Recurrent Aphthous Stomatitis Flashcards

1
Q

What are Aphthous ulcers?

A
  • Immunologically generated Recurring oral ulcers
  • An ulcer is a break in the epithelium
  • Follow a set pattern depending on ulcer type
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2
Q

What is the aetiology of aphthous ulcers?

A
  • Genetically driven with environmental modification
  • Multifactorial environmental triggers and variable expression
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3
Q

What are the main forms of Recurrent Aphthous Stomatitis (RAS)?

A
  • Minor
  • Major
  • Herpetiform
  • Oro- Genital ulcer syndromes e.g. Behcet’s syndrome
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4
Q

What type of Aphthous ulcer does this picture show?

A
  • Minor
  • Yellow fibrinous ulceration surrounded by red erythematous
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5
Q

What are the findings common to Minor Apthous ulcers?

A
  • Yellow oval ulcerative area on mucosa
  • Peri lesional Erythematous surrounding area
  • Less than 10mm diameter
  • Last up to 2 weeks
  • Only affect non-keratinised mucosa
  • Heal without scarring
  • Usually have good response to topical steroids
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6
Q

What is the commonest type of recurrent oral ulceration?

A
  • Minor
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7
Q

What type of Aphthous ulcer is this?

A
  • Major
  • Area of epithelial loss with fibrinous edge covering
  • Peri lesional erythematous halo
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8
Q

What are the findings for Major Aphthous ulcers?

A
  • Can last for months
  • Can affect any part of oral mucosa i.e. keratinised or non keratinised
  • May scar when healing
  • Poorly responsive to topical steroids (intralesional steroids more useful)
  • Usually larger than 10mm
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9
Q

What are the common findings of Herpetiform Aphthae?

A
  • Rarest form of Aphthous ulcers
  • Multiple small ulcers on non-keratinised mucosa
  • Heal within 2 weeks
  • Can coalesce into larger areas of ulceration
  • Nothing to do with Herpes virus
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10
Q

What is the difference between HSV and Herpetiform Aphthae?

A
  • HSV involves keratinised epithelium , herpetiform aphthae does not
  • HSV usually not recurrent
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11
Q

What can Herpetiform recurrent aphthae ulcers be confused with in early stages?

A
  • In early stages herpetiform aphthae can look like primary herpetic gingivostomatitis
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12
Q

What does this show?

A
  • Herpetiform Recurrent Aphthous stomatitis
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13
Q

What does this show?

A
  • Herpetiform Recurrent Aphthous stomatitis
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14
Q

What does this show?

A
  • Herpetiform Recurrent Aphthous stomatitis
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15
Q

What are the classical findings of Behcets disease?

A
  • 3 episodes of mouth ulcers in a year
  • At least two of the following, genital sores, eye inflammation, skin ulcers, pathergy
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16
Q

What are some other oro-gneital ulcerative conditions exist?

A
  • Lichen planus
  • Veiculobullous disease
17
Q

What does this picture show?

A
  • Behcet disease
  • Minor or major recurrent aphthous stomatitis
18
Q

What is Behcets disease primarily termed?

A
  • Vasculitis (inflammation of blood vessels)
19
Q

What areas of the body can Behcets disease affect?

A
  • Oral and genital ulcertation
  • Eye disease (anterior or posterior uveitis and can lead to loss of vision in 20%)
  • Bowel ulceration (iliocaecal area - pain and cramping)
  • Heart and lungs
  • Brain
  • Joints
20
Q

What is the management of Behcets disease?

A
  • Treat local oral disease or RAS
  • Systemic immunomodulation
    - Colchicine as off label first txt
    • Azathioprine/Mycophenolate
    • Biologics like infliximab
  • Managed with help of rheumatology and national specialist txt centres
21
Q

What are some predisposing factors of RAS?

A
  • Genetic predispotion
  • Systemic disease
  • Stress
  • Viral and bacterial infections
  • Microelement deficiences like iron or B12
  • Hormonal fluctuations i.e. premenstrual
22
Q

What is the immunologicalpathology of RAS?

A
  • Occurs at basal cell membrane
  • Damages the basal cells meaning stem cells no longer able to produce epithelial replacement cells
  • Ulceration appears as no epithelial cells to replace them as exposure of connective tissue at epithelial membrane
23
Q

When is the txt most effective for RAS?

A
  • Damage happens before ulcer appears
  • Txt most effective in ulcer prodrome period (feel prodromal tingling)
  • If pt has ulcer morbidity then may use phrophylaxis
24
Q

What blood test can be used to investigating Aphthous ulcers?

A
  • Haematinic deficiencies to assess Iron (ferritin) , B12 and Folic acid
  • Coeliac disease using TTG (tissue transglutaminase) - if TTG positive then test Anti-gliadin and Anti-endomysial antibodies
25
Q

What allergy tests can be used to investigate Aphthous ulcers?

A
  • Use contact (delayed) or immediate hypersenitivty testing
  • Test food additives E210-219 (Benzoate and Sorbate, Cinnamon) and chocolate
26
Q

What is the management of RAS?

A
  • Correct Ferritin, Folic acid, Vit B12 deficiencies
  • Refer to GP for investigation if coeliac positivity
  • Avoid dietary triggers like SLS containing toothpaste and food triggers identified from testing
27
Q

What toothpastes are SLS free?

A
  • Sensodyne Pronamel
  • Kingfisher
28
Q

What is SLS?

A
  • Sodium lauryl sulfate
29
Q

When are Apththous ulcers seen most commonly in children?

A
  • 8-11 yrs and 13-16 yrs
  • Periods of rapid growth
    -Give iron supplements
30
Q

When should you refer to Oral Med?

A
  • When simple investigations for haematinic deficiency’s and topical txt does not work
  • Children under 12
31
Q

Local measure for ulcers?

A
  • Warm salty mouth rinse up to 4 times a day to relive pain and swelling
32
Q

What can you prescribe for oral ulcerations?

A

Benzydamine mouthwash 0.15%
- Rinse or gargle using 15ml every 1.5 hrs as required
- Spit out after rinsing
- Not given more than 7 days

33
Q
A