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APHTHOUS ULCERATION

APHTHOUS ULCERATION. Jennifer E. Guss, MD Baylor College of Medicine Med-Peds. APHTHOUS ULCERATION-THE FACTS. AKA: Recurrent aphthous stomatitis, aphthae, canker sores Definition:recurrent, painful ulcers of the mouth, round or ovoid in shape, with inflammatory halos

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APHTHOUS ULCERATION

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  1. APHTHOUS ULCERATION Jennifer E. Guss, MD Baylor College of Medicine Med-Peds

  2. APHTHOUS ULCERATION-THE FACTS • AKA: Recurrent aphthous stomatitis, aphthae, canker sores • Definition:recurrent, painful ulcers of the mouth, round or ovoid in shape, with inflammatory halos • Benign and localized condition that must be differentiated from oral ulcers occurring as part of systemic illnesses

  3. APHTHOUS ULCERATION:DDX • Behcet’s Syndrome • Gluten Sensitive Enteropathy • Inflammatory Bowel Disease • HIV • Cyclic Neutropenia • Trauma

  4. APHTHOUS ULCERS:MAKING THE DIAGNOSIS • How does the clinician differentiate between simple aphthous ulcers and other more serious conditions? • Medical History • Physical Exam • Labs only if the diagnosis is NOT consistent with Aphthous Ulcers in isolation

  5. EVALUATING THE PATIENT • H + P- most important to differentiate between Aphthous Ulceration and oral ulcers as part of a chronic and systemic disease. Ruling out a secondary cause is esp important if presentation is atypical, e.g. first outbreak in teen years. • Typical History:recurrent uclers, typical in appearance and shape(ovoid/round) in mouth since childhood. Possible fhx of aphthous ulcers.

  6. EVALUATING THE PATIENT • PE:typical-round and ovoid ulcers on buccal and labial mucosa, non-keratinized surfaces • Otherwise HEALTHY patient • Ulcers recur intermittently at varying intervals depending on the individual

  7. APHTHOUS ULCERS:CHARACTERISTICS • Three forms of Ulcers • 1.Minor • 2.Major • 3.Herpetiform

  8. APHTHOUS ULCERS:CHARACTERISTICS • 80% of ulcers Minor, i.e. 2-8 mm diameter • Affect nonkeratinized mucosa, