case presentation 4 RECURRENT APTHOUS STOMATITIS (2).pptx

recurrent apthous stomatitis

1. 1 CASE PRESENTATION Dr. Nitha Willy First Year PG Department Of Oral Medicine And Radiology

2. 2 BIOGRAPHIC DATA Name : Augustin Reji Age :21 Sex :Male Occupation :Student Address : Alukkal (H), Karayamparambu O P No :165274 Phone no: 8330819451

3. 3 CHIEF COMPLAINT Patient complaints of a painful ulcer in mouth since 4 days.

4. 4 HISTORY OF PRESENTING ILLNESS History reveals ulcer in left mucosa since 4 days associated with pain which is intermittent, and pricking type. The pain is exacerbated by movement of the area affected by the ulcer and also aggravates on having hot and spicy food and relief is obtained when mouth is rinsed with cold water . The patient swished mouth with buttermilk and turmeric and saline rinses, and no relief obtained .

5. 5 Patient gives a history of frequently forming single ulcer, once in three months since one year in different areas in mouth which heals within three to five days when patient swishes mouth with buttermilk and turmeric and saline rinses. Patient is unaware of the onset of ulcer occurs and the initial size of ulcer. Patient has mainly noticed the ulcer during the time of exams and work submission deadlines. Patient is aware about ulcer only when pain occurs.

6. 6 MEDICAL HISTORY No history of previous serious illness childhood diseases hospitalization/operations injuries to head and neck

7. 7 DRUG ALLERGY No allergy to medications No allergic reactions in general

8. 8 REVIEW OF SYSTEMS CNS: No abnormalities reported GIT: No abnormalities reported Respiratory system: No abnormalities reported CVS: No abnormalities reported Endocrine system: No abnormalities reported Genitourinary system: No abnormalities reported

9. 9 PAST DENTAL VISIT Patient visited a dentist in a private dental clinic for similar problem five months back and patient was prescribed dologel ointment for topical application .

10. 10 PERSONAL HISTORY Marital status: Unmarried Sleep and appetite: Normal Bowel and bladder movements: Regular Diet: Mixed Oral hygiene: Brushes twice daily using toothpaste and toothbrush No deleterious and parafunctional habits noticed

11. 11 FAMILY HISTORY No history of genetic or hereditary diseases.

12. 12 GENERAL PHYSICAL EXAMINATION Patient was conscious, co-operative and well oriented with person, place, time. Gait: steady gait Built: moderately built Nourishment: moderately nourished Temperature: 37 ͦ C Pulse rate:72 beats/minute

13. 13 Respiratory rate: 16 breaths/minute Blood pressure: 110/80 mm Hg No Pallor, No Icterus, No Cyanosis, No Clubbing, No Edema And No Lymphadenopathy Height: 5 ft 3 in Weight: 55 kg

14. 14 LOCAL EXAMINATION OF HEAD AND NECK Extra oral examination Head : Mesencephalic Hair : No abnormalities detected Face :Apparently symmetrical Skin : no abnormalities detected Eyes : no abnormalities detected

15. 15 Ears : no abnormalities detected Nose: no abnormalities detected Lips :competent Finger and nails: normal TMJ : Mouth Opening Within Normal Limits, No Deviation, No Clicking, No Crepitus Muscles of mastication : non-tender Lymph nodes : not palpable Cranial nerve examination: no abnormalities

16. 16 INTRA ORAL EXAMINATION Soft tissue examination Labial mucosa: no abnormalities detected Labial vestibule: no abnormalities detected Buccal mucosa: On left buccal mucosa, a single ovoid ulcer with yellowish pseudomembrane and erythematous halo. Buccal vestibule: no abnormalities detected. Gingiva : coral pink color, scalloped contours with knife edge margins, stippling present, gingiva is firm and resilient.

