Recurrent Aphthous Stomatitis Flashcards
What are Aphthous ulcers?
- Immunologically generated Recurring oral ulcers
- An ulcer is a break in the epithelium
- Follow a set pattern depending on ulcer type
What is the aetiology of aphthous ulcers?
- Genetically driven with environmental modification
- Multifactorial environmental triggers and variable expression
What are the main forms of Recurrent Aphthous Stomatitis (RAS)?
- Minor
- Major
- Herpetiform
- Oro- Genital ulcer syndromes e.g. Behcet’s syndrome
What type of Aphthous ulcer does this picture show?
- Minor
- Yellow fibrinous ulceration surrounded by red erythematous
What are the findings common to Minor Apthous ulcers?
- 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
What is the commonest type of recurrent oral ulceration?
- Minor
What type of Aphthous ulcer is this?
- Major
- Area of epithelial loss with fibrinous edge covering
- Peri lesional erythematous halo
What are the findings for Major Aphthous ulcers?
- 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
What are the common findings of Herpetiform Aphthae?
- 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
What is the difference between HSV and Herpetiform Aphthae?
- HSV involves keratinised epithelium , herpetiform aphthae does not
- HSV usually not recurrent
What can Herpetiform recurrent aphthae ulcers be confused with in early stages?
- In early stages herpetiform aphthae can look like primary herpetic gingivostomatitis
What does this show?
- Herpetiform Recurrent Aphthous stomatitis
What does this show?
- Herpetiform Recurrent Aphthous stomatitis
What does this show?
- Herpetiform Recurrent Aphthous stomatitis
What are the classical findings of Behcets disease?
- 3 episodes of mouth ulcers in a year
- At least two of the following, genital sores, eye inflammation, skin ulcers, pathergy
What are some other oro-gneital ulcerative conditions exist?
- Lichen planus
- Veiculobullous disease
What does this picture show?
- Behcet disease
- Minor or major recurrent aphthous stomatitis
What is Behcets disease primarily termed?
- Vasculitis (inflammation of blood vessels)
What areas of the body can Behcets disease affect?
- 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
What is the management of Behcets disease?
- 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
What are some predisposing factors of RAS?
- Genetic predispotion
- Systemic disease
- Stress
- Viral and bacterial infections
- Microelement deficiences like iron or B12
- Hormonal fluctuations i.e. premenstrual
What is the immunologicalpathology of RAS?
- 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
When is the txt most effective for RAS?
- Damage happens before ulcer appears
- Txt most effective in ulcer prodrome period (feel prodromal tingling)
- If pt has ulcer morbidity then may use phrophylaxis
What blood test can be used to investigating Aphthous ulcers?
- 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
What allergy tests can be used to investigate Aphthous ulcers?
- Use contact (delayed) or immediate hypersenitivty testing
- Test food additives E210-219 (Benzoate and Sorbate, Cinnamon) and chocolate
What is the management of RAS?
- 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
What toothpastes are SLS free?
- Sensodyne Pronamel
- Kingfisher
What is SLS?
- Sodium lauryl sulfate
When are Apththous ulcers seen most commonly in children?
- 8-11 yrs and 13-16 yrs
- Periods of rapid growth
-Give iron supplements
When should you refer to Oral Med?
- When simple investigations for haematinic deficiency’s and topical txt does not work
- Children under 12
Local measure for ulcers?
- Warm salty mouth rinse up to 4 times a day to relive pain and swelling
What can you prescribe for oral ulcerations?
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
