Recurrent Aphthous Stomatitis Flashcards by Zach Geddes

What are the causes of aphthous ulcers?

Generated by immunological process in epithelial or connective tissues

Aetiology- multifactorial with genetic base (familial) in conjunction with environmental triggers
-> Can change with times

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What are the types of RAS?

Minor (most common)

Major

Herpetiform

Oro-Genital ulcer syndromes – e.g. Behçet’s syndrome

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How is diagnosis of RAS achieved?

History- as patient may not currently have ulcer

Examination- presence of yellow/grey base with erythematous margin

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What are the features of Minor Aphthous Ulcers?

Less than 10mm diameter

Last up to 2 weeks

ONLY affect NON-Keratinised mucosa

Heal without scarring

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How do Minor Aphthous ulcers appear?

As a yellow oval ulcerative area on oral mucosa
-> Base is yellow due to deposition of fibrinous tissue and exposed connective tissue
-> Will have erythematous halo of inflammatory change around ulcer

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What is the ulcer free period a good guide for?

Morbidity- gives level of suffering and indicates treatment need
-> infrequent and longer periods between would be preferable

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What treatment do minor aphthous respond well to normally?

Topical steroids

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What are the features of Major Aphthous ulcers?

> 10mm

Can occur with minor ulcers too

Can last for months

Can affect ANY part of the oral mucosa- K/NK or both

MAY scar when healing

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How do Major aphthous ulcers appear?

Areas of epithelial loss, fibrinous exudate and peri-lesional erythematous halo

-> similar to minor

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If both minor and major present, how is the diagnosis classified?

Off the worst lesion

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What is the treatment for Major Aphthous Ulcers?

Intra-lesional Steroids

-> poor response to topical

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What is the issue with scarring on healing of Major ulcers in throat area?

Stricture formation

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What are the features of Herpetiform Aphthae?

Rarest form of Aphthous ulcers

Multiple small ulcers on non-keratinized mucosa

Heal within 2 weeks

Can coalesce into larger areas of ulceration

Appears like PHG

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How can Herpetiform Aphthae be distinguished from PHG?

These patients would not have fever/systemic symptoms —> nothing to do with HSV which would also affect keratinised epithelial and be are non-recurrent

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What are the types of Oro-genital Ulcerative Conditions?

Behcet’s- immunological tendency coded for at HLA level

Lichen Planus

Vesiculo-bullous diseases

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What are the signs and symptoms of Behcet’s?

Three episodes of mouth ulcers in a year (major/minor)
AND

At least two of the following: genital sores, eye inflammation, skin ulcers, pathergy

What type of disease is Behcet’s?

Vasculitis – inflammation of blood vessels

What other structures can Behcet’s affect?

Eye disease- anterior or posterior uveitis (can lead to loss of vision in 20%)

Bowel ulceration – iliocaecal area (pain and cramping)

Heart and lungs

Brain

Joints

How is Behcet’s managed?

Treat local oral disease or RAS

Systemic immunomodulation where multisystem involvement:
Colchicine used ‘off label’ often a first treatment
Azathioprine/Mycophenolate
Biologics – infliximab and others

Who else may we consult if we suspect Behcet’s?

Rheumatology Specialists

National specialist treatment centres

What are the predisposing factors for RAS?

Systemic diseases

Stress

Viral/bacterial infections

Genetic Predisposition

Hormone level fluctuations (menstrual)

Microelement deficiency

What are examples of some of the immune processes causing RAS?

Increased level of NK cells

Increased B lymphocytes

Reactivation/hyperactivity of neutrophils

Decreased CD4+ lymphocytes
-> disrupted CD4/CD8 ratio

Decreased expression of HSP

High level of complement system ingredients

How does damage in RAS occur?

 Basal cells become damaged by immune system - can no longer produce further epithelial replacement cells

 When existing cells move up through prickle layer to surface they are lost- ulceration (exposure of connective tissue) will appear as there are no new epithelial cells to replace them

 Presentation occurs 3-4 days after immunological process occur

When is ideal time to treat RAS? How would it be done?

During prodromal phrase- as on presentation the immunological process has been reversed and healing has begun and would not produce same benefit

Prodormal tingling can be identified- apply topical steroids at that stage
-> Reduces severity of following ulceration

How would prophylactic treatment for RAS work?

Use daily topical steroid mouth rinse if patient has high morbidity and short ulcer free periods ->Reduces frequency and severity- catches ulcers during prodromal period

What is the general rule with ulcers?

Recurrent self-healing ulcers affecting exclusively the non-keratinised mucosa are inevitably aphthae

Which investigations can be helpful for patient with Aphthous ulcers?

Blood tests: Haematinic deficiencies – Iron (ferritin), B12, Folic acid Coeliac Tests ->TTG (tissue transgutaminase) -> If TTG positive test Anti-gliadin & Anti-endomysial antibodies Allergy tests – contact (delayed) or immediate hypersensitivity

Which food additives may be responsible for hypersensitivity reactions leading to RAS?

E210-219 (Benzoate & Sorbate, Cinnamon) Chocolate

How is RAS managed?

Correct blood deficiencies- Ferritin (iron), Folic Acid, Vit B12 Refer for investigation if Coeliac positive -> endoscopy and jejunal biopsy Avoid dietary triggers (identified through testing)- Empirical dietary avoidance – use FOOD MAESTRO Avoid SLS containing toothpaste – (Sensodyne Pronamel and Kingfisher are SLS free)

What drugs are used for different ulcers generally?

Non-Steroid Topical Therapy- For inconvenient lesions Steroid Topical Therapy- For disabling lesions

When do children tend to suffer from RAS?

Children frequently get Aphthous ulcers during periods of rapid growth – very few before this -> 8-11 years and 13-16 years

How are ulcers associated with growth in children usually treated?

With 3 months of iron supplements -> Lower iron levels often associated as children are using nutrients rapidly during growth (so restore levels)

How are ulcers treated in children if they are not related to growth? (genetic cause)

Consider allergy testing as well as blood Give symptomatic treatment during ulcer periods: -> Issues with Betnesol under age 12 - licence -> Issues with Betnesol if child unable to spit mouthrinse out reliably (usually can from 5-8)

When should RAS be referred to OM?

After arranging blood and allergy tests/ following SDCEP guidelines for treatment -> If these options haven't worked Children under 12