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Recurrent Aphthous Stomatitis
Approaches to Therapy for Stomatitis & Ulceration

Recurrent Ulceration
• Recurrent Aphthous Stomatitis (RAS)
o Minor ! ignore if not troublesome or treat
...

o Herpetiform ! treat
...

• Smoking Related Aphthous Ulcers ! treat
...

• PFAPA syndrome (Periodic Fever, Aphthae, Pharyngitis, cervical Adenitis NB Cimetidine)
• Recurrent Erythema Multiforme
...
MINOR Recurrent Aphthous Stomatitis (RAS)

Characteristics
MAJOR Recurrent Aphthous Stomatitis
MINOR Recurrent Aphthous Stomatitis
(RAS)
(RAS)
SIZE
>10mm diameter
<10mm diameter
SHAPE
Irregular/oval
Oval
COLOUR
Grey base +/- indurated edge – hardened
Grey base, erythema border
edge
DURATION
2/52 – 3/12, scar on healing
1/52 – 2/52, no scarring
SITE
Any surface – especially fauces
Non-keratinized – especially buccal mucosa
...
5-3mm diameter
SHAPE
Round – may coalesce to irregular
...

ONSET









SUMMARY TABLE – MAJOR vs
...
HERPETIFORM Recurrent Aphthous Stomatitis (RAS)





















Behcet’s Disease – International Criteria
• Recurrent Oral Ulceration (ROU)
...

" PLUS TWO OF THE FOLLOWING:
• Recurrent genital ulceration
...


• Eye Lesions – gritty, sore eyes
...

o Cells in the vitreous on slit lamp exam
...

• Skin Lesions
o Erythema Nodusum – raised plaques on
legs

o Pseudofolliculitis or Papulopustular
lesions
...


Behcet’s Disease is most common in people of Turkish origin
...


Ulcer Severity Scoring System
Ulcer Severity Score (USS) – Recurrent Aphthous Stomatitis

Based on six characteristics of the ulcers:

1
...

2
...

3
...

4
...

5
...

6
...





A Comparison of the Range of Scores of Minor,
Major and Herpetiform RAS

Generally higher score as they get larger and more painful
...

o Infections: Herpes Simplex, Mycoplasma
...

o Clinically: Oral ulceration anterior mouth, crustation of lips, skin
target lesions
...

• Immune complex formation and deposition in the microvasculature
(cutaneous/mucosal) is thought to play a role in the pathogenesis
...

" Mycoplasma Pneumoniae
...

• Provisional diagnosis
...

• Decision to treat, not treat or to refer
...

• Assessment of response
...

• Eliminate local aggravating factors
...

o Systemic antimicrobials
...

Promote healing
...

Maintenance/Prevent recurrence
...

• Examination
...


• Provisional diagnosis
...

Haematological Abnormality
...

o LFT’s
...

• Scans
o Relevant to specialist centres
...


• Restoration of function (speech, swallowing)
...

• Prevention of dental disease
...


Therapeutic Options
• Optimize oral hygiene
...

• Benzydamine hydrochloride, 5% Lignocaine gel
...
5mg Betamethasone tablets) mouthwash
...

o Triamcinolone/other steroid pastes/ointments
...

• Other topical agents
...

o Lignocaine 2% gel
...

o Benzocaine 10mg Lozenges
...
7% choline 0
...


Analgesics
• Aspirin ! 300-600mg
• Paracetamol ! 500-1000mg
• Dihydrocodeine ! 30mg
• Ibuprofen ! 400mg
...

• Azathioprine
...


•
•
•

Mycophenolate Mofetil
...

Pulsed methyl Prednisolone/Cyclophosphamide
...
1%
o Hydrocortisone pellets 2
...

o Fluticasone inhaler 125μg per puff
...
5mg as mouthwash
...
5mg/sq inch
...

• Systemic
o Corticotrophin (ACTH) 20-80 iu I/M
...

• Immunosuppressive effects – given early
...


Management of Recurrent Aphthous Stomatitis (RAS)

If Atypical Features: Raise suspicion for underlying conditions:
• Iron/Vitamin Deficiency
• GI disease
...


Investigations:
• Bloods FBC, Haematinics, +/- Coeliacs Screen
• ? Biopsy- atypical
...

• Promote healing
...

• Monitor response
...

• Prevent Secondary Infection: Corsodyl
...

• Systemic: Prednisolone

Alternatives:
• Colchicine – Anti-inflammatory agent
...

• Thalidomide – Sedative
...

o Depot ACTH – Synacthen 0
...

• Cytotoxics:
o Azathioprine 50-150mg/day
...




•

Alkylating Agents:
o Cyclophosphamide 50mg
...

o Immunosuppressive
...

o Gastrointestinal
...

o Dermatological
...


Azathiaprine – Toxicity
• TPMT activity is expressed as autosomal co-dominant alleles
...

• Deficiency allows an increased production of 6-TGNs resulting in greater toxicity and immunesuppression
...

• Major RAS
...

• Suspected Behcets
...


Management of RAS
• Clinical Examination
• Investigations
• Diagnosis
• Therapy
o Eliminate local aggravating factors
...

o Control infection
...

• Assessment of response to therapy
...


Drug Treatments in RAS
TREATMENT
Topical Steroids
0
...

2
...

0
...

Systemic Steroids –
Prednisolone
...

Immunostimulant –
Levamisole
...

Hormonal – Ethinyl Oestradiol
0
...

o Inhibits Interleukin-1 production
...

• Inhibits microtubules in ciliated cells, leucocytes
...

• Inhibits DNA synthesis
...
Nausea, Myopathy, neuropathy, Pancytopenia
...

• Varicella Zoster
...

• Hand, foot and mouth
...

Antivirals
...

• If potentially malignant – refer
...

• Trauma induced:
o Remove source of trauma
...

• If persistent and unidentifiable cause – REFER!

If Treatment Fails
• Is the patient taking the drug?
• Is the drug being absorbed?
• Is the dose adequate?
• Is the drug reaching the site of infection/problem?
• Is the drug targeting the relevant cell type?

Management of Mucosal Ulcerative Lesions – Aims & Objectives
• Be able to diagnose and treat common oral ulcerative conditions
...

• Be aware of common oral manifestations of systemic disease
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o Scoring Disease Severity
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SUMMARY: Management of Mucosal Lesions
• Importance of diagnosis before treatment
...

o Non-ulcerative conditions
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• Difference between treatment of current condition and
prevention of new disease
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SUMMARY: Recurrent Ulcers
• Many types of mouth ulcers
...

• Aphthous stomatitis is a specific diagnosis not just any ‘recurrent
oral ulcers’
...

• Steroids for RAS
...

• Scoring ulcer severity can be useful for assessing treatment response

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