aphthous ulcers

1. RECURRENT APHTHOUS
STOMATITIS
PRESENTER: BHUPESH JOSHI
BDS 4TH YEAR
(5TH BATCH)
(First Phase)

2. CONTENTS
1. Definition
2. Etiology
3. Types
4. Clinical features
5. Presentation
6. Clinical types
7. Histopathology
8. Syndromes associated with aphthous ulcers
9. Differential diagnosis
10. Treatment
11. Conclusion
12. References

4. DEFINITION OF ULCER
•ANY BREACH IN THE CONTINUITY OF
THE EPITHELIUM OF THE SKIN OR
MUCOUS MEMBRANE TO INVOLVE THE
UNDERLYING CONNECTIVE TISSUE AS
A RESULT OF MICROMOLECULAR CELL
DEATH OF SURFACE EPITHELIUM OR
ITS TRAUMATIC REMOVAL.

5. DEFINITION
It is a common disorder
characterized by recurring
ulcers confined to oral mucosa
with no other signs of
systemic diseases.

6. ETIOLOGY
BACTERIAL INFECTION- an α-hemolytic streptococci, and
streptococcus sanguis play a significant role.
IMMUNOLOGIC ABNORMALITIES
Iron, vitamin B12, folic acid deficiency
TRAUMA- due to self –inflicted bites,oral surgical
procedures,tooth brushing,dental procedures,needle
injections,dental trauma
ENDOCRINE CONDITION-during premenstrual period and
at postovulation period.

7. ETIOLOGY
 Cessation of smoking increases the frequency and
severity of
RAS.
 Increased prevalence seen among children of RAS
positive
parents (HLA – B 51)
Acute psychological problems appear to precipitate the
attacks
of RAS.(more in examination; less in vacation)

8. CLINICAL FEATURES
•Age: second, third and fourth decades.
•Sex: Females>Males
•A higher prevalence has been found in the
higher socioeconomic groups and among
individuals with stress, such as students at
the time of examinations.

9. PRESENTATION
Ulcer begins as a
round or oval
area of erythema
Pin-point central
area of white
ulceration
Next 3-7 days
The ulcer enlarges
laterally
Becomes
saucerized or
cupped out.
As healing
commences
The erythematous
area diminishes
Small punctate red
areas dot the white
ulcer bed

10. CLASSIFICATION
Simple aphthous is described when
1. Ulcer recurrences are few
2. Not associated with systemic factors
3. Occur only 2–4 times each year.
Complex aphthous is described when
1. Develop recurrent oral and genital aphthous ulcers
2. When there is a continuous disease activity with new lesions
developing as older lesions heal
3. When ulcers are associated with systemic diseases.

11. CLINICAL TYPES:
RECURRENT APHTHOUS
MINOR
RECURRENT APHTHOUS
MAJOR
RECURRENT
HERPETIFORM
ULCERATIONS

12. AGE- 10-30yr
GENDER- women>men
SITE- common on non-keratinized mucosa e.g –
buccal & labial mucosa, buccal & lingual sulci,
tongue, soft palate, pharynx,gingiva.
APPEARANCE- begins as a single or multiple
superficial erosions covered by greyish – white
removable fibrinopurulent membrane encircled by
erythematous halo.

13. Number-1-6
SIZE- 2-3 mm to 10 mm in diameter.
Persist for 7-14 days & heal without scarring.

15. Previously it represent a separate disease entity k/n as
periadenitis mucosa necrotica recurrens (mikulicz’s
scarring aphthae or sutton’s disease)
It is now regarded as severe expression of aphthous
stomatitis.
 COMMON SITE- lips, cheeks, tongue, soft palate,
fauces, cause severe pain & dysphagia.
Also involve keratinized mucosa
INCIDENCE – common in HIV patient.
SIZE – Larger than the minor apthous ulcer diameter
more than 10mm.

16. NO.-1-10 in no.
Takes 4-6 weeks to heal.
Heal with scarring
Recurrs in less than a month time.
APPEARANCE- extend deeper and may present as
crater-like ulcers with rolled margins which are
indurated on palpation because of underlying fibrosis.

