Recurrent Aphthous Ulcers Flashcards
what are aphthous ulcers
Immunologically generated RECURRING oral ulcers
Follow a set pattern depending upon the ulcer type
Genetically driven with environmental modification
Multifactorial environmental triggers and variable expression
Ulcer experience may change as ‘risk factors’ change over life
yellow/grey base with erythematous margin
Recurrent Aphthous Stomatitis types
4
Minor
Major
Herpetiform
Oro-Genital ulcer syndromes – e.g. Behçet’s syndrome
dx of Recurrent aphthous stomatitis by
history
examination - yellow/grey base with erythematous margin
minor apthous ulcers
Less than 10mm diameter
Last up to 2 weeks
ONLY affect NON-Keratinised mucosa (not hard palate or attached gingivae)
Heal without scarring
Usually a good response to topical steroids
This is the commonest type of recurrent oral ulceration
one is a nuisance, many more at once can be disabling
good indication to morbidity for RAS
ULCER FREE PERIOD
longer ulcer free + less morbidity
major aphthous ulcers
Can last for months
Can affect ANY part of the oral mucosa
* Keratinised OR non Keratinised or both
MAY scar when healing
Poorly responsive to topical steroids
* Intralesional steroids often more useful
Usually LARGER than 10mm
* May get smaller ulcers too – diagnose from the worst ulcer
herpetiform ulcers
Rarest form of Aphthous ulcers
Multiple small ulcers on non-keratinized mucosa
Heal within 2 weeks
Can coalesce into larger areas of ulceration
NOTHING to do with herpes viruses
* In the early stages looks like primary herpetic gingivostomatitis
* In HSV get KERATINISED epithelium involved – not in herpetiform aphthae
* HSV also have systemic symptoms – fever – and is likely non-recurrent (unlike herpetiform aphthae)
oral and genital recurrent ulceration
Classically ‘Behçet’s Disease’
Many who don’t meet the criteria
Commoner in Asiatic races – 2:1000 turkey
Diagnosis
* three episodes of mouth ulcers in a year
* at least two of the following: genital sores, eye inflammation, skin ulcers, pathergy
Other Oro-genital ‘ulcerative’ conditions exist
* Vesiculobullous diseases (Pemphigoid)
* Lichen Planus
Bechet’s disease
PRIMARILY a Vasculitis – inflammation of blood vessels
* Oral & genital ulceration
* 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
Dx
* three episodes of mouth ulcers in a year
* at least two of the following: genital sores, eye inflammation, skin ulcers, pathergy
Can appear as minor or major - disabling, frequent (systemic tx needed)
management of Bechets
Treat local oral disease or RAS (recurrent aphthous stomatitis)
Systemic immunomodulation where multisystem involvement
* Colchicine used ‘off label’ often a first treatment
* Azathioprine/Mycophenolate
* Biologics – infliximab and others
Managed with help of Rheumatology
Also National specialist treatment centres
recurrent aphthous ulcers predisposing factors
7
multifactorial - differing levels of importance for different pts
Mechanical injury
* damage to mucosa from parafunctional clenching (edges of tongue), lower bite appliances take away edges of teeth trauma can help relieve
Microelement deficiency (iron, B12, folate)
* May have underlying undiagnosed medical condition
Systemic diseases
Stress
Viral and bacterial infections
Genetic predisposition
Hormonal level fluctuations
* e.g. premenstrual ulceration, pregnancy
immunopathology of apthae
Trigger at a particular time unknown
Process takes at basement membrane, damage basal cells no longer produce epithelial replacement cells, so as move up through prickle layers to surface ulceration will appear as no new epithelial cells to replace them
Damage happens BEFORE the ulcer appears (immunological process happens 3-4 days prior at epithelial connective tissue junction)
* Treatment is most effective in ulcer prodrome period
key thing to remember about aphthous ulcer management
Damage happens BEFORE the ulcer appears
* Treatment is most effective in ulcer prodrome period
When ulcer appeared, immunological process has occurred already (3-4 days prior at epithelial connective tissue junction (BM)) and starting to heal
* topical steroid onto oral ulcer site has little benefit
but if used before - when epithelium is intact but immunological damage happening can have significant effect
* pts often feel a prodromal tingling sensation in the area of mucosa about to get ulcer – train to recognise and apply topical steroid at this stage to reduce severity of ulcers.
Treat prophylactically if significant ulcer morbitidy with short ulcer free period,
* daily steroid mouthwash reduce severity and frequency of ulcers by catching in prodromal period
general rule for recurrent ulcers
Recurrent self-healing ulcers affecting exclusively the non-keratinised mucosa are inevitably aphthae
2 tests that can be done when investigating aphthous ulcers
blood tests
allergy tests
blood tests when investigating aphthous ulcers
Haematinic deficiencies – Iron (ferritin), B12, Folic acid
Coeliac Disease
* TTG (tissue transgutaminase)
* If TTG positive test Anti-gliadin & Anti-endomysial antibodies
allergy tests when investigating aphthous ulcers
contact (delayed) or immediate hypersensitivity
Food additives – E210-219 (Benzoate & Sorbate, Cinnamon), Chocolate
Unsure how predictive this is
tx options for recurrent aphthae
4 modes
Correct blood deficiencies
* Ferritin (iron), Folic Acid, Vit B12
Refer for investigation if Coeliac positive
* endoscopy and jejunal biopsy
Avoid dietary triggers
SLS containing toothpaste – (Sensodyne Pronamel and Kingfisher are SLS free)
Dietary triggers
* identified from testing
* Empirical dietary avoidance – use FOOD MAESTRO app to help with identifying foods
* Avoid for 3months and still getting ulcer, unlikely to be the true cause
drugs
* Non-steroidal topical therapy
* steroid topical therapy
SDCEP guidance
non-steroidal topical therapy for recurrent aphthae
3 options
CHX gluconate mouthwash, benzydamine spray or mouth rinse
For inconvenient lesions, support for couple of days
steroid topical therapy for recurrent aphthae
For disabling lesions
Need to be used in prodromal region of ulcer, not all pts can identify this
Continual daily steroid mouth rinses can be helpful for some pt by catching ulcers early in the process – SDCEP
* betamethasone tablets dissolved
* beclomethasone MDI
* hydrocoritsone mucoadhesive
aphthous ulcers in children
Children frequently get Aphthous ulcers 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’
Usually respond to 3/12 iron supplements – always check the diet for peculiarities - As body uses store rapidly in growth
If ulcers NOT related to growth (present since birth) then largely a genetic component
* Consider allergy and blood testing
* give symptomatic tx during ulcer periods
caution with medication for ulcers in children
Issues with Betnesol under age 12
* topical steroid rinsing not licensed for children under 12, so practitioners not comfortable in prescribing
* Steroid rinsing cannot be used if child unable to spit mouthrinse out reliably - need to assess
when to refer to oral med for recurrent aphthae
3
After below have been achieved and no good result
* simple investigations (bloods and done 3/12 replacement therapy for boderline)
* topical tx
Major aphthous ulcer
Children under 12
when dx is clear to be minor aphthous ulcers
primary care tx
Try and arrange simple investigations in primary care
* Blood tests for Haematinic deficiency via the GP
* If deficiency or borderline then 3/12 replacement therapy
Topical treatment as outlined in SDCEP guidance
* Non-steroid for infrequent ulcers
* Steroid based for More disabling, more frequent lesions
