Apthous-like Oral ulcers

Apthous-like Oral ulcers

1. Other syndromes

   • Reiter's
   • Crohn's disease
   • Coeliac

2. Recurrent Aphthous Stomatitis

   • Prevalence
     • 5-25%
   • Onset
     • Childhood/puberty
   • Presentation
     • Almost always on non-keratinised epithelium
     • Seen in healthy individuals
     • Ulcer with red ring (inflammation)
     • Painful, recurrent
       • Should occur every 3-4 weeks
     • Definition
       • Recurrant ulceration with no obvious cause
   • Types
     • Minor
       • 85%
       • 2-10mm
       • Last 7-14 days
       • 1-5 per crop
       • No scarring
       • Non-keratinised mucosa
     • Major
       • Scars
       • Non-keratinised mucosa
       • 10%
       • >10mm
       • 1-2 per crop
       • Lasts >14 days
     • Herpetiform
       • Scars
       • Can form on keratinised epithelium
       • 5%
       • <5mm
       • >10 per crop
       • Lasts 7-21 days
   • Unknown aetiology - idiopathic
     • Possible aetiological factors
       • B12/Folate
       • HIV
       • Genetic
       • Food allergy
       • Coeliac
       • Drugs
         • Nicorandil
         • Beta Blockers
         • NSAIDs
       • Local
         • Trauma
   • Diagnosis -> exclude other causes
     • Bloods
       • FBC
       • Ferritin
       • B12 / folate
     • Check for Viruses
     • Biopsy for major apthae
     • GI investigations
   • Management in practice
     • Minor RAS
       • Chx
         • 0.12% MW
         • 1% gel
       • 0.03% Gengigel
         • Hyaluronic acid
       • 2nd line
         • Topical steroid
           • Clobetasol in orabase
     • Exclude related diseases, treat precipitating factors
     • Major RAS
       • Topical steroid + Anti-fungal
       • 2nd line
         • Systemic steroids
     • Herpetiform RAS
       • Systemic steroids

3. Taking a history of a patient with ulcers

   • How often does it occur?
   • Family history?
   • Nutritional deficiencies?
     • GI
       • Coeliac?
   • Onset as a child/teenager?
   • Distributed on non-keratinised mucosa
   • Any problems with genitals or eyes?
     • Rule out Behcet's
   • Problem with skin?
     • Lichen planus
   • Drug history

4. Behcets

   • Gene
     • HLA-B51
   • Who does it affect?
     • Adult males
       • Mediterranean
       • Japan
     • Turkey
   • Differential diagnosis
     • Complex apthosis
       • Presence of CONSTANT >3 oral/genital apthae but no systemic manifestations
       • Diagnosis
         • Vit B12
         • Red cell folate
         • Ferritin
         • FBC
         • HLA-B27,B51
     • RAS
     • Erythema multiform
     • Reiter's syndrome
     • Syphilis
   • Management
     • Oral & Genital ulcers
       • Topical steroids
     • Oral & Genital ulcers + skin lesions
       • Colchicine = systemic immunosuppressant
         • 0.5-1.5mg/day
   • = oral ulcers + genital ulcers + eye inflammation (vasculitis)
     • Clinical features
       • Uveitis
       • Musculoskeletal disorders
       • Recurrent aphthous like ulcers
         • Genital
         • Oral
           • Usually major
           • More aggressive & in multiple sites > RAS
       • Skin lesions
         • Erythema nodosum
       • Chronic, good & bad phases
   • MAGIC syndrome = Behcets + Relapsing Polychondritis manifestations
   • Onset = 20-30yrs

5. Cyclic Neutropenia

   • = periodic decrease in neutrophils
     • Usually occurs every 3wks, lasts 3-5days
   • Onset = birth
   • Inherited disorder
   • Clinical features
     • Recurrent fever
     • Recurrent infections
     • Aphthous-like ulcers
     • Abdominal pain
     • Pharyngitis, gingivitis

6. PFAPA syndrome

   • Unknown aetiology
   • Clinical features
     • Recurrent fever
       • Occurs every 3-6wks, lasting 3-5days
       • Most common cause in european children
     • Aphthous-like ulcers
     • Pharyngitis