A presetation on most common oral mucosal disease i.e. recurrent aphthous ulcers.

1. RECURRENT APHTHOUS
STOMATITIS
A Difficult Clinical Entity
Presented by: Dr. Sidra Fahim

2. Introduction
 The term aphthous is defined as a breach
in the oral epithelium which typically
exposes nerve endings in the underlying
lamina propria resulting in pain and
soreness.

3. Introduction
• RAS is characterised by spontaneous,
self-limiting ulcerations of the mucosa of
oral cavity, recurring at intervals of
approx 3-4 weeks.
• Lesions can be single or multiple.
• Generally affect the non-keratinized
mucosa of the cheeks, the soft palate, the
fauces, the mouth floor, the tongue, and
the gums.

4. Aetiology
 Genetic predisposition
 Exaggerated response to trauma
 Infections – Bacterial (Streptococci)
 Immunological abnormalities
 Gastrointestinal disorders
 Haematological deficiencies
(zinc/iron/folate)
 Hormonal disturbances (Menstrual
cycle)
 Stress
 Certain foods (chocolates)

5. Aetiology
 It can also occur as widespread lesions in
association with systemic diseases
including Behçet’s syndrome,
gastrointestinal malabsorption disorders
like Crohn’s and celiac diseases and
immunodeficiency syndromes such as
infection with the human
immunodeficiency virus (HIV) or cyclic
neutropenia.

6. Clinical Features
 Onset – Frequently in childhood but peak
in adolescence and early adult life
 Attacks at relatively regular intervals
 Most patients are otherwise healthy
 Few patients have haematological defects
 Most patients are non-smokers
 Usually self-limiting eventually

7. RAS ─ Classification
 Minor Aphthae (most common type)
 Major Aphthae
 Herpetiform Aphthae

8. Minor Aphthae
 Non-keratinized mocosa affected e.g.
buccal mucosa, lateral borders of the
tongue, sulci
 Persist upto 7-10 days
 Ulcers are shallow, 5-7mm across, with an
erythematous margin and yellowish floor
 One or several ulcers may be present

10. Major Aphthae
 Uncommon
 Persist upto 6 weeks
 Ulcers frequently several centimeters
across
 Sometimes mimic a malignant ulcer
 Masticatory mucosa (dorsum of the
tongue, gingivae) may be involved
 Scarring may follow healing

12. Herpetiform Aphthae
 Uncommon,
 Non-keratinised mucosa affected
 Ulcers are 1-2 mm across
 Dozens or hundreds may be present
 May coalesce to form irregular ulcers
 Widespread bright erythema round the
ulcer
 Healing generally occurs in 1-2 weeks

14. Diagnosis
History Examination Special
Investigations
o Recurrences?
o Pattern?
o Onset?
o Family History
o Distribution only
on non-
keratinised
mucosa
o Signs/symptoms
of Behcet’s
Disease?
o Discreet well-
defined ulcers
o Scarring or
soft palate
involvement
suggesting
major
aphthae
o Anemia, iron, red
cell folate and
vitamin B12
status
o H/O diarrhea,
constipation, or
blood in stools
suggesting celiac
disease/
malabsorption

15. Management
General Measures Medication
o Reduce the painful
symptoms through
antiseptic gels
o L/A benzocaine & lidocaine
o Help the patient get out of
stress
Topical Systemic
o Steroids
o Azathioprine
o Colchicine
o Thalidomide
o Intralesional
Steroid Inj
(Maj Ras)

16. Topical Medication
 Covering agents e.g. Carboxy
methylcellulose (Orabase)
 Topical gels e.g. choline salicylate
(Bonjela)
 Benzydamine and Chlorhexidine mouth
washes.
 Tetracycline mouth rinses – the contents
of a tetracycline capsule 250mg stirred in
a little water and held in mouth for 2-3
mins TDS 5 days.

17. Topical Medication
 Corlan (hydrocortisone hemisuccinate) -
2.5mg pellets allowed to dissolve in the
mouth QDS.
 Triamcinolone dental paste 0.1% –
corticosteroid in a vehicle – apply QDS
with moist finger.
 Steroid aerosols – 1 puff per ulcer QDS
 Steroid m/w (Betamethasone) – Dissolve
0.5mg in 5ml water & rinse for 2-3 mins
QDS

18. Miscellaneous Treatments
 Laser can be an alternative treatment for
aphthous ulcers.
 Low Level Lasers Therapy (LLLT) -
Dosimetry depends upon the size of the
lesion.
 Photobanding - The technique consists of
the formation of a protective layer on
exposed connective tissue using lasers.
 These treatments reduce healing time and
inflammatory reaction and provides
immediate pain relief.

19. Miscellaneous Treatments
 One study has demonstrated the efficacy and
the rapidity of response of the Lactobacillus
brevis CD2 lozenges (at least 1 billion live
bacteria per lozenge) in resolving the clinical
signs and symptoms of aphthous stomatitis,
with a significantly rapid improvement of pain.
 The Lactobacillus brevis CD2 strain is endowed
with high levels of arginine deiminase, an
enzyme that plays a fundamental role in the
metabolism of arginine thus preventing the
growth of arginine-dependent inflammatory
microorganisms.

20.  Nano gum gel, antioxidant therapy
 Royal Jelly (Propillus) is one of the
contents.

24. References
 Chireen Chamas, Dolly Roukoz, Nadia Skandri.
Pain Relief of Aphthous Ulcers by Lasers: A
Literature Review. Dental News.
http://www.dentalnews.com/2014/12/20/pain-
relief-of-aphthous-ulcers-by-lasers-a-literature-
review/
 V Trinchieri, SD Carlo, M Bossu’, A Polimeni. Use
of Lozenges Containing Lactobacillus brevisCD2 in
Recurrent Aphthous Stomatitis: A Double-Blind
Placebo-Controlled Trial.Ulcers;
Volume 2011 (2011); Article ID 439425, 6 pages.
http://dx.doi.org/10.1155/2011/439425