OM - Recurrent Aphthous Ulcers Flashcards
Describe a recurrent aphthous ulcer.
Recurrent self-healing ulcers affecting exclusively the non-keratinised mucosa are inevitably aphthae
What are aphthous ulcers?
Immunologically generated RECURRING oral ulcers in the epithelium/CT – usually follow a set pattern depending upon the ulcer type
What causes recurrent aphthous ulcers?
Genetically driven with environmental modification
- Multifactorial environmental triggers are required for ulcers to appear (degree of triggers differs between patients)
- Ulcer experience may change as ‘risk factors’ change over life
What are the predisposing factors to recurrent aphthous ulcers? (7)
Key factors differ between patients although all are genetically predisposed;
- Genetic predisposition
- Systemic disease
- Stress
- Mechanical injuries
- Hormone fluctuations
- Microelement deficiencies (iron, B12, folic acid) – cause or a symptom
- Viral and bacterial infections
What are the types of recurrent aphthous stomatitis? (4)
- Minor
- Major
- Herpetiform
- Oro-Genital ulcer syndromes – e.g. Behçet’s syndrome
How do we diagnose recurrent aphthous ulcers? (2)
History – important as patient may not have ulcer when they visit
Examination – look for current ulceration or scarring = past ulceration
What is the most common recurrent aphthous ulcer?
Minor aphthous ulcer
How do minor recurrent aphthous ulcers present clinically? (3)
- Yellow/grey ulcerative base (from fibrous deposition over the exposed CT)
- Oval shape
- Erythematous halo of inflammatory change (perilesional erythematous halo)
List the characteristics of a minor recurrent aphthous ulcer. (4)
- Less than 10mm diameter
- Last up to 2 weeks
- ONLY affect NON-Keratinised mucosa
- Heal without scarring
How do we treat minor recurrent aphthous ulcers?
- Usually a good response to topical steroids
Why is it important to ask about ulcer free periods?
good guide to morbidity and treatment need;
– longer ulcer free + less morbidity
How to major recurrent aphthous ulcer present clinically? (3)
- Yellow/grey ulcerative base (from fibrous deposition over the exposed CT)
- Erythematous halo of inflammatory change (perilesional erythematous halo)
- Large lesions commonly associated with other smaller ulcers
What are the characteristics of a major recurrent aphthous ulcer? (5)
- Usually LARGER than 10mm
May get smaller ulcers alongside too – diagnose from the worst ulcer - Can last for months
- Can affect ANY part of the oral mucosa: including Keratinised OR non Keratinised or both
- Have potential to scar when healing, not always
- Poorly responsive to topical steroids
Intralesional steroids often more useful
What are the differences between minor and major recurrent aphthous ulcers? (3)
Size:
minor = less than 10mm
major = larger than 10mm
location
minor = non-keratinised mucosa
major = keratinised and non-keratinised
duration:
minor = up to 2 weeks
major = months
What are the characteristics of herpetiform aphthae? (4)
- Multiple small ulcers on non-keratinized mucosa
- Heal within 2 weeks
- Can coalesce into larger areas of ulceration
(NOTHING to do with herpes viruses)
What are the differences between herpetiform aphthae and primary herpetic gingivostomatitis? (4)
PHG = systemic symtoms
HA = none
PHG = affects keratinised and non-keratinised tissue
HA = non-keratinised only
PHG = rarely reoccur
HA = recurrent
PHG = associated with HSV
HA = no association
What is Behcets disease?
Oral and genital ulceration - from an Immunological tendency coded for at the HLA gene level
What is the criteria for a behcets diagnosis? (2)
3 episodes of mouth ulcers in a year: can be minor or major however both are disabling and frequent = need systemic meds
and
at least two of the following: genital sores, eye inflammation, skin ulcers, pathergy
If patient doesn’t have the above symptoms however has genital ulceration and oral ulceration = not behcets
What other oro-genital conditions exist other than behcets? (2)
- Vesiculobullous diseases – pemphioid, pemphigus.
- Lichen Planus
What structures can behcets affect? (5)
- Eye disease - Anterior or posterior uveitis (can lead to loss of vision in 20%)
- Bowel ulceration – iliocaecal area – pain and cramping
- Heart and lungs
- Brain
- Joints
What type of disease is behcets?
Primarily a Vasculitis = inflammation of blood vessels
How is behcets managed? (2)
Manage oral ulceration with topical or systemic means as you would for recurrent aphthous stomatitis
Use Systemic immunomodulation when there is multisystem involvement;
- Colchicine used ‘off label’ often a first treatment
- Azathioprine/Mycophenolate
- Biologics – infliximab and others
Describe the immunological process of recurrent aphthous ulcers. (3)
Process occurs at basement membrane at the epithelial connective tissue junction
There is damage to the basal cells = no further epithelial replacement cells produced
Therefore when existing cells move towards the surface to be lost, ulceration appears are no new epithelial cells are made to replace = exposure of CT
Ulcers appear 3-4 days after immunological process starts
Describe when topical steroids should eb used to treat ulcers and why. (3)
Treatment to prevent ulceration should happen at immunological stage i.e. before ulcer appears.
When an ulcer is present, that means that the immunological process has reversed and the patient is healing – using topical steroids on the ulcer has little benefit at this stage.
Topical steroids should be used when the epithelium is intact and the patient is feeling the prodromal pain/tingling as this is when immunological process is occurring beneath the surface (train them to identify this and treat prophylactically during prodromal period)
What investigation do we use to diagnose recurrent aphthous ulcers? Give examples (3)
Blood tests:
* Haematinic deficiencies
- Iron (ferritin)
- B12
- Folic acid
- Coeliac Disease can lead to the above deficiencies
- TTG (tissue transgutaminase) test to screen coeliac risk
- Allergy tests – contact (delayed hypersensitivity) or immediate hypersensitivity
- Food additives – E210-219 (Benzoate & Sorbate, Cinnamon), Chocolate
How do we manage recurrent aphthous ulcers? (5)
- Correct blood deficiencies
- Ferritin (iron), Folic Acid, Vit B12
- if they have a deficiency/borderline deficiency = 3/12 (3 month) replacement therapy
- Refer for investigation if Coeliac positive = endoscopy and jejunal biopsy
- Avoid environmental triggers
- SLS containing toothpaste
- Dietary triggers (identified from testing) dietary avoidance
- Non-Steroid Topical Therapy = For inconvenient lesions
Chlorhexidine mouthwash
Benzdamine spray/mouthrinse - Steroid Topical Therapy = For disabling lesions
Must be used at prodromal period
What children are at risk of recurrent aphthous ulcers?
Children during periods of rapid growth – very few before this;
8-11 years and 13-16 years = Feet usually grow first so look for ‘new shoe sign’
How do we treat recurrent aphthous ulcers in children? (2)
Usually due to low iron levels (body uses up stores during rapid growth)
- 3/12 (3 months) iron supplements
- Use standard topical treatments to reduce ulcer duration
Why is this issues with the use of Betnesol to treat recurrent aphthous ulcers in children? (2)
under age 12 = unlicensed
Issues with Betnesol if child unable to spit mouth rinse out reliably (5-8 child able to do so)
When do we refer recurrent aphthous ulcers? (3)
- After standard SDCEP guidance is ineffective for clear diagnosis and treatment
- Major aphthous ulceration
- Children under 12