18. consist of clusters
resemble herpetic lesions.
HERPETIFORM
crops of ulcer
present
ULCERATIONS
• First described by Cooke in 1960 later by Lehner , Brooke
& Sapp
due to tendency to
reccur
RECURRENT

19. SITE- any intra oral site
SIZE-1-3 mm in diameter
APPEARANCE – characterized by crop of small, shallow
ulcers ,that may be joined together and form large
ulcer.
No. – 10 – 100
Healing occur in 1 to 2 weeks.
Heal with scarring.
Lesions persist for 1 to 3 year with short remissions

21. HISTOPATHOLOGY

22. SYNDROMES ASSOCIATED WITH
APTHOUS ULCERS
1. Behcet’s Syndrome
2. Magic Syndrome: Mouth and genital ulcers with
inflamed cartilage syndrome. It is a cutaneous
condition with features of both Behçet's disease and
relapsing polychondritis.
3. Cyclic Neutropenia

23. SYNDROMES ASSOCIATED WITH
APHTHOUS ULCERS
4. PFAPA Syndrome : Periodic fever, Aphthous stomatitis,
Pharyngitis and Adenitis
• high fever occurs periodically at intervals of about 3–5
weeks, frequently
• accompanied by aphthous - like ulcers
• pharyngitis
• and/or cervical adenitis (cervical lymphadenopathy).

24. DIFFERENTIAL DIAGNOSIS
• Recurrent herpes simplex infection
• Bednar’s aphthae
• Cyclic neutropenia
• Erosive lichen planus
• Stomatitis medicamentosa
• Squamous cell carcinoma

25. TREATMENT
• Tetracycline mouthrinse : Dosage 250mg per 5ml. It is
usually taken by diluting the tetracycline capsules in 5 ml
of water and is gargled in the mouth four times a day for
5 to 7 days.
This treatment produced a good response in nearly 70 %
of the Patients tested, by reliving the pain, reducing the
size of the lesions and reducing the healing time.

26. TREATMENT
• 5%Amlexanox is an anti- inflammatory, antiallergic used
to treat Recurrent Apthous Ulcers during prodromal
phases.
• It is applied on the Ulcer’s directly 3-4 times a day.

27. TREATMENT
• TRIAMCINOLONE a corticosteroid.
It is used to reduce swelling and ulcers in the mouth.
Applied 3-4 times a day on the ulcer.

28. TREATMENT
• Analgesic’s and Antiseptics such as Deltagel and
Quadragel which contain lignocaine hydrochloride
,metronidazole benzoate,menthol and chlorohexidine
gluconanate helps in reliving pain and help preventing
secondary infections.

29. TREATMENT
• Vitamin B12, Folic Acid Iron
• Not much of positive results are found with administration
of vitamin B12 in patients with Recurrent Apthous Ulcer’s.

30. TREATMENT
• Intralesional injection of steroid
– Triamcinolone acetonide (0.1-0.5 ml/l) or
– Betamethasone propionate and sodium phosphate
• Placing of gauze sponge containing topical steroids on ulcers in
cases of larger ulcers.

31. TREATMENT
• Drugs reported to reduce number of ulcers in selected
cases of major apthae:-
–Colchicine
–Pentoxifylline
–Dapsone
–Short bursts of systemic steroids
–Thalidomide

32. TREATMENT
• Surgical
– Laser surgery

33. CONCLUSION
Recurrent aphthous ulcers, or canker sores, are the most
common recurrent oral ulcers. There are three subtypes:
minor, major, and herpetiform. They appear as a yellowish
white round to oval ulcer with an erythematous halo. The
etiology of aphthous stomatitis is unknown. Bacterial,
autoimmune, allergic, and nutritional causes have been
suspected. Treatment is palliative, and the minor lesions
heal in 7-10 days without scarring. Major aphthae requires
2-4 weeks to heal and may do so with submucosal
scarring. Topical steroids offer some hope for long-term
management of recurrence.

34. REFERENCES
• Shafer’s textbook of Oral pathology -7th edition
• Burkets oral medicine-11th edition
• Textbook of Oral medicine Oral diagnosis and Oral
radiology-Ravikiran Ongole 2nd edition
• Textbook of oral medicine -Anil Govindarao Ghom 3rd
edition
• www.google.com

35. ACKNOWLEDGEMENT
Finally I would like to express my deep
honor to
– Dr Sartaj Singh Wazir ,MDS
–Dr Preeti Gupta ,Medical Officer
for your consistent guidance and support
during the phases of completion of this
seminar .