Recurrent Aphthous Ulcers Flashcards
What are Aphthous Ulcers?
Immunologically generated recurring oral ulcers
Follow a set pattern depending upon the ulcer type
–Minor, major or herpetiform
Genetically driven with environmental modification
Multifactorial environmental triggers and variable expression
What is a minor aphthous ulcer?
Yellow oval ulcerative area on the mucosa
Has an erythematous halo of inflammatory change surrounding the ulcer
Less than 10mm in diameter
Last up to 2 weeks
Only affect non-keratinised mucosa
Heal without scarring
Commonest type
What are major aphthous ulcers?
Usually larger than 10mm (diagnose from the worst ulcer)
Last for months
Can affect any part of the oral mucosa
–keratinised or non-keratinised or both
May scar when healing
What is Herpetiform Aphthae?
Rarest form
Multiple small ulcers on non-keratinised mucosa
Heal within 2 weeks
Can coalesce into larger areas of ulceration
What is the diagnosis for Behcet’s disease?
Three episodes of mouth ulcers in a year
At least 2 of the following: genital sores, eye inflammation, skin ulcers, pathology
What are the predisposing factors for recurrent aphthous ulcers?
Genetic predisposition
Systemic diseases
Stress
Mechanical injuries
Hormonal level fluctuations
Microelement deficiencies
Viral and bacterial infections
What is the immunopathology of recurrent aphthous ulcers?
Immunological process takes place at the basement membrane and by damaging the basal cells these are no longer able to produce epithelial replacement cells. As these existing cells move up through the prickle layer to the surface and are lost the ulceration will appear as there are no new cells to replace them.
This means that as the ulcer appears in the mouth it is 3 or 4 days after the immunological process has commenced
Why do topical steroids have little benefit for recurrent aphthous ulcers?
The patient is starting to heal as the ulcer appears
What investigations would you carry out for aphthous ulcers?
Blood tests
–Haematinic deficiencies - ferritin, B12, folate
–Coeliac disease (TTG) - assess coeliac risk
Allergy test
–Food additives E210-219 (benzoate, sorbate, cinnamon) common ones to avoid
What is the treatment of recurrent aphthous ulcers?
Correct blood deficiencies
Refer for investigation if coeliac positive
Avoid dietary triggers
–SLS containing toothpaste- sensodyne pronamel
What drugs are prescribed to treat aphthous ulcers?
Non-steroid topical therapy (for inconvenient lesions)
–Benzdamine spray or mouth rinse
–Chlorhexidine gluconate mouthwash
Steroid topical therapy (for disabling lesions)
–topical steroid spray or mouthwash
–betamethasone soluble tablets (500mg dissolve in water)
When should a GDP refer to a specialist?
GDP’s should try to 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
Refer when these have been achieved with no good result OR
if the patient is under 12 years old
