Recurrent Aphthous Stomatitis Flashcards
What are the causes of aphthous ulcers?
Generated by immunological process in epithelial or connective tissues
Aetiology- multifactorial with genetic base (familial) in conjunction with environmental triggers
-> Can change with times
What are the types of RAS?
Minor (most common)
Major
Herpetiform
Oro-Genital ulcer syndromes – e.g. Behçet’s syndrome
How is diagnosis of RAS achieved?
History- as patient may not currently have ulcer
Examination- presence of yellow/grey base with erythematous margin
What are the features of Minor Aphthous Ulcers?
Less than 10mm diameter
Last up to 2 weeks
ONLY affect NON-Keratinised mucosa
Heal without scarring
How do Minor Aphthous ulcers appear?
As a yellow oval ulcerative area on oral mucosa
-> Base is yellow due to deposition of fibrinous tissue and exposed connective tissue
-> Will have erythematous halo of inflammatory change around ulcer
What is the ulcer free period a good guide for?
Morbidity- gives level of suffering and indicates treatment need
-> infrequent and longer periods between would be preferable
What treatment do minor aphthous respond well to normally?
Topical steroids
What are the features of Major Aphthous ulcers?
> 10mm
Can occur with minor ulcers too
Can last for months
Can affect ANY part of the oral mucosa- K/NK or both
MAY scar when healing
How do Major aphthous ulcers appear?
Areas of epithelial loss, fibrinous exudate and peri-lesional erythematous halo
-> similar to minor
If both minor and major present, how is the diagnosis classified?
Off the worst lesion
What is the treatment for Major Aphthous Ulcers?
Intra-lesional Steroids
-> poor response to topical
What is the issue with scarring on healing of Major ulcers in throat area?
Stricture formation
What are the features of Herpetiform Aphthae?
Rarest form of Aphthous ulcers
Multiple small ulcers on non-keratinized mucosa
Heal within 2 weeks
Can coalesce into larger areas of ulceration
Appears like PHG
How can Herpetiform Aphthae be distinguished from PHG?
These patients would not have fever/systemic symptoms —> nothing to do with HSV which would also affect keratinised epithelial and be are non-recurrent
What are the types of Oro-genital Ulcerative Conditions?
Behcet’s- immunological tendency coded for at HLA level
Lichen Planus
Vesiculo-bullous diseases
What are the signs and symptoms of Behcet’s?
Three episodes of mouth ulcers in a year (major/minor)
AND
At least two of the following: genital sores, eye inflammation, skin ulcers, pathergy
What type of disease is Behcet’s?
Vasculitis – inflammation of blood vessels
What other structures can Behcet’s affect?
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
How is Behcet’s managed?
Treat local oral disease or RAS
Systemic immunomodulation where multisystem involvement:
Colchicine used ‘off label’ often a first treatment
Azathioprine/Mycophenolate
Biologics – infliximab and others
Who else may we consult if we suspect Behcet’s?
Rheumatology Specialists
National specialist treatment centres
What are the predisposing factors for RAS?
Systemic diseases
Stress
Viral/bacterial infections
Genetic Predisposition
Hormone level fluctuations (menstrual)
Microelement deficiency
What are examples of some of the immune processes causing RAS?
Increased level of NK cells
Increased B lymphocytes
Reactivation/hyperactivity of neutrophils
Decreased CD4+ lymphocytes
-> disrupted CD4/CD8 ratio
Decreased expression of HSP
High level of complement system ingredients
How does damage in RAS occur?
Basal cells become damaged by immune system - can no longer produce further epithelial replacement cells
When existing cells move up through prickle layer to surface they are lost- ulceration (exposure of connective tissue) will appear as there are no new epithelial cells to replace them
Presentation occurs 3-4 days after immunological process occur
When is ideal time to treat RAS? How would it be done?
During prodromal phrase- as on presentation the immunological process has been reversed and healing has begun and would not produce same benefit
Prodormal tingling can be identified- apply topical steroids at that stage
-> Reduces severity of following ulceration
How would prophylactic treatment for RAS work?
Use daily topical steroid mouth rinse if patient has high morbidity and short ulcer free periods
->Reduces frequency and severity- catches ulcers during prodromal period
What is the general rule with ulcers?
Recurrent self-healing ulcers affecting exclusively the non-keratinised mucosa are inevitably aphthae
Which investigations can be helpful for patient with Aphthous ulcers?
Blood tests:
Haematinic deficiencies – Iron (ferritin), B12, Folic acid
Coeliac Tests
->TTG (tissue transgutaminase)
-> If TTG positive test Anti-gliadin & Anti-endomysial antibodies
Allergy tests – contact (delayed) or immediate hypersensitivity
Which food additives may be responsible for hypersensitivity reactions leading to RAS?
E210-219 (Benzoate & Sorbate, Cinnamon)
Chocolate
How is RAS managed?
Correct blood deficiencies- Ferritin (iron), Folic Acid, Vit B12
Refer for investigation if Coeliac positive
-> endoscopy and jejunal biopsy
Avoid dietary triggers (identified through testing)- Empirical dietary avoidance – use FOOD MAESTRO
Avoid SLS containing toothpaste – (Sensodyne Pronamel and Kingfisher are SLS free)
What drugs are used for different ulcers generally?
Non-Steroid Topical Therapy- For inconvenient lesions
Steroid Topical Therapy- For disabling lesions
When do children tend to suffer from RAS?
Children frequently get Aphthous ulcers during periods of rapid growth – very few before this
-> 8-11 years and 13-16 years
How are ulcers associated with growth in children usually treated?
With 3 months of iron supplements
-> Lower iron levels often associated as children are using nutrients rapidly during growth (so restore levels)
How are ulcers treated in children if they are not related to growth? (genetic cause)
Consider allergy testing as well as blood
Give symptomatic treatment during ulcer periods:
-> Issues with Betnesol under age 12 - licence
-> Issues with Betnesol if child unable to spit mouthrinse out reliably (usually can from 5-8)
When should RAS be referred to OM?
After arranging blood and allergy tests/ following SDCEP guidelines for treatment
-> If these options haven’t worked
Children under 12
