Brody, D.D.s.,• and Sol Suvermatn, Jr., M.A., D.D.S.,••
San Francisco, Calif.
SCHOOL OF DENTISTRY, UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
MEDICAL CENTER
Recurrent aphthous lesions remain a problem with respect to differential
diagnosis and management. Estimates of their incidence vary from 15 per cent
to more than 50 per cent of the population. The disease appears to be twice as
frequent in female patients. Onset is usually between the ages of 10 and 20; the
lesions rarely occur for the first time after the age of 50. Attacks are variable.
Most patients appear to have fewer than six per year, each attack consisting
of one or two superficial lesions which heal spontaneously within 10 to 14 days;
at the other extreme, some patients have deep, persistent, and painful lesions
at all times. The aphthae vary from pinpoint ulcers to lesions more than 0.5 em.
in diameter; they are usually circular and may be well circumscribed or irregularly defined. The ulcers usually become covered by a yellow to gray pseudomembrane and are surrounded by an erythematous and edematous area. With
such a varied clinical appearance and course, it is not surprising that many
names are given this disease.1 The terms MikuZicz's aphthae, herpetiform aphthae, and periadenitis aphthae will be used in this study to describe the types
of aphthous lesion. These names are selected solely because they have been most
commonly used in the literature.
The present article is the first of a series dealing with various aspects of this
common and puzzling disease. The purpose of this report is to compare clinical
and laboratory findings from a group of patients with recurrent aphthous
lesions.
*Assistant Professor, Division of Oral Biology.
**Professor and Chairman, Division of Oral Biology.
27
28
Brody and Silverman
O.S., O.M. & O.P.
January, 1969
BACKGROUND
The cause of these lesions is not known. A preponderance of evidence suggests
that thQ disease is not viral in nature. This evidence includes work on histology, 2
viral isolation, tissue culture, 3 • 4 and antibody titers. 5 In spite of an occasional
report associating the disease with the herpes simplex vims, 0 the classification
of herpetic stomatitis or recurrent herpetic gingivostomatitis at this time seems
out of order. Different species of bacteria have been indicated as the causative
agents, only to be disproved by subsequent studies. The role of bacteria correlated with a form of delayed hypersensitivity has been postulated. In 1963
Barile, Graykowski, and co-workers 7 repeatedly isolated an L-form of Streptococcus sangt~is from patients with recurrent aphthae. They then were able to
produce lesions of the aphthous type in rabbits and guinea pigs by inoculating the animals with representative Streptococcus sanguis isolates. 8 They also
reported positive skin test reactions in aphthous patients to a saline suspension
of streptococcus.0
Immunologic factors have been implicated by various studies, and complement-fixation tests, hemagglutination tests, and precipitation tests, have shown
significant differences between aphthous and control patients. 10 In other studies
of early aphthous lesions, gamma globulin binding in the stratum spinosum has
been observed. 11 Also, increased levels of serum globulin in aphthous patients
have been found. 12 • 13
Trauma has been implicated as a predisposing factor, 14 but other investigators
find no substantial evidence of this.15 Some studies have indicated an increased
incidence of aphthous lesions in patients with allergic diseases10 as well as in
patients under emotional tension. 8 • 17 Ship and associates18 recently reported
finding significant differences between aphthous patients and controls when both
groups were evaluated by the Cornell Medical Index as to depression, tension,
inadequacy, anxiety, and anger. Still other reports linlc the outbreak of aphthous lesions to hormonal changes during pregnancy or relate it to the menstmal cycle. 10 Although trauma, hormonal changes, emotional tension, diet, and
allergy seem to be significant co-factors in some patients, their etiologic importance cannot be delineated in group studies.
MATERIALS AND METHODS
In the present study the subjects were thirteen patients \vith chronically
recurring intraoral ulcers. Their lesions could not be correlated \vith any
systemic diseases, dmgs, or environmental changes.
Twenty-one biopsy specimens were obtained, including nineteen from 'the
labial mucosa. Eight of the specimens were taken from one patient hi. order to
compare sequential changes. Small biopsy punches were used to , remoye the
specimens following administration of a local anesthetic. · These specimens were
fixed in 10 per cent buffered formalin and stained with hematoxylin and eosin.
Eleven specimens were also stained by a modification of the Dominichi technique to demonstrate mast cells.20 In six patients active lesions were biopsied for
immunofluorescent studies. These were quick-frozen in a slush of Dry Ice and
Volume 27
Number 1
Recurrent oral aphthae 29
acetone, after which they were cut in a cryostat and washed. They then were
stained with :fluorescein-labeled rabbit antihuman sera prepared specifically for
immunoglobulin G, immunoglobulin M, and immunoglobulin A. Fluorescing
material was detected by means of an ultraviolet microscope.
