Recurrent Aphthous Stomatitis-Current Perspective

Dr. Prabhakar M Sangolli Dr. Prabhakar M Sangolli

Dept of DermatologyDept of Dermatology

Dr.B.R.AMBEDKAR MEDICAL COLLEGEDr.B.R.AMBEDKAR MEDICAL COLLEGE

BangaloreBangalore

Canker SoreCanker Sore

Recurring ulcers in the oral Recurring ulcers in the oral mucous membrane with no signs mucous membrane with no signs of systemic disease.of systemic disease.

Common manifestation of Common manifestation of haematological, immunological haematological, immunological and psychological disorders.and psychological disorders.

AetiopathogenesisAetiopathogenesis

Genetic ( HLA)-40% casesGenetic ( HLA)-40% cases NutritionalNutritional-Iron-Iron,,folicfolic acidacid,B,B11,B,B22,B,B33, , BB1212,C,C Endocrinal-Premenstrual,pregnancyEndocrinal-Premenstrual,pregnancy Infective-Strep.sanguis(Hsp), HIVInfective-Strep.sanguis(Hsp), HIV StressStress Smoking cessationSmoking cessation TraumaTrauma Immunological(ADCC)Immunological(ADCC)

Clinical FeaturesClinical Features

-20% of general population-20% of general population -Precipitated by trauma,menses-Precipitated by trauma,menses -Prodrome 2-48 hrs-Prodrome 2-48 hrs Pre ulcerativePre ulcerative UlcerativeUlcerative ResolvingResolving

TYPESTYPES

Minor (Mikulicz) Major (Sutton) Herpetic

No. 1-10 1-10 numerous

Size 2-4mm >1cm 2mm

Site Non keratinized Keratinized+ non-

keratinized

Non-keratinized

Healing

Time

10 days

>6 weeks

10 days

Scar - + -

DISEASES SIMULATING DISEASES SIMULATING RASRAS

Behcet’s: oral, genital, neuro-ocularBehcet’s: oral, genital, neuro-ocular Sweet’s syndromeSweet’s syndrome Blood dyscrasiasBlood dyscrasias GIT malabsorption (GIT malabsorption (Coeliac disease,IBDCoeliac disease,IBD)) Collagen vascular diseasesCollagen vascular diseases Cyclic neutropeniaCyclic neutropenia Reiter’s DiseaseReiter’s Disease Recurrent Intra oral HerpesRecurrent Intra oral Herpes

MANAGEMENTMANAGEMENT

History :History : Stress Stress

TraumaTrauma

SmokingSmoking

Premenstrual flarePremenstrual flare Clinical examination: EyeClinical examination: Eye

GenitalGenital

RectalRectal

CNSCNS

InvestigationsInvestigations

MaRAS,onset >25yrs age,pt with MaRAS,onset >25yrs age,pt with syst.symptomssyst.symptoms

CBCCBC Serum iron,BSerum iron,B1212,RBC folate

levels,ferritin ANA

GENERAL MEASURESGENERAL MEASURES

Stress avoidanceStress avoidance Nicotine patchesNicotine patches Soft tooth brushSoft tooth brush BB1212 supplements:1000mcg twice wkly-6wks supplements:1000mcg twice wkly-6wks

1000mcg once a month-1 1000mcg once a month-1 yr (low serum Byr (low serum B12 12 level)level)

Folic acid, Iron, B-complex, C supplementsFolic acid, Iron, B-complex, C supplements Pre & Probiotics Pre & Probiotics

TOPICAL THERAPYTOPICAL THERAPY

Mild cases - To promote healing, useMild cases - To promote healing, use 0.1% Triamcinolone with orabase, qid0.1% Triamcinolone with orabase, qid 2% xylocaine viscous to relieve pain2% xylocaine viscous to relieve pain Severe cases :Clobetasol, FlucinoloneSevere cases :Clobetasol, Flucinolone Tetracycline in 30 ml water q.i.d &Tetracycline in 30 ml water q.i.d & 5% Amlexanox paste-Accelerate healing .5% Amlexanox paste-Accelerate healing .

SEVERE CASESSEVERE CASES

Prednisolone 1mg/kg/day, taper Prednisolone 1mg/kg/day, taper over 2 weeksover 2 weeks

Azathioprine - 50mg b.i.dAzathioprine - 50mg b.i.d

Watch for CandidiasisWatch for Candidiasis

PREVENTION OF PREVENTION OF RECURRENCERECURRENCE

Oral Pentoxyfylline : 400mg t.i.d-3mthsOral Pentoxyfylline : 400mg t.i.d-3mths

Colchicine- 0.5mg t. i. dColchicine- 0.5mg t. i. d S/ES/E: Myopathy, neuropathy, nausea,diarrhoa, : Myopathy, neuropathy, nausea,diarrhoa,

blood dyscrasias.Potent teratogenblood dyscrasias.Potent teratogen

DDS+ColchcineDDS+Colchcine

Prevention of recurrence Prevention of recurrence (contd..)(contd..)

Thalidomide 100mg t.i.d, tapering to Thalidomide 100mg t.i.d, tapering to 50mg /d as maintenance.50mg /d as maintenance.

Teratogenic, neurotoxicTeratogenic, neurotoxic STEPS-(System for Thalidomide STEPS-(System for Thalidomide

Education Prescribing Safety)Education Prescribing Safety) Other measuresOther measures: : Topical tacrolimusTopical tacrolimus Levamisole Levamisole

Points to ponderPoints to ponder

H.PyloriH.Pylori CMV,EBVCMV,EBV HandednessHandedness Glutein free dietGlutein free diet Non enzymatic AOsNon enzymatic AOs IontophoresisIontophoresis Detergents in toothpasteDetergents in toothpaste

SUMMARY

Stress avoidanceStress avoidance Soft tooth brushSoft tooth brush Supplements-BSupplements-B1212,folic acid,B,folic acid,B33,C,iron,C,iron Steroids with orabaseSteroids with orabase Local anaesthetic, tetracycline Local anaesthetic, tetracycline

mouthwashmouthwash Systemic steroids-severe casesSystemic steroids-severe cases

Summary (contd..)Summary (contd..)

Pentoxyfylline,Colchicine & Pentoxyfylline,Colchicine & Dapsone-severe relapsing patientsDapsone-severe relapsing patients

STEPS Assisted ThalidomideSTEPS Assisted Thalidomide