Management and Treatment modalities of Recurrent Apthous Ulcer's with new treatment modalities.

1. Presented by:
Yawer Dar
Student of Dental Surgery
ITS Dental College, Hospital and Research Centre
Email: yawerdar@gmail.com

2.  Discontinuity in the
oral epithelium or
breach in the
continuity of the oral
epithelium is known
as an Apthous ulcer.
 It shows cell by cell
destruction pattern.
 Development of
painful solitary or
multiple ulcerations
of the oral mucosa.

3.  They appear as small,
round, or ovoid ulcers.
 They have well
circumscribed and raised
margins.
 They have a erythematous
halo and a necrotic centre.
 They have Yellow or gray
floors.
 They are very painful and
the pain is aggravated by
taking spicy foods and
acidic drinks.
 There is difficulty in speech
due to pain.

4. Recurrent
Apthous Ulcers
Minor Apthous
Ulcers
Major Apthous
Ulcers
Herpetic
Apthous Ulcers

5.  The most common type of the
disease seen.
 It is referred as a “Canker sore” by
a lay man or referred as a “chaala”
in Hindi.
 It has all the basic characteristics
of an Apthous ulcer.
 Occurs somewhat more frequently
in females than males between the
age of 10 to 30 years.
 Nearly 20% of the world
population is affected by this
disease and commonly seen in
professional school students.
 Size: 2-3mm to 10 mm in
diameter.

6.  Major Apthous ulcers are
simply more severe form of
minor Apthous ulcer’s.
 They are larger in size
 They are more painful.
 Seen commonly on the lips,
cheeks, tongue, soft palate
and rarely on the hard palate.
 More common in HIV infected
patients.
 They are more ulcerated
lesions and take a longer time
to heal than the usual time.
 Size: They can exceed 1cm in
Diameter and can leave a scar
upon healing.

7.  Herpetic ulcer’s are characterized by
crops of multiple small, shallow
ulcers often up to 100 in number.
 It may occur at any site in the oral
cavity.
 The lesions are more painful than
suspected by there small size.
 First described by Cooke in 1960.
Lehner, Brooke and Sapp expanded it
later.
 They look like lesions of herpes
simplex but they are not associated
with herpes virus and look more like
Apthous ulcers.
 Females have a greater predilection.
 The exact nature of this disease is yet
unknown.

8.  Etiology of Apthous Ulcer’s is unknown but
following are the factors known to cause Apthous
Ulcer’s:
 Bacterial infections
 Genetic predisposition
 Immunologic Abnormalities
 Iron, Vitamin B12 or Folic Acid deficiency
 Trauma
 Endocrine Conditions
 Stress and Emotional upset
 Allergic Factors
 Systemic Diseases

9.  Barile and Stanley strongly
implicated Streptococcus
Sanguis as the causative
agent of the disease.
 This organism has been
consistently isolated from
the lesions of patients with
typical Apthous ulcer’s.
 It has been suggested that
there is a T-cell mediated
response to the bacteria that
produces cross-reaction
between streptococcal heat
shock protein and oral
mucosa and leads to
mucosal damage.

10.  There is a positive
family history and
occurrence of
Recurrent Apthous
Ulcer’s is associated
with HLA-B51(Human
leukocyte antigen)
 Individuals with
positive family
history develop the
ulcer’s at an early
stage of their life.

11.  Lehner has proposed that the
recurrent apthous ulcer’s is the
result of an autoimmune
response of the oral epithelium,
by using fluorescent antibody
technique he has shown both IgG
and IgM binding by epithelial cells
of the spinious layer of oral
mucosa in patients suffering from
Recurrent Apthous Ulcer’s.
 It’s is suggested that the disease
is the result of diffusion of
bacterial toxins, food and other
substances acting allergens and
haptens which initiate an immune
response causing ulcer’s.

12. •There has been some evidence
that nutritional deficiencies
might be of significance in the
etiology of recurrent Apthous
stomatitis.
•A study reported by Wray and
his colleagues suggested that
patients deficient with Iron and
vitamin B12 have a greater risk
of Apthous ulcer’s and on
appropriate vitamin therapy
showed improved results.