In eight patients serum was drawn to determine the immunoglobulin levels
by the agar-diffusion techniques outlined by Fahey and McKelvey. 21
Etg. 1 . .&, Mi.kulicz's aphthae of 4 days' duration. This is the most co=on form of the disease. B, Herpetiform aphthae of 7 days' duration demonstrating coalescence of small
ulcerations to form irregular-shaped larger ulcers. C, Periadenitis aphthous lesion of 1
month's duration associated with moderately severe pain. This lesion persisted for 3 more
weeks.
30
O.S., O.M. & O.P.
January, 1969
B1·ody and Silverman
Isolation of herpes simplex virus was attempted by aspirating the contents
of vesicles from four patients. The aspirant, collected with a tuberculin syringe
containing Coleman-Eagle's medium, was transferred immediately by layer
inoculum over a Maben cell line. This was incubated in conventional cell culture
conditions and observed daily for cytopathogenic effects. 22 When cytopathogenic
effects were obtained, a neutralization test with specific herpes antiserum was
carried out. Herpes labialis lesions were used as controls.
In this article, lesions will be referred to as follows: (1) Mikulicz's aphthae,
the most common form of the disease, usually characterized by two to four
superficial circumscribed lesions which heal spontaneously within 10 to 15 clays
(Fig. 1,A); (.2) herpetiform aphthae 23 consisting of 10 to 100 pinpoint ulcers
which often coalesce to form irregularly defined lesions (Fig. 1,B) ; and (3)
periadenitis aphthae, referring to the deeper, persistent, and more painful
lesions (Fig. 1,0).
FINDINGS
Table I lists the vital statistics and clinical characteristics of the thirteen
patients. The age of onset was extremely variable. Although the lesions persisted from 2 to 90 days, the average duration of a single lesion was about 12
clays. Ten of the patients had two or more forms of the disease during the course
of this study. In seven of the eight patients with siblings or children, family
histories were positive for aphthous lesions.
Ten patients thought that anxiety was a precipitating factor, and two
blamed trauma. Five complained of associated stomach pains, but medical and
x-ray evaluations were negative. Nine patients also had a history of herpetic
lip lesions (herpes labialis).
Five patients reported the initial changes to be tingling and swelling fol-
Table 1. Clinical findings in aphthous patients
.Age at onset
.Age (years)
(years)
Sez
p
17
12
23
F
18
26
c.o.
F
5
F
25
B.P.
28
F
J.W.
35
5
K.H.
F
13
37
M
A.S.
15
1
17
M
12
R.R.
M
18
23
R.V.
25
M
16
D.C.
28
M
15
M.A.
52
M
T.T.
7
72
M
5
R.L.
*Occasional
Approximately five attacks per year. Moderate
tM
Mikulicz's. H = Herpetiform. P
Periadenitis.
tNumber with aphthous lesions.
Patient
G.T.
P.S.
=
=
=
D'tllraticm (days)
.Average
I Ran,qe
10
4 to40
7
2 to 14
10
2 to 21
10
2 to 21
7
3 to 14
21
5 to 90
7
2 to 21
14
4 to 21
7
5 to 14
10
4to 14
10 to 20
14
14
3 to 30
14
5 to 90
- An attack each month.
\'
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Recurrent oral aphthae
31
lowed by the formation of a vesicle, which quickly broke. This phenomenon
was documented by observation and biopsy. In four of these five patients, in
whom isolation of herpes virus from intraoral vesicles was attempted by tissueculture techniques, there were no cytopathogenic effects. However, the aspirant
from herpes labialis contained virus. This latter conclusion is based upon the
finding of cytopathogenic effects in tissue culture which was precluded when
herpes simplex antisera were used for neutralization.
Histologically, lesions of the same age but from different patients were indistinguishable. Early lesions (up to 2 days old) could be distinguished f!'om
older lesions on the basis of the following features: (1) The prickle-cell layer
in early lesions demonstrated various degrees of hyperplasia and mild
dysplasia; (2) the predominant inflammatory cell was the lymphocyte, whereas
in older lesions the polymorphonuclear leukocytes predominated; (3) a large
number of mast cells were found in the depths of the ulcer in the early lesions ;
and (4) there was subepithelial vesicle formation in prodromal lesions (Fig. 2).
None of the specimens revealed giant cells or inclusion bodies.
Immunofl.uorescent studies revealed a strongly :fluorescent reticular network
at the site of the ulcer and extending downward into the connective tissue in
all six patients. This binding was positive only with immunoglobulin A. Six
other ulcerative lesions from other patients served as controls and were negative.
