Aphthous Ulceration:

Question 1

Aphthous Ulceration:

Risk Factors:

Answer 1

1. Vitamin micronutrient deficiencies
2. Stress
3. Drugs
4. Allergies
5. Bacterial Viral factors?
6. Hematologic abnormalities
7. Local injury
8. Immunologic factors
9. Underlying systemic diseases
10. Hormonal factors
11. Smoking cessation
12. Genetic factors

Question 2

Aphthous Ulceration:

Minor RAS

Answer 2

• Arise almost exclusively on nonkeratinized mucosa and may be preceded by an erythematous macule in association with prodromal symptoms of burning, itching, or stinging
• Demonstrate a yellow-white, removable fibrino- purulent membrane that is encircled by an erythematous halo
• Measure between 3 -10 mm in diameter, demonstrate a variable recurrence rate, and heal without scarring in 7 to 14 days
• Pain is out of proportion for the size of the ulceration

Question 3

Aphthous Ulceration:

Major Aphthous Ulcerations- Clinical Features:

Answer 3

• Larger and deeper than minor aphthae with longest duration per episode
• Measure from 1 to 3 cm in diameter, may have irregular raised borders take from 2 to 6 weeks to heal, and may cause scarring
• Labial mucosa, soft palate, and tonsillar fauces are involved most commonly

Question 4

Aphthous Ulceration:

Herpetiform Aphthous Ulcerations - Clinical Features:

Answer 4

1 to 2 mm in diameter in clusters of 10 to 100 in groups or throughout the mouth, which usually heal within a few weeks

Question 5

Aphthous Ulceration:

Clinical Manifestations:

Answer 5

• Burning or itching sensation 24-48 hours before the onset of ulcerations
• Fever, rash, headache, or lymphadenopathy are typically absent and would suggest a different diagnosis such as herpangina or PFAPA syndrome (periodic fever, pharyngitis, adenitis, and oral ulceration)
• A history of prior ulceration is typical On physical exam, patients with aphthous stomatitis are well- appearing and afebrile
• Assess for clinical signs of dehydration, especially in infants and children
• Involvement of the eye (uveitis) or genitalia suggest other diagnoses, such as Behçet syndrome or MAGIC syndrome (mouth and genital ulcers with inflamed cartilage)

Question 6

Aphthous Ulceration:

Diagnostic Procedures:

Answer 6

• Diagnosis of aphthous stomatitis is clinical, and laboratory testing is usually unnecessary Diagnostic testing might be considered in persistent, severe, or recurrent cases
• A CBC demonstrating anemia might suggest hematinic deficiency such as iron, folate, or vitamin B12.
• Neutropenia might prompt consideration of cyclic neutropenia as a cause of ulcerations
• Gluten-sensitive enteropathy (celiac disease) present in fewer than 5% of recurrent aphthous stomatitis cases and can be identified with serum anti- endomysial antibody and transglutaminase assay
• The detection of anti-transglutaminase IgA (tTG) and anti-endomysial (EMA) is used for screening of celiac disease (CD) with a sensitivity and specificity of 90 and 99% respectively
• Consider HIV testing in cases with complex or severe involvement, persistent herpetiform or major aphthous stomatitis, or those involving keratinized mucosa (adherent gingival, dorsum of the tongue, hard palate)

Question 7

Aphthous Ulceration:

Treatment:

Answer 7

No definitive curative treatment for RAS has been established to date The primary objectives of treatment are to:

• relieve pain
• accelerate healing
• reduce the frequency and severity of episodes of RAS

The approach to therapy should be based on:

• the severity of symptoms
• the frequency and duration of the outbreaks
• the clinical history, and
• the patient’s ability to tolerate medication

Patients with isolated episodes of simple RAS that last only a few days require no more than topical treatments for relief of pain and a series of general measures, mainly good oral hygiene

Systemic therapy is indicated in patients who experience multiple episodes of RAS and/or severe cases that involve intense pain and difficulty eating and do not respond to topical medication

Despite the frequency of this condition, few high-quality studies have appropriately evaluated treatment of RAS. Therefore, there is no standard therapy. The multiple topical and systemic treatments used have had varying degrees of success

Question 8

Aphthous Ulceration:

General Measures:

Answer 8

• Oral hygiene: It is important to ensure appropriate oral hygiene and to avoid injury, since this leads to mouth ulcers. We recommend using a soft toothbrush, toothpaste that does not contain sodium lauryl sulfate and an alcohol-free mouthwash
• Eating: In general, we should try to avoid products that are frequently associated with triggering flare-ups, especially if the patient reports an association with the products
• Supplements: It is necessary to rule out nutritional deficiencies (e.g., vitamin B12, folic acid, iron, zinc), since in these cases, patients improve when they receive appropriate treatment

Question 9

Aphthous Ulceration:

Treatment:

Answer 9

Topical Treatments

1. Topical anesthetics and barrier agents
2. Topical antiinflammatory and antiseptic agents
3. Topical corticosteroids
4. Amlexanox5%
5. Cauterization

Systemic Treatments

1. FirstLine:Oral corticosteroids
2. 2. Second-Line:

• Colchicine
• Thalidomide
• Dapsone
• Montelukast
• Clofazimine
• Pentoxifylline

Biological Treatments: Anti-TNF-alfa

Other Treatments:

• CO2, Nd:YAG, and diode laser
• Apremilast
• Bee propolis

Question 10

Aphthous Ulceration:

Algorithm:

Answer 10