13.  Local trauma has
been found to be the
precipitating factor
by Graykowski and
his coworkers.
 The traumatic
incidents include self
inflicted bites, oral
surgical prodedures,
tooth brushing,
dental procedures,
needle injections and
dental trauma.

14.  Incidence of Apthous
ulcer’s is greatest
during the
premenstrual period.
 Ulceration is maximal
in the post ovulation
period and it is related
to blood level of
progesterone.
 On rare occasions the
onset of the disease
has been associated
with menarche and
menopause.

15. • It is interesting to note that
approximately 55% of a large
group of professional school
students studied by ship and his
associates gave a positive history
of recurrent Apthous Ulcer’s,
therefore making Stress and
educational pressure as a major
factor in Recurrent Apthous
Ulcer’s
•Recurrent Apthous are also
commonly seen in People who
stay emotionally upset and
isolated.

16.  In one study, 20 individuals
who had suffered from
recurrent aphthous ulcers,
some for more than 11 years,
were given a gluten-free diet
to follow. Five of these, 25%,
became ulcer free and when
challenge tested with gluten
the ulcers returned.
 In a 1990 study tomatoes,
oranges, nuts, eggplant, tea,
cola , cinnamon oil,
pineapple and flavouring
agents were known to cause
Apthous Ulcer’s.
 Sodium lauryl sulfate present
in toothpaste’s is also
suggestive of causing
Apthous ulcers.

17.  Apthous Ulceration occurs
in various systemic
disease like behcet
syndrome, cyclic
neutropenia, magic
syndrome(major Apthous
and generalized inflamed
cartilage) and HIV
infection..
 Apthous ulcer’s occur in
patients with systemic
illness like crohn’s
disease, ulcerative colitis
and gluten sensitive
enteropathy.

18.  Exhibits a fibrinopurulent membrane
covering the ulcerated area.
 An intense inflammatory cell infiltration
is present in the connective tissue
beneath the ulcer with considerable
necrosis of tissue near the surface of the
lesion.
 Granulation tissue may be noted near
the base of the lesion.
 Epithelial proliferation is present at the
margin’s of the lesion.

21.  Dosage 250mg per 5ml.
 It is usually taken by
diluting the tetracycline
capsules in 5 ml of water
and is gargled in the
mouth four times a day
for 5 to 7 days.
 This treatment produced a
good response in nearly
70 % of the Patients
tested, by reliving the
pain, reducing the size of
the lesions and reducing
the healing time.

22.  Levamisole is an
immunopotentiating agent that
has demonstrated the ability to
normalize the CD4+ cell/CD8+
cell ratio and improve
symptoms in Recurrent Apthous
ulcer patients. Correction of T-
suppressor-cell deficiency may
reduce the inflammatory
response resulting from cellular
immunity and promote
resolution of aphthae.
 It is taken once a week for a
period of 10 months.

23.  Amlexanox is an anti-
inflammatory, antiallergic
immunomodulator used to
treat Recurrent Apthous
Ulcers.
 A 2011 review found it to be
the most effective treatment
of the eight treatments
investigated for recurrent
canker sores.
 It is applied on the Ulcer’s
directly 3-4 times a day.
 In India Apthasol comes
under the brand name
Lexanox.

24.  TRIAMCINOLONE a
corticosteroid. It is
used to reduce
swelling and ulcers
in the mouth. It
helps treat and
relieve mouth
sores.
 Applied 3-4 times a
day on the ulcer.

25.  Analgesic’s and
Antiseptics such as
Dologel-CT and Hexigel
which contain Choline
salicylate, lignocaine
hydrochloride and
chlorohexidine
gluconanate(Hexigel)
helps in reliving pain and
help preventing secondary
infections.
 Analgesics are applied
prior to meals so that the
patient feels comfortable
while eating.

26.  Vitamin B12, Folic
Acid
 Iron
 Zinc Sulfate
 Not much of positive
results are found
with administration
of vitamin B12 in
patients with
Recurrent Apthous
Ulcer’s