Six of the eight aphthous patients whose sera were studied for immunoglobulin
levels showed decreased immunoglobulin A levels. 24 • 25
DISCUSSION
Clinically, recurrent aphthae have been classified into three forms in order
to identify patient groups. Histories and personal observations have revealed
that many patients begin by having an occasional ulcer and years later develop
Family history
Frequency•
Constant
Constant
Constant
Constant
Constant
Constant
Moderate
Moderate
Oeca.sional
Occasional
Moderate
Constant
Constant
Constant
=
Form of
diaeaaet
M,H,P
M,H
M,H,P
M,H
M,H
p
M,P
M,H
M,H
M
M
M,P
M,P
Siblings
Smoking
+
+
+
+
+
+
+
+
Patient is seldom free of lesions.
I
No.
I
+t
0
4
5
5
0
4
0
6
0
0
Children
No.
0
I
+t
1
5
8
1
4
I
I
1
4
4
5
0
5
4
6
0
0
0
0
1
0
0
1
3
32
Brody and Silverman
O.S., O.M. & O.P.
January, 1969
F i g. e. Histologic specimen of prodromal lesion from labial mucosa, demonstrating sub·
epithelial vesicle formation ( V ) and intracellular vacuolization containing lymphocytes
(arrows ) . Note that at this stage there is uo ulceration. (Magnification, xl OO.)
more severe lesions. A number of patients have crops of pinpoint ulcers (herpetiform type) and large discrete ulcers (periadenitis type), further documenting
the belief that various forms may occur at different times or simultaneously.
These observations and the histologic findings indicate that lesions of the
herpetiform, lVIilrulicz's, and peridadenitis varieties are all different forms of
the same basic disease.
The clinical course of two aphthous lesions in the same general area in the
same patient can be quite different as regards pain, duration, and associated
findings. In our study, neither the investigator nor the patient could predict
the duration of a given lesion. The development of a new lesion next to a healing
lesion could not be differentiated by the patient. This individual and erratic
behavior reflects the extreme variations which occur and the difficulties encountered in classification and assessment of treatment.
Trauma was not an apparent etiologic factor in this study. This was assumed from the histories and from the fact that no lesions developed at the site
of injections or biopsies. Furthermore, biopsies accelerated healing and diminished anticipated aphthous symptoms. Most of the patients in this study
stated that emotional upsets did play a role in the development of their ulcers.
However, attempts to prevent or manage the ulcerative lesions with general
supportive emotional care failed.
Ship and associates18 have reported that susceptibility to recurrent herpes
labialis is associated with susceptibility to recurrent aphthous lesions. This is
borne out in our study in which nine of thirteen patients with recurrent aphthae
also had herpes labalis. Unlike Griffin, 6 we were tmable to isolate any virus
from intraoral lesions.
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Recurrent oral aphthae
33
Graykowski and co-workers9 reported that in some instances early aphthous
lesions are associated with, and possibly the result of, epithelial disturbances
of the ducts of minor salivary glands. In our series minor salivary gland ducts
were not observed in any specimens and, therefore, could not be assumed to
play a role in the pathogenesis.
Although the histopathologic findings are nonspecific, large numbers of
lymphocytes and mast cells found in the early lesions may suggest delayed
hypersensitivity or immunologic response. In addition, the finding of bound
immunoglobulin A at the site of the ulcer and the regressions seen in a preliminary therapeutic trial with high dosages of corticosteroids indicate that recurrent aphthous lesions are possibly an expression of ·a genetically predetermined immulogic abnormality.
a
SUMMARY
Twenty-one biopsy specimens were obtained from thirteen patients with
recurrent aphthous lesions to correlate histologic features with the clinical
course of this disease. From one patient group specimens were obtained also
fo:r; virus isolation, immunofluorescence, and serum immunoglobulin levels.
Early lesions were characterizea by prickle-cell hyperplasia and dysplasia,
lymphocytic inflammatory infiltration, and the presence of large numbers of
mast cells. Subepithelial vesicles were seen in prodromallesi9ns.
Emotion, trauma, hormonal changes, allergy, and diet did not seem to be
etiologic factors. Herpes virus could· not be isolated from any aspirate collected,
and giant cells or nuclear inclusion bodies were not observed. However, positive
immunofluorescence for immunoglobulin A and altered serum globulin, together
with the finding of mast cells and lymphocytes, suggest an immunologic component in this disease.
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J. Dist. Columbia D. Soe. 38: 7-15, 1963.
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Brody and Silvennan
O.S., O.M. & O.P.
January, 1969
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