Recurrent Aphthous ulcers

Question 1

What are Recurrent Aphthous ulcers?

Answer 1

immunologically generating recurring oral ulcers
follow a set pattern depending on ulcer type
genetically driven with environmental modifications
multifactorial environmental triggers and variable expression
ulcer experience may change as ‘risk factors’ change over life

Question 2

Recurrent aphthous stomatitis/RAS types

Answer 2

minor
major
herpetiform
oro-genital ulcer syndromes
- e.g. Behcet’s syndrome

Question 3

minor aphthous ulcers - features

Answer 3

commonest type of recurrent ulcertaion
less than 10mm diameter
last up to 2 weeks
only affect non-keratinised mucosa
heals without scarring
usually a good response to topical steroids

Question 4

major aphthous ulcers - features

Answer 4

can last for months
can affect any part of the oral mucosa
may scar when healing
poor response to topical steroids
- intralesional steroids more effective
usually larger than 10mm

Question 5

herptiform apthae features

Answer 5

rarest form of aphthous ulcers
multiple small ulcers on. non-keratinised or non-keratinised
heals within 2 weeks
can coalesce into larger areas of ulceration

Question 6

Behcets disease diagnosis

Answer 6

• 3 episodes of mouth ulcers in a year
• at least 2 of the following: genital sore, eye inflammation, skin ulcers, pathergy

Question 7

Behcets disease features

Answer 7

commoner in asiatic races particularly turkey

primarily a vasculitis - inflammation of blood vessels
oral and genital ulceration
eye disease
- can lead to loss of vision in 20%
bowl ulceration
can affect heart, lungs, brain and joints

Question 8

Behcets disease management

Answer 8

treat local oral disease or RAS
systemic immunomodulation where multi system involvement
- colchicine often first treatment
- azathioprine
- biologics e.g. infliximab
managed with help of rheumatology

Question 9

RAS predisposing factors

Answer 9

genetics
viral and bacterial infections
systemic disease
stress
hormonal fluctuations
mechanical injuries/trauma
microelement deficiency

Question 10

When is ulcer treatment most effective?

Answer 10

in prodrome period

Question 11

aphthous ulcers - investigations

Answer 11

blood tests
- haematinic deficiecnies - iron, b12, folic acid
- coeliac disease - TTG
allergy tests
- contact or immediate hypersensitivity

Question 12

recurrent aphthae treatment

Answer 12

correct blood deficiencies
refer for investigations if coeliac positive - endoscopy
avoid dietary triggers
- SLS toothpaste e.g. sensodyne proenamel
- identify dietary triggers from testing - food maestro app

Question 13

drug prescribing for aphthous ulcers

Answer 13

inconvenient lesions
- non steroid topical therapy
disabling lesions
- steroid topical therapy
SEE SDCEP

Question 14

aphthous ulcers in children

Answer 14

common during periods of rapid growth
8-11 and 13-16
usually response to iron supplements
consider allergy and blood testing if not related to growth

Question 15

when to refer to oral medicine for RAS

Answer 15

no good result from treatment
children under 12