Recurrent Aphthous Stomatitis

Question 1

What are the causes of aphthous ulcers?

Answer 1

Generated by immunological process in epithelial or connective tissues

Aetiology- multifactorial with genetic base (familial) in conjunction with environmental triggers
-> Can change with times

Question 2

What are the types of RAS?

Answer 2

Minor (most common)

Major

Herpetiform

Oro-Genital ulcer syndromes – e.g. Behçet’s syndrome

Question 3

How is diagnosis of RAS achieved?

Answer 3

History- as patient may not currently have ulcer

Examination- presence of yellow/grey base with erythematous margin

Question 4

What are the features of Minor Aphthous Ulcers?

Answer 4

Less than 10mm diameter

Last up to 2 weeks

ONLY affect NON-Keratinised mucosa

Heal without scarring

Question 5

How do Minor Aphthous ulcers appear?

Answer 5

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

Question 6

What is the ulcer free period a good guide for?

Answer 6

Morbidity- gives level of suffering and indicates treatment need
-> infrequent and longer periods between would be preferable

Question 7

What treatment do minor aphthous respond well to normally?

Answer 7

Topical steroids

Question 8

What are the features of Major Aphthous ulcers?

Answer 8

> 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

Question 9

How do Major aphthous ulcers appear?

Answer 9

Areas of epithelial loss, fibrinous exudate and peri-lesional erythematous halo

-> similar to minor

Question 10

If both minor and major present, how is the diagnosis classified?

Answer 10

Off the worst lesion

Question 11

What is the treatment for Major Aphthous Ulcers?

Answer 11

Intra-lesional Steroids

-> poor response to topical

Question 12

What is the issue with scarring on healing of Major ulcers in throat area?

Answer 12

Stricture formation

Question 13

What are the features of Herpetiform Aphthae?

Answer 13

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

Question 14

How can Herpetiform Aphthae be distinguished from PHG?

Answer 14

These patients would not have fever/systemic symptoms —> nothing to do with HSV which would also affect keratinised epithelial and be are non-recurrent

Question 15

What are the types of Oro-genital Ulcerative Conditions?

Answer 15

Behcet’s- immunological tendency coded for at HLA level

Lichen Planus

Vesiculo-bullous diseases

Question 16

What are the signs and symptoms of Behcet’s?

Answer 16

Three episodes of mouth ulcers in a year (major/minor)
AND

At least two of the following: genital sores, eye inflammation, skin ulcers, pathergy

Question 17

What type of disease is Behcet’s?

Answer 17

Vasculitis – inflammation of blood vessels

Question 18

What other structures can Behcet’s affect?

Answer 18

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

Question 19

How is Behcet’s managed?

Answer 19

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

Question 20

Who else may we consult if we suspect Behcet’s?

Answer 20

Rheumatology Specialists

National specialist treatment centres

Question 21

What are the predisposing factors for RAS?

Answer 21

Systemic diseases

Stress

Viral/bacterial infections

Genetic Predisposition

Hormone level fluctuations (menstrual)

Microelement deficiency

Question 22

What are examples of some of the immune processes causing RAS?

Answer 22

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

Question 23

How does damage in RAS occur?

Answer 23

 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

Question 24

When is ideal time to treat RAS? How would it be done?

Answer 24

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

Question 25

How would prophylactic treatment for RAS work?

Answer 25

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

Question 26

What is the general rule with ulcers?

Answer 26

Recurrent self-healing ulcers affecting exclusively the non-keratinised mucosa are inevitably aphthae

Question 27

Which investigations can be helpful for patient with Aphthous ulcers?

Answer 27

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

Question 28

Which food additives may be responsible for hypersensitivity reactions leading to RAS?

Answer 28

E210-219 (Benzoate & Sorbate, Cinnamon)

Chocolate

Question 29

How is RAS managed?

Answer 29

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)

Question 30

What drugs are used for different ulcers generally?

Answer 30

Non-Steroid Topical Therapy- For inconvenient lesions

Steroid Topical Therapy- For disabling lesions

Question 31

When do children tend to suffer from RAS?

Answer 31

Children frequently get Aphthous ulcers during periods of rapid growth – very few before this
-> 8-11 years and 13-16 years

Question 32

How are ulcers associated with growth in children usually treated?

Answer 32

With 3 months of iron supplements
-> Lower iron levels often associated as children are using nutrients rapidly during growth (so restore levels)

Question 33

How are ulcers treated in children if they are not related to growth? (genetic cause)

Answer 33

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)

Question 34

When should RAS be referred to OM?

Answer 34

After arranging blood and allergy tests/ following SDCEP guidelines for treatment
-> If these options haven’t worked

Children under 12