2- Patients with rrecurring oral

ulcer 1-Recurrent Aphthous stomatitis

A-Minor form

B-Major form

C-Herpetiform

2- Behcet’s disease

3- Recurrent herpes simplex virus infection

A-Recurrent intraoral herpes

B-Recurrent herpes labialis

Minor form 80% Herpetiform 10%

Aphthous ulcers

Major form 10%

Definition:- Painful, single or multiple recurring

ulceration, commonly affect the non keratinized oral

mucosa Prevalence:- the most common lesions of the mouth after

caries and periodontal diseases

Age:- childhood and teenagers. Sex:- Females more than males.

Site:- more in non keratinized mucosa and rare on keratinized mucosa

Types

Minor Aphthous ulceration

prodromal

features 24 hours

tingling and

burning

sensation

Erythematous

macule or

papules

Necrosis of

the covering

epithelium

Sloughing of

the necrotic

epithelium

Aphthous

Ulceration

Healing in

10-14 days by

epithelization

from the

margin with

no scar

Minor Aphthous ulcers

Chief complain Rate of recurrence

First:- very painful

due to tissue

destruction.

Later on:- 4-6 days,

discomfort due to

decreased tissue

destruction and the

ulcer had reached its

maximum size.

Frequent: every month

or every few months.

Infrequent:- once or

twice every year or

several years.

In some persons:- there

is no ulcer free period.

i.e. development of new

ulcers during the healing

of the previous ones.

Major Aphthous ulceration

(periadenitis mucosa necrotica recurrence)

prodromal features

fever, headach,

maliase and

regional

lymphadenopathy

Erythematous

macule or

papules

Necrosis of

the covering

epithelium

Sloughing of

the necrotic

epithelium

Aphthous

Ulceration

Healing after few

months with scar

due to destruction

of the deep tissues.

A cobblestone

appearance due to

continuous recurrence

and multiple scaring

Major Aphthous ulcers (periadenitis mucosa necrotica recurrence)

Chief complain Rate of recurrence

@ Interference with

mobility of tongue

and uvula.

@ Difficulty in eating

and swallowing. This

due to:-

• deep destruction.

• slow healing.

•Scar formation.

The lesions may last for

few months, with

tendency to form

elevated margin for the

ulcer.

So; it may be mistaken

as a malignant ulcer.

N.B. several minor ulcers may coalesce

to form larger ulcer more than 1cm but

in this case isn't considered to be MAU

Major aphthous ulcers Minor aphthous ulcers

solitary or multiple 1 - 6 Number

any where especially soft

palate & tonsillar areas

Common on non

keratinized mucosa

Rare on keratinized

Sites

Irregular Rounded (lip and cheek)

oval(vestibules) Shape

larger than 1 cm less than 1 cm Size

leave scars formation healing without scarring Scar formation

lymph nodes enlargement No lymph nodes

enlargement lymph nodes

Deeper in C.T, minor

salivary glands, facial

muscles

shallow Depth

Raised due to edema, shiny

and erythematous

Slightly raised, regular and

erythematous Margins

Covered by gray slough Covered by grayish or

yellowish white fibrinous

exudate

Floor

Indurated Non indurated Base

The least common variant of RAS. Not preceded by vesicles as HS

Multiple (dozen) Number

Tiny pinhead sized (1 – 2mm) may coalesce forming larger ulcer. Size

Extremely painful, interfere with eating and speaking Chief Complaint

Non keratinized mucosa,

Tongue (lateral margin and tip)

Floor of the mouth.

Site

Quicker than MAU and MiAU, without scar healing

The whole cycle takes 3 -4 days with the development of new crops,

the whole cycling pattern takes 2 weeks.

duration

Frequent:- development of new set of ulcers that overlaps the

previous group.

Spontaneous remission:- occurs after 5 years.

Recurrence Rate

Herpetiform Aphthous Ulceration

Histopathological features

• Preulcerative stage:- T4 lymphocytes

accumulates in submucosa and around

blood vessels.

• Ulcerative stage:-

@ T8 begin to dominate.

@ Extravasation of RBCs and neutrophils.

@ Mast cells and macrophages are present

in the ulcer base.

Etiology • Although the primary cause is unknown RAU may

be attributed to:-

1- Hereditary

Factors:-

• Occur more

frequently in

related persons.

•Frequent

association with

MHC class II.

2- Immunological factors:-

A- Cell mediated cytotoxic reaction; these

reactions are against oral epithelial cells.

Mediated by neutrophils, natural killer

cells and T-cytotoxic cells.

B- Alteration of Ts/Th cells ratio.

C- Local immune complex reaction:-

antigen +antibody deposited around blood

vessels and activate the complement.

3- Aphthous ulcer may be

associated with :

A- Hematological deficiencies,

deficient folate, Vit.B12,

zinc, iron and deficiency in

circulating neutrophils.

B- GIT diseases:- ulcerative

colitis and Crohn’s disease.

