Oral Aphthous Ulcers

Question 1

What are other names for AU

Answer 1

• Canker Sores
• Aphthous Stomatitis
• Recurrent Aphthous Stomatitis

Question 2

What are AU

Answer 2

Recurrent, painful, inflammatory, noninfectious, non-vesicular, immunologically-mediated mucosal disease

• White centre, red inflammed halo
• Occur on nonkeratinized oral mucosal surfaces (not on hard palate or lips)

Question 3

When are AU most common

Answer 3

in childhood to early adulthood

Question 4

Impact of AU

Answer 4

pain
weight loss (avoid eating, lose appetite)
decrease in QOL

Question 5

What are precipitating factors for AU

Answer 5

Local trauma (mucosal injury) - biting cheek, braces, dentures
Stress
Food - salty, acidic, coffee
Immunologic states
Systemic conditions
Nutritional deficiencies - Vit B, iron, zinc, folic acid
Allergy or sensitivity - celiac disease
Cessation or restarting tobacco use - causes changes to mucosa
Genetic predisposition
Medications - like NSAIDS
Hormonal changes

Question 6

Risk factors

Answer 6

Family history
Female
Age less than 40
Immunocompromised
individuals in middle and upper-middle class socioeconomic groups (more stressful jobs)
Vitamin and mineral deficiencies (B1, B2, B6, B12, zinc, iron, folic acid)

Question 7

What is the clinical presentation

Answer 7

• One or more shallow sores with a white or cream-coloured coating
• Erythematous “halo” of inflamed tissue surrounds the ulcer
• Painful
• History of recurrent episodes

Question 8

What are the 3 types of AU

Answer 8

minor
major
herpetiform

Question 9

what are minor AU

Answer 9

2-10 mm
Occur singly or in clusters ≤5
Oval shape 
7-10 days (self-limiting)
No Scarring

Question 10

What are major AU

Answer 10

>10 mm, deeper
Occur in clusters of 2 or more
Irregular shape
May persist for weeks
Scar potential

Question 11

what are herpetiform

Answer 11

2-3 mm
Occur in clusters of 10-100
Irregular shape 
7-30 days
Scar Potential

Question 12

what AU can RPhs treat

Answer 12

only minor

Question 13

DD: Behçet syndrome

Answer 13

Blood vessel inflammation

Question 14

DD: Inflammatory bowel disease (Crohn’s)

Answer 14

other symptoms will be related to GI

Question 15

DD: Lupus erythematosus

Answer 15

blistering

on lips, extend inwards

Question 16

DD: Leukoplakia

Answer 16

• white lesion
• on tongue/cheeks
• usually males <30, smokers or ex-smokers
• precancer

Question 17

DD: Viral infections (cold sores)

Answer 17

• additional symptoms like fever

Question 18

DD: Treponemal infection (syphilis)

Answer 18

• will appear on tongue

Question 19

DD: Fungal infections (thrush)

Answer 19

• white coating

Question 20

DD: Hematologic diseases (cyclic neutropenia)

Answer 20

• can cause ulcerations

- often on tongue

Question 21

DD: Neoplasms (squamous cell carcinoma)

Answer 21

• on lips

- usually on areas exposed to sun (skin cancer)

Question 22

How do drug-induced oral ulcers occur

Answer 22

1. direct trauma - direct application of essential oils or effervescent tablet
2. long-term medication use (Isotretinoin/accutane, histamine-2 receptor antagonists)
3. direct association of oral ulcerations (NSAIDs, immunosuppressants, etc)

Question 23

Red flags that indication another condition

Answer 23

• 1st aphthous ulcer was after the age of 30
• Systemic illness symptoms
• Immunocompromised due to medication or disease state, or immunodeficiency disorder
• Behcet’s, SLE, IBD, HIV
• Lesions present elsewhere on the body
• hard palate, gums, genitals, lips
• Severe pain
• Radiation therapy
• Recurrences > 6 times per year

Question 24

Red flags that indicate major or herpetiform ulcers (require referral)

Answer 24

• Ulcer diameter >10 mm
• Ulcer duration >14 days
• > 5 ulcers present
• multiple clusters of ulcers that may have coalesced
• difficulty chewing or swallowing due to pain
• History of having ulcers that last >14 days, heal with scarring and recur 6-12 times/year

