Recurrent Aphthous Stomatitis

Question 1

What are Aphthous ulcers?

Answer 1

• Immunologically generated Recurring oral ulcers
• An ulcer is a break in the epithelium
• Follow a set pattern depending on ulcer type

Question 2

What is the aetiology of aphthous ulcers?

Answer 2

• Genetically driven with environmental modification
• Multifactorial environmental triggers and variable expression

Question 3

What are the main forms of Recurrent Aphthous Stomatitis (RAS)?

Answer 3

• Minor
• Major
• Herpetiform
• Oro- Genital ulcer syndromes e.g. Behcet’s syndrome

Question 4

What type of Aphthous ulcer does this picture show?

Answer 4

• Minor
• Yellow fibrinous ulceration surrounded by red erythematous

Question 5

What are the findings common to Minor Apthous ulcers?

Answer 5

• 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

Question 6

What is the commonest type of recurrent oral ulceration?

Answer 6

• Minor

Question 7

What type of Aphthous ulcer is this?

Answer 7

• Major
• Area of epithelial loss with fibrinous edge covering
• Peri lesional erythematous halo

Question 8

What are the findings for Major Aphthous ulcers?

Answer 8

• 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

Question 9

What are the common findings of Herpetiform Aphthae?

Answer 9

• 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

Question 10

What is the difference between HSV and Herpetiform Aphthae?

Answer 10

• HSV involves keratinised epithelium , herpetiform aphthae does not
• HSV usually not recurrent

Question 11

What can Herpetiform recurrent aphthae ulcers be confused with in early stages?

Answer 11

• In early stages herpetiform aphthae can look like primary herpetic gingivostomatitis

Question 12

What does this show?

Answer 12

• Herpetiform Recurrent Aphthous stomatitis

Question 13

What does this show?

Answer 13

• Herpetiform Recurrent Aphthous stomatitis

Question 14

What does this show?

Answer 14

• Herpetiform Recurrent Aphthous stomatitis

Question 15

What are the classical findings of Behcets disease?

Answer 15

• 3 episodes of mouth ulcers in a year
• At least two of the following, genital sores, eye inflammation, skin ulcers, pathergy

Question 16

What are some other oro-gneital ulcerative conditions exist?

Answer 16

• Lichen planus
• Veiculobullous disease

Question 17

What does this picture show?

Answer 17

• Behcet disease
• Minor or major recurrent aphthous stomatitis

Question 18

What is Behcets disease primarily termed?

Answer 18

• Vasculitis (inflammation of blood vessels)

Question 19

What areas of the body can Behcets disease affect?

Answer 19

• 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

Question 20

What is the management of Behcets disease?

Answer 20

• 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

Question 21

What are some predisposing factors of RAS?

Answer 21

• Genetic predispotion
• Systemic disease
• Stress
• Viral and bacterial infections
• Microelement deficiences like iron or B12
• Hormonal fluctuations i.e. premenstrual

Question 22

What is the immunologicalpathology of RAS?

Answer 22

• 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

Question 23

When is the txt most effective for RAS?

Answer 23

• Damage happens before ulcer appears
• Txt most effective in ulcer prodrome period (feel prodromal tingling)
• If pt has ulcer morbidity then may use phrophylaxis

Question 24

What blood test can be used to investigating Aphthous ulcers?

Answer 24

• 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

Question 25

What allergy tests can be used to investigate Aphthous ulcers?

Answer 25

• Use contact (delayed) or immediate hypersenitivty testing
• Test food additives E210-219 (Benzoate and Sorbate, Cinnamon) and chocolate

Question 26

What is the management of RAS?

Answer 26

• 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

Question 27

What toothpastes are SLS free?

Answer 27

• Sensodyne Pronamel
• Kingfisher

Question 28

What is SLS?

Answer 28

• Sodium lauryl sulfate

Question 29

When are Apththous ulcers seen most commonly in children?

Answer 29

• 8-11 yrs and 13-16 yrs
• Periods of rapid growth
  -Give iron supplements

Question 30

When should you refer to Oral Med?

Answer 30

• When simple investigations for haematinic deficiency’s and topical txt does not work
• Children under 12

Question 31

Local measure for ulcers?

Answer 31

• Warm salty mouth rinse up to 4 times a day to relive pain and swelling

Question 32

What can you prescribe for oral ulcerations?

Answer 32

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