C- Allergic factors:- atopy, drug

and food allergy.

D- Behcet’s disease.

E- AIDs.

F- FAPA syndrome in children

less than 5 years

4- Recurrence

precipitated by:-

A- Trauma.

B- Hormonal changes;

decreasing oestrogen and

increasing progesterone.

During menstruation,

ulcers fall during

pregnancy and

exacerbated during

menopause.

C- Emotional factors:-

increased incidence

during examination

Treatment of RAU

1- RAU secondary to systemic disease:-

As:- @ Chronic inflammatory bowel diseases.

@ Cyclic neutropenia.

@ Behcet’s disease.

@ FAPA syndrome.

@ Aids.

@ Iron and Folate deficiency.

Treatment of the underlying systemic disease.

Treatment of RAU

2- RAU unrelated to systemic disease:-

The treatment is directed toward controlling

rather than curing of the lesion.

First step;- is patient education regarding

the:-

@ Nature of the disease.

@ Clinical course of the disease.

@ Recurrence.

@ Aim of the drug prescribed.

Treatment of RAU

2- RAU unrelated to systemic disease:-

Second step;- active treatment of the ulcers

A- Corticosteroids:-

1- Topical steroids:-

Used for 2 months

(for MAU) used as

mouth bath or

aerosol.

With antifungal drug

one week out of every

4 weeks

2- Short course

systemic steroids

(for MAU):- 20-

40mg predisone

1.5hrs after arising

as single dose for 5 -

7 days reduced to

10-20mg over the

next few days

3- Intralesional

injection of

steroid:- ulcer

resistant to healing

for 5-7 days.

10-20mg injectable

triamcinolone

acetonide diluted to

0.5-1ml with 2%

lidocain, used 2-

3times/week

1) Topical corticosteroids Start with weak preparations

hydrocortisone hemisuccinate lozenges 2.5 mg q.d.s.

0.1% triamcinolone ointment in

orabase q.d.s

0.1% - 0.2% triamcinolone

acetonide mouth wash

Mouth rinse, prepared by the pharmacist from injectable triamcinolone

acetonide and distilled water. The patient is advised to use 5ml as mouth rinse

q.d.s.

this provides:-

* ease of use

* wide spread

*effective application compared with cream or ointments or lozenges.

4- betamethasone 0.1 mg lozenges q.d.s.

5- Betamethasone valerate

aerosol

effective in mild cases

All topical corticosteroids should be applied four times per day

after meal time and at bed time and to take nothing by mouth for

at least one hour after application of the drug

2) systemic corticosteroids

High dose (20 - 40 mg) of

prednisone given as a single

dose daily 1.5 hour after

arising for 5 – 7 consecutive

days, followed by 10 – 20 mg

1.5 hours after arising every

other morning for additional 2

weeks.

short course of systemic

steroid to supplement the

topical steroid specially in

case of ulceration.

3- intralesional steroid injection:-

Used in resistant ulcers.

2-3 injections weekly starts 5-7 days after topical or systemic steroid therapy.

10 – 20 mg of injectable triamcinolone acetonide diluted to 0.5 – 1 ml with lidocaine 2% because steroid injection is very painful.

Treatment of RAU

2- RAU unrelated to systemic disease:-

Second step;- active treatment of the ulcers B- Tetracycline mouth bath:- C- the dentist should avoid

D- the patient should avoid

Tetracycline + nystatin

(Mysteclin capsules)

or Tetracycline +

amphotericin (Mysteclin

syrup); dissolved in 5ml of

water/3minutes/t.d.s better to

be followed by topical steroids.

The best line for treatment of

herpetiform AU

Using silver nitrate, phenol and

other caustics in treatment of

aphthous ulcer, this will relief pain

but it delay healing and enhance

healing with scar.

Consuming irritating

substances , it causes pain

Summary of treatment of RAU

A- Mild to moderate cases:- B- Severe cases:-

D- the patient should avoid

1- Analgesic before eating to

releif pain, lidocain gel, or

benzydamine hydrochloride as

mouth bath.

2- Ora base (sodium carboxy

methyl cellulose), topical

steroids, chlortetracycline

mouth bath/after eating and bed

time.

3- Short course of non-steroidal

anti-inflammatory drug as adjunct.

1- Chloretetracycline mouth

bath followed by potent

topical steroid after eating and

at bed time.

2- Systemic corticosteroid.

3- Intra-lesional injection of

steroids.

4- Dapsone may be tried in

Major AU.

iii-Dapsone:- (Malaria, pneumocystis

carinii and leprosy)

Used in severe bullous – erosive lesions.

Control T lymphocyte mediated process.

Modulates the release of inflammatory chemotactic factors from mast cells or neutrophils.

Treatment

1- Treatment of under lying systemic diseases

2- Corticosteroids:

a- Systemic b- Topical

3 -Tetracycline mouth bath.

4-Dentist should avoid irritating substances as

phenol.

5-Patient should avoid citrus fruits & spiced food.