Question 25

Goals of therapy

Answer 25

1. Relieve local pain & discomfort 2. Restore function & oral hygiene practices (speaking, swallowing) 3. Ensure adequate nutritional intake 4. Reduce duration of ulcer(s) 5. Decrease frequency & severity of recurrences (AU cannot be cured!) 6. Prevent complications

Question 26

Prevention Measures

Answer 26

``` Avoid Local Trauma • Avoid self-biting • Avoid sharp-edged foods • Replace toothbrush heads early Avoid allergens Avoid dehydration (makes AU very uncomfy) Avoid nutritional deficiencies Avoid/minimize emotional stress Manage drug-induced causes Manage underlying systemic disease causes ```

Question 27

Nonpharm Treatment

Answer 27

• Repair or remove oral trauma-causing agent • Avoid food & drinks that cause pain (alcohol, caffeine, salty, spicy) • Avoid using harsh toothpastes and mouthwashes with SLS • Maintain regular daily oral hygiene • Ice application (short increments: 10-20 mins PRN) • Cleanse the lesion: Rinse the mouth with salt water (2.5-5 mL table salt per 250 mL warm water) several times a day, especially after meals

Question 28

Should cleaning rinses and antiseptics be used

Answer 28

NO evidence that benefit over saline rinses

Question 29

How to determine treatment approach

Answer 29

the choice of agent will depend on severity of pain, number of ulcers, frequency of episodes and patient's tolerance to treatment.

Question 30

What is the 1st line treatment

Answer 30

topical agents: • Anesthetics (local) • Anti-inflammatories • Mucosal Protectants

Question 31

Mucosal Protectants and dosing

Answer 31

* Hydroxypropyl cellulose, carboxymethyl cellulose (Orabase Paste®) * Protective layer over lesion = temporary pain relief * To be applied PRN (often TID - QID)

Question 32

Local oral anesthetics and dosing

Answer 32

• Benzocaine (Orajel®, Anbesol®), lidocaine (Xylocaine Viscous®) <20% • Short duration of action; may be used with protectants or oral analgesics • MAX QID for <1 week; apply with cotton swab apply ice before using a gel formulation (since there is a high alcohol concentration, can be painful) • Avoid eating, drinking, speaking for 30 min post-application (do not swallow)

Question 33

Local Oral Anesthetic + Mucosal Protectant

Answer 33

combination: numbs and protects (more expensive) | Orabase with benzocaine ®, Kank-a ®, Zilactin-B

Question 34

Which oral analgesics can be used?

Answer 34

Acetaminophen; AVOID NSAIDS

Question 35

Which vitamins to supplement with

Answer 35

Vitamin B1, B2, B6, B12, Iron, Folic Acid, Zinc | - studies show shortens episodes, reduces number of ulcers, and reduces pain

Question 36

Milk of Magnesia & Diphenhydramine Allergy Liquid (mixed 1:1)

Answer 36

Swish 5mL in mouth for 1 minute then spit Q4-6 hours to help pain

Question 37

Is canker cover effective?

Answer 37

does not have evidence to support

Question 38

Should baking soda, witch hazel, raw egg, etc be used?

Answer 38

No

Question 39

Avoid or use: menthol and camphor

Answer 39

counterirritants should be avoided | worsen disease state

Question 40

How to use ASA

Answer 40

do not place directly over lesion

Question 41

Avoid or use: dentrifrices with SLS

Answer 41

Avoid

Question 42

Avoid or use: benzocaine/lidocaine

Answer 42

Avoid -caines in patients with hypersensitivity

Question 43

What causes black hairy tongue

Answer 43

swallowing oral debriding and wound cleansing agents

Question 44

When to follow up

Answer 44

Assess benefits and AE of treatment Patient: daily RPh: 3-7 days x 1st week then 1 week later

Question 45

What to do if the ulcer is still present or worsened after 14 days

Answer 45

refer

Question 46

What is LESS

Answer 46

Non pharm strategies to lessen duration of ulcer

Question 47

What is L in LESS

Answer 47

Local trauma: avoid sharp, spicy, acidic foods. Avoid SLS

Question 48

what is E in LESS

Answer 48

Emotional and environmental stress management

Question 49

what is S in LESS | first S

Answer 49

Supplementation: increase foods in iron, folate, B12 or B6 if suspected deficiency

Question 50

what is S in LESS | second S

Answer 50

Start Ice: apply in 10 min increments

Question 51

ON vs SK (medSask)

Answer 51

Both can assess patient to determine if minor AU present | - SK can prescribe treatment for minor AU, ON cannot