recurrent aphthous stomatitis

Question 1

What are aphthous ulcers?

Answer 1

Immunologically generated recurring ulcers that follow a set pattern depending upon the ulcer type

Question 2

What are the different types of recurrent aphthous stomatitis (RAS)

Answer 2

Minor
Major
Herpetiform
Oro-genital ulcer syndromes eg - Behçet’s syndrome

Question 3

Describe minor aphthous ulcers

Answer 3

Less than 10mm in diameter
Last up to 2 weeks
Only affects non-keratinised mucosa
Heals without scarring
Responds well to topical steroids
Commonest type of recurrent oral ulceration

Question 4

Describe major aphthous ulcers

Answer 4

Can last for months
Can affect any part of the oral mucosa - keratinised or non-keratinised
May scar when healing
Responds poorly to topical steroids - intralesional steroids more useful
Usually larger than 10mm - may get smaller ulcers too, diagnose from the worst ulcer

Question 5

Describe herpetiform aphthae

Answer 5

Rarest form of aphthous ulcers
Multiple small ulcers on non-keratinised mucosa
Heal within 2 weeks
Similar to primary herpetic gingivostomatitis in site and number but without the systemic effects (fever)
Can coalesce into larger areas of ulceration
Nothing to do with herpes virus - in HSV keratinised epithelium is involved

Question 6

How is oral and genital ulceration diagnosed?

Answer 6

3 episodes of mouth ulcers in a year
At least 2 of the following:
- genital sores
- eye inflammation
- skin ulcers
- pathergy

Question 7

Give 3 examples of oro-genital ulcerative conditions

Answer 7

Classically is Behçet’s disease
Vesiculobullous diseases eg - pemphigoid, pemphigus
Lichen planus

Question 8

Give 4 signs of Behçet’s disease

Answer 8

Any from:
- primarily will have vasculitis - inflammation of blood vessels
- oral and genital ulceration
- eye disease
- bowel ulceration
- may also involve heart, lungs, brain and joints

Question 9

How is Behçet’s disease managed?

Answer 9

Treat local oral disease or RAS
Systemic immunomodulation where multiple systems are involved - azathioprine/mycophenolate or biologics
Managed with help from rheumatology

Question 10

Give 4 predisposing factors for RAS

Answer 10

Any from:
- genetic predisposition
- systemic disease
- stress
- mechanical injuries
- hormonal level fluctuations
- microelement deficiencies
- viral and bacterial infections

Question 11

During which period is tx for RAS ideal and why is this?

Answer 11

Tx most effective during the prodrome period - early signs and symptoms before the ulcers appear
Damage in aphthous ulcers happens before the ulcer appears
Stem cells in basal layer aren’t able to produce new epithelial cells so ulcer is formed by the exposure of connective tissue

Question 12

When is RAS almost inevitably the correct diagnosis?

Answer 12

For recurrent, self-healing ulcers affecting exclusively the non-keratinised mucosa

Question 13

What investigations can be used for RAS?

Answer 13

Blood tests:
- haematinic deficiencies - iron, B12 and folic acid
- coeliac disease (TTG)
Allergy tests

Question 14

How is RAS treated?

Answer 14

Correct haematinic deficiencies
Refer for investigation if coeliac is positive
Avoid dietary triggers identified from testing

Question 15

How is drug therapy used for RAS?

Answer 15

Follow SDCEP guidance
Non-steroid topical therapy for inconvenient lesions
Steroid topical therapy for disabling lesions

Question 16

How is RAS commonly seen and treated in children?

Answer 16

Usually seen during periods of rapid growth - 8-11 and 13-16
Usually respond to iron supplements

Question 17

When should RAS be referred to oral medicine?

Answer 17

Blood tests and haematinics have been carried out and no good result
Topical treatment as outlined in SDCEP has been carried out and not worked
If children under 12