Aphthous Stomatitis Flashcards
(32 cards)
Aphthous Ulcers
Most common oral mucosal disorder.
• Polygenic mode of inheritance
• >40% of RAS sufferers have 1st degree relatives with RAS.
• Acute and extremely painful recurring mouth ulcers
usually involving non-keratinized oral mucosal sites.
• May interfere with eating, drinking, or swallowing.
• They may be classified as minor, major or herpetiform.
Minor RAS
• “Canker sores” • High prevalence: 5-25% • 75-85% of all RAS cases • <10mm in diameter • Ulcer is shallow, round/oval, a yellow pseudomembrane with slightly raised margin and erythematous halo. • Resolve without treatment in 7-14 days • No scarring • Recurrence rates vary
Major RAS
- 10-15% all RAS cases
- > 10mm in diameter
- Ulcer is deeper, often with irregular border
- Healing can take weeks or months
- May be associated with fever or malaise
- Predilection for the throat
- Often leaves scarring
- Recurrence rates vary
Herpetiform RAS
• 5-10% all RAS cases • Crops of ulcers <5mm in diameter which may fuse. • Resolve without treatment in 7-14 days • No scarring • Recurrence rates vary
Etiology of RAS
vast and unknown!
- local/oral factors
- microbial
- nutritional/allergic
- systemic conditions/factors
- genetic/immunologic
Most likely mucosa damage sets the stage and (???) and then triggers a cytotoxic cascade
Ulcer Formation
T-helper cells initially predominate and affect a Th1 immune response
• Adjacent keratinocytes express HLA-DR (MHC-class II) and ICAM-1
molecules
• Local blood vessels express E-selectin and VCAM-1 molecules
• Release of pro-inflammatory cytokines eg IL-1, IL-6, TNF-a, IFN-g
• Cytotoxic T-cells mediate keratinolysis
• Neutrophils, macrophages & NK cells also seen
Histopathology of Ulcer
Ulcer filled with inflammatory cells and fibrin pseudomembrane
Classification
• Simple
- minor, major, herpetiform
• Complex
- diagnosis almost constant presence of greater than 3 oral aphthae or recurrent oral/genital aphthae and exclusion of Behcet’s disease
- forms of complex include
1. primary, idiopathic complex aphthosis
2. secondary complex aphthosis
a. Inflammatory Bowel Disease
b. HIV
c. cyclic neutropenia
d. FAPA (fever, aphthous stomatitis, pharyngitis,
adenitis)
e. Hematinic deficiency (iron, zinc, folate,
vitamins, B1, B2, B6, B12)
f. Gluten sensitivity enteropathy
g. Ulcus vulvae acutum
• Behcet’s
• Magic Syndrome
- NB Magic syndrome may be a systemic
manifestation of BD. Polychondritis affects ears,
nose, throat and ribcage.
HIV-Associated Aphthous
CD4 counts <100 cells/mm³ are predisposed
to major RAS
• Other sites may be affected: esophagus,
genitals, anus/rectum
• We see this less frequently since ART
• Diagnosis is important, particularly if no
prior history
Periodic fever, aphthosis, pharyngitis, adenitis syndrome (PFAPA)
Marshall’s syndrome
•Unknown cause: bacterial ?
• Affects young children (mean age <5 yrs)
• Periodicity of episodes q3-4 weeks
•High fevers lasting 4-6 days (up to 40ºC)
• Perfect health between episodes
Hematinic Deficiencies
- Equivocal associations with iron, Vit B1, B2, B6, B12, and folate.
- Blood tests are not recommended routinely in all patients with RAS.
- Indications for blood work:
- Older patient with recent RAS history
- Suspicious medical history/review of systems
- Strict vegetarian patients
Celiac Disease
Celiac sprue or gluten-sensitive enteropathy • Small intestinal malabsorption • 4% of patients presenting with RAS • Gluten-rich foods: cereals eg wheat, rye, barley • European descent, 7:1 female:male • Associated clinical findings: • chronic diarrhea or flatulence • Laboratory findings • é IgG and IgA antigliadin & IgA anti-endomysial levels • Malabsorption tests • Treatment • strict gluten-free diet
Reiter’s Syndrome
• Reactive arthritis usually following dysentery or a sexually transmitted
infection
• HLA-B27-positive
• Oligoarthritis (knee/ankle), conjunctivitis, urethritis, and mouth ulcers
most common features
Smoking & RAS
• Cigarette smoking prevents RAS
• Increase keratinization &/or effects of nicotene ?
• Use of smokeless tobacco & nicotine therapy may have a beneficial
effect on RAS.
Others for Complex
• Sweet’s Syndrome
- Acute febrile neutrophilic dermatosis
- May occur in conjunction with leukemia
• Cyclic Neutropenia
• Medication-induced RAS
Behçet’s Disease
Recurrent inflammatory disorder of unknown cause:
bacterial ?
• Affects Middle Eastern Males & Asian Females
• Onset 3rd-4th decade
• HLA-B51 association
• Recurrent aphthous ulcers generally precede other signs:
genital/skin/eye lesions & others (arthritis, GI lesions, CNS
symptoms, vascular lesions)
• Diagnosis based upon criteria: no laboratory tests
Steps in managing RAS patients
History of RAS • Medical History • Medications • Review of Systems • Social History • Dental History • Diet/Nutritional History • Physical Examination • Laboratory Tests
History of RAS Outbreaks
Onset (childhood vs adult) • Level of pain & quality of life • Dysphagia • Weight loss ? • Recurrence rate • Healing time • Possible precipitating factors • Extra-oral ulcers (eg genitals) • Prodrome ? • Associated signs & symptoms during episodes
Medical History
• Associated medical conditions • Review of systems • Skin, GI, throat, eyes, joints, genitals, neurological system, immune system, hematological • Medications • NSAIDs, nicorandil (UK)
Social History
- Tobacco history
- Recrudescence since tobacco cessation ?
- Alcoho
Oral/Dental History
- Oral hygiene practices/products
* Dry mouth
Diet/Nutritional History
- Able to eat ?
- Foods
- Gluten ?
- Citrus
- Vegetarian ?
Physical Examination
- Extra-oral
- Lymphadenoapathy ?
- Skin ?
- Intra-oral
- Number, location, size
RAS Treatment Plan
Treatment dictated by: • Associated symptoms & ability to function • Number & location of ulcers • Recurrence history • Possible underlying cause Consider 4 options (can combine): • No treatment • Prevention/treatment of/for possible causes • Topical therapy • Systemic therapy • Referral for severe disease
