Aphthous ulcer-oral medicine and radiology.pptx

aphthous ulcer

1. Aphthous ulcer Dr Sinitha Sreedhar Dept of oral medicine & radiology

2. Introduction Most common inflammatory ulcerative condition of the oral cavity From greek word “ Aphthae ” = ulcer Also called canker sores

3. Definition Acute, single/multiple, recurrent, small, round or ovoid ulcers with circumscribed margins , erythematous haloes and yellow or grey floors typically presenting first in childhood or adolescence

4. Epidemiology Female predominance Higher among professional–school students: stress during student life Children with RAS positive parents have a 90% chance of developing RAS

5. Etiology Genetics – HLA-A2, HLA-B5, HLA-B12, HLA- B44, HLA-B51, HLA-B52,HLA DR2,HLA-DR7 and HLA-DQ series Local factors Trauma – edema – early cellular inflammation associated with an increased viscosity of the oral submucosal extracellular matrix Changes in salivary composition– pH, stress induced rise in salivary cortisol Microbial factors Bacterial : streptococci Viral : varicella zoster, cytomegalovirus

6. Systemic diseases Behcet’s syndrome MAGIC syndrome Sweet’s syndrome PFAPA syndrome Cyclic neutropenia Crohn’s disease HIV Disease Allergic factors Hypersensitivity to Food substances : chocolates, coffee, peanuts, cereals, almonds, strawberries, cheese, wheat flour Oral microbes such as Streptococcus Sanguis Microbial heat shock protein Sodium lauryl sulfate

7. Behcet’s syndrome Results from vasculitis of small and medium sized vessels and inflammation of the epithelium Usually affects adults Abnormal inflammation is caused by immune complexes induced by T-lymphocytes and plasma cells Multisystem disorder with RAS like ulcerations, recurrent genital ulcerations , cutaneous disease ( papulo pustular lesions or erythema nodosum ), ocular disease(posterior uveitis ) and a range of other gastrointestinal, neurological, renal,joint , and hematological abnormalities

8. MAGIC Syndrome Varient of Behcet’s syndrome which includes relapsing polychondritis ---mouth and genital ulcers with inflammed cartilage Sweet’s syndrome Also termed as acute neutrophilic dermatosis Superficial ulcerations with sudden onset of fever, leucocytosis , well-demarcated cutaneous , plum coloured papules or plaques. In 50% of patients, associated malignancy. Middle aged females PFAPA syndrome Periodic fever , aphthae like oral mucosal ulceration, pharyngitis , and cervical adenitis. Occur in young children and self-limiting and non-recurrent

9. Immunologic factors Local T- lymphocytes cytotoxicity Abnormal CD4:CD8 ratio Dysregulated cytokine levels Nutritional factors Iron, folic acid , zinc deficiencies Vitamin B1, B2,B6 and B12 deficiencies Gluten- sensitive enteropathy Psychological stress Antioxidants such as SOD and catalase seen higher levels in patients with RAS

10. Clinical features Prodromal symptoms of tingling or burning sensation 2-48 hrs before Intervals of a few months to a few days Erythema – papule – ulcerates – enlarges Round, symmetric, shallow, no tissue tags Confined to oral mucosa Minor Major Herpetiform

11. Differential diagnosis Traumatic ulcer Herpetic gingivostomatitis EM minor

12. Histopathology A fibrinopurulent membrane covering the ulcerated area Intense inflammatory cell infiltration is present in connective tissue beneath the ulcer Granulation tissue near base of the lesion Presence of Anitschkow cells – cells with elongated nuclei containing a linear bar of chromatin with radiating processes of chromatin extending towards the nuclear membrane

13. Management Removal of predisposing factor Topical corticosteroids Triamcenolone acetonide 0.1% Clobetasol 0.05% Topical anesthetics- Benzidamine hydrochoride mouthwash Topical H2 blocker – Rebamipide Topical anti inflammatory and antiallergic – Amlexanox paste Systemic corticosteroids – Prednisolone 60mg Immunosuppressants – Dapsone 100 mg Systemic immunomodulators – Cyclosporine 1.25 mg/kg upto 4 mg Topical immunomodulatory drugs Cyclosporine cream 0.05 % 5 amino salicylic acid Alpha-interferon Topical antibiotics – Tetracyclins mouthwashes Antimicrobial – Chlorhexidine cream Laser therapy