17. 17 6. Bleeding on probing: absent 7. Periodontal pocket: absent 8. Tongue: no abnormalities detected Floor of mouth: no abnormalities detected Frenal attachment : mucosal attachment of frenum Palate: no abnormalities detected Oropharynx: no abnormalities detected Salivary gland orifices: no abnormalities detected

18. 18 HARD TISSUE EXAMINATION Number of teeth : 32 Carious teeth : 27 and 17 Missing teeth : 48 Root stump: 0 Restored tooth: 0

19. 19 Fractured tooth: 0 Mobility : 0 Attrition : nil Calculus : ++ Stains: + Tenderness on percussion : nil

20. 20 ON INSPECTION An irregular ovoid ulcer of approximate size 0.5*0.6 cm seen on left buccal mucosa with yellowish pseudomembrane on the floor and surrounded by erythematous halo. The ulcer is seen along the occluding line in relation to 34, 1.5 cm posterior to retrocommissure of left lips

21. 21 ON PALPATION Non tender No induration No bleeding No pus discharge

22. 22 CASE SUMMARY A 21 year old male patient reported to our department with chief complaint of a painful ulcer in mouth since 4 days . History reveals painful ulcer in left mucosa since 4 days and pain is intermittent, pricking , the pain is exacerbated by movement of the area affected by the ulcer aggravating on having hot and spicy food and relief obtained when mouth is rinsed with cold water. Inspite of swishing mouth with buttermilk and turmeric and saline rinses , the ulcer was not healed this time. Patient also gave a history of frequently forming single ulcer, once in three months in different areas in mouth which heals within three to five days when patient swishes mouth with buttermilk and turmeric and saline rinses.

23. 23 On inspection , an irregular ovoid ulcer of approximate size 0.5*0.6 cm seen on left buccal mucosa with yellowish pseudomembrane at the floor and erythematous halo . The ulcer is seen along the occluding line in relation to 34 and 1.5 cm posterior to retrocommissure of lips. On palpation , non tender , no induration , no bleeding, no pus discharge

24. 24 PROVISIONAL DIAGNOSIS MINOR RECURRENT APTHOUS ULCER

25. 25 CRITERIA FOR RECOGNIZING AND DIAGNOSING THE CONDITION AS RAU MINOR External appearance : Single oval shaped ulcers, never preceded by vesicles . The ulcers are shallow and have a yellow–grey base surrounded by thin erythematous halos. Size less than 1 cm in diameter . Age at onset : The first RAU attack started before the age of 20 year Location of ulcers : Occur on non-keratinized oral mucosa. Duration of the lesion : ulceration lasts from a few days to two weeks. Pattern of recurrence :Irregular

26. 26 Presence of a precipitating fact or :The attacks are triggered by stress . Negative association with smoking : RAU patient is a non-smoker Recurrence : At least three attacks of RAU within the past 3 years and the recurrences do not affect the same focal site . Mechanical hyperalgesia : The lesion is painful and the pain is exacerbated by movement of the area affected by the ulcer. Self-limitation of the condition : The ulcer heals spontaneously without sequelae either with or without treatment.

27. 27 DIFFERENTIAL DIAGNOSIS Traumatic ulcer Viral stomatitis Cyclic neutropenia Behcet’s disease

28. 28 INVESTIGATIONS Complete blood count Serum ferritin Serum iron Total iron binding capacity Vitamin B12

29. 29 TREATMENT PLAN Tab Zincovit (Multivitamin and multimineral with grape seed extract) 1-0-0* 30 days composition: Vitamin A: 5000IU , Vitamin D3:400 IU , Vitamin E: 15mg , Thiamine Nitrate : 10 mg, Riboflavin:10 mg, Pyridoxine Hydrochloride: 2 mg, Cyanocobalamin:7.5mcg , Nicotinamide :50 mg, Calcium Pantothenate : 10 mg, Ascorbic acid:75 mg, Magnesium Oxide: 30 mg, Manganese Sulphate :2.8 mg, Copper Sulphate Pentahydrate :2 mg, Zinc sulphate Monohydrate :63 mg, Selenium Dioxide:70 mcg Topical application : Chlorogesic M ointment ( Chlorhexidine gluconate 1 %, Metronidazole 1%, Lignocaine Hydrochloride 2% ) - 1-1-1* five days Review after 5 days

30. 30 DISCUSSION

31. 31 Aphthous Greek word Aphtha Ulcer First valid clinical description by von Mickuliz Most common disease of oral mucosa Children and women are commonly affected Common age : 10- 19 years

32. 32 Ulcer is defined as a deeper crater that extends through the entire thickness of surface epithelium and involves underlying connective tissue . Recurrent aphthous stomatitis is an ulcerative disease of oral mucosa presenting as painful round, shallow ulcers with well defined erythematous margin and yellowish-grey pseudomembranous center .

33. 33 Etiologic factors associated with recurrent aphthous stomatitis Local Trauma , smoking , dysregulated saliva composition Microbial Bacterial: streptococci , Viral: Varicella Zoster, cytomegalovirus Systemic Behcet disease,magic syndrome,crohn disease , ulcerative colitis , HIV infection ,PFAPA syndrome, cyclic neutropenia, stress , psychological imbalance , menstrual cycle Nutritional Gluten-sensitive enteropathy ,iron , folic acid, zinc deficiencies , Vitamin B1,B2,B6,B12 deficiencies Genetic Ethnicity , Human Leukocyte Antigen Halotypes Allergic/immunologic Local T-lymphocyte cytotoxicity , abnormal CD4: CD8 ratio, dysregulated cytokine levels, Microbe induced hypersensitivity , Sodium lauryl sulfate sensitivity , food sensitivity others Antioxidants , NSAIDS , Beta Blockers, Immunosuppressive drugs

34. 34 STAGES OF APHTHOUS ULCER: Stage 1: Prodromal : symptoms but without any visible clinical sign. Stage 2: Pre-ulcerative : initial presentation, usually erythema and slight oedema. Stage3: Ulcerative: formation of the epithelial defect. Stage4: Healing: symptom abatement and progressive healing. Stage5: Remission: no evidence of lesions

35. 35 Phase 2: PRE-ULCERATIVE STAGE: Damage to the epithelium usually begins in the basal layer and progresses through the superficial layers. The presence of extravasated erythrocytes around the ulcer margin, subepithelial extravascular neutrophils, numerous macrophages loaded with phagolysosomes, and the nonspecific binding of stratum spinosum cells to immunoglobulins and complements as a result of vascular leakage and passive diffusion of serum proteins causing erythema.

36. 36 Generation of T cells, and production of TNF- α . Secrete high amount of TNF- α TNF- α -mediated endothelial cell adhesion neutrophil chemotaxis initiate the cascade of inflammatory processes ulceration . Phase 3: ULCERATIVE PHASE

37. 37 Important effector cells participating in the inflammatory events of RAU NEUTROPHILS : marked concentration of neutrophils seen in ulcerative phase human neutrophil- type matrix metalloproteinase-8 (MMP-8 ): intracellularly in the ulcer area and extracelluraly in the area of basement membrane lateral to the ulcer MACROPHAGES : mainly function to clear the tissue of neutrophil remnants . MAST CELLS : activation and degranulation in site of RAU

38. 38 GAMMA /DELTA T LYMPHOCYTES have the ability to recognize non-peptide molecules commonly associated with micro- oraganisms and stressed cells. Commonly seen in the peripheral blood affected by RAU during the active phase of the disease. CYTOKINES : high plasma levels of IL-2 and a significant increase in IL-2 receptor expression by activated peripheral lymphocytes .

39. 39 Phase 4: HEALING PHASE Finally there is healing with epithelial regeneration A whitish membrane or layer may develop over the ulcer as part of the healing process . This membrane is often composed of fibrin, dead cells, and other debris, and it is a natural part of the healing response.

40. 40 Classification of RAS Minor Recurrent Aphthous Stomatitis / Mikulicz Ulcer Major Recurrent Aphthous Stomatitis/ Sutton’s Ulcer / Periadenitis Mucosa Necrotica Recurrens Herpetiform Ulceration

41. 41 Classification based on the nature of recurrence: Simple apthosis : recurrence occurs 2-4 times a year Complex aphthosis : continuous throughout the year with newer lesions developing as older lesions heal Classification based on the frequency of recurrence: Type A : RAS episodes lasting a few days with tolerable pain and few occurrences a year Type B : Painful RAS lasting 3-10 days with recurrence every month Type C : chronic painful course with disease activity almost continuous throughout the year

42. 42 CLINICAL FEATURES OF RAS Character Type Of RAS Minor Major Herpetiform Peak Age of Onset Second First and second Third Number of Ulcers 1-5 1-3 5-20 Size of Ulcers 2-5 mm >10 mm <5 Duration , Recurrence rate 7-14 days, 1-4 months 2 weeks- 3 months , <1 mon 7-14 days, < 1 month Healing with Scarring No Yes No Site Non keratinized mucosa especially labial/buccal mucosa. Dorsum and lateral borders of tongue Keratinized and non-keratinized mucosa , particularly soft palate Non keratinized mucosa but particularly floor of the mouth and ventral surface of the tongue Percentage of all aphthae 75-85 10-15 5-10

43. 43 DIAGNOSTIC CLASSIFICATION OF A CLINICAL ULCER 1 )Short Term Ulcer : those that persists no longer than three weeks and regress spontaneously or as a result of nonsurgical treatment. 2) Long Term Ulcer : those that lasts for weeks and months .

44. 44 Short term ulcers Traumatic ulcer RAU,RIHS and herpetiform ulcers Ulcer occurring as a result of odontogenic infection Ulcer occurring as a herald lesion of generalised mucositis or vesiculobullous disease Ulcer secondary to noninfectious systemic disease

45. 45 Long term ulcer Major aphthous ulcer Squamous cell carcinoma Ulcer secondary to systemic disease Ulcer in HIV disease Traumatized tumor that doesnot usually ulcerate Low grade mucoepidermoid tumor Metastatic tumor Keratoacanthoma Necrotising sialometaplasia Systemic mycosis Chancre Gumma

46. 46 Management of Recurrent Aphthous Stomatitis The basic protocols for the management is Pain relief Maintenance of normal function Reduction of ulcer duration and recurrence

47. 47 Lifestyle modification : Vitamin supplements Iron deficiency supplements Dietary changes Maintenance of good oral hygiene Use of Sodium Lauryl Sulfate free toothpaste Safety during dental treatment and appliance correction Aloe vera

48. 48 Topical Therapy : Topical Anaesthetics : 1% lidocaine cream 2% lidocaine gel/spray used alone or, in combination with adrenaline (1:8000), benzocaine lozenges polidocanol paste spray combining tetracaine 0.5% and polidocanol 0.1% Diclofenac 3% gel combining with 2.5% hyaluronic acid directly applied on the ulcer can relief the pain and prolong the remission period making the patient comfortable to eat and drink.

49. 49 B . Mouthwashes : Chlorhexidine Gluconate : 0.2% Chlorhexidine gluconate as an aqueous mouth rinse 0.1% Chlorhexidine gluconate as mouthwash 1%Chlorhexidine spray/gel Chlorhexidine in combination with dexpanthenol spray , solution and tablets is effective, too . ii . Listerine : Regular use . Listerine can produce prolong recurrence period of RAS. iii . Tetracycline and Minocycline Mouthwashes : Tetracycline has antibacterial effect and minocycline has immunological regulatory property . 0.25 % chlortetracycline containing mouthwash produces healing but 0.2% minocycline containing mouthwash is way too effective than tetracycline mouthwash .

50. 50 C .Topical Corticosteroids : Triamcinolone oral paste Dexamethasone Phenytoin 0.05 % Clobetasol Propionate produces rapid healing and pain relief from ulceration and treatment of choice in RAS when previous treatment regimens fail. Long term use of these steroids can give rise to candidal infection .

51. 51 D . Intralesional Corticosteroids : Use of topical anaesthetic prior to submucosal application of 0.1-0.5 ml of triamcinolone acetonide intralesional injection can reduce inflammation and pain. E. 5% Amlexanox Hydrochloride oral Cream: 5% Amlexanox Hydrochloride formulation can produce rapid healing by re-epithelialization of the epithelial breaching in ulcerative oral mucosa , thus reproducing epithelial integrity . 3-4 times application daily can reduce the pain and can make the patient comfortable for normal oral functions .

52. 52 Systemic Therapy : Colchicine: Daily use of 0.5–2 mg of colchicine can help in reducing RAS recurrence episodes but the optimal dose of 1.5 mg daily seems to be accurate for healing. If colchicine alone can’t produce significant healing , benzathine penicillin adjuvant therapy is proven to be more outstanding. The use should be continued otherwise discontinuation can bring up the recurrence.

53. 53 B . Pentoxifylline : Pentoxifylline is proven to inhibit TNF-α production . 3 times daily use of 300-400 mg of pentoxifylline can reduce the pain and recurrence episodes. C . Systemic Corticosteroid Therapy : Daily dose of oral corticosteroid , prednisolone 10–30 mg orally can be taken not more than a month OR 40-60 mg single dose in the morning for not more than 2 weeks D . Other Systemic Agents : daily dose of antimicrobial drug : 40 mg of doxycycline daily dose of 300 mg of zinc sulfate

54. 54 Immunomodulatory drugs(steroid sparing drugs): Levamisole- 150 mg bid for 5 days Dapsone- 100 mg/day for 5 days Azathioprine-50 mg/day for 5 days

55. 55 LASER THERAPY Mechanism of action

56. 56

57. 57 New Treatment Strategies for the treatment of RAS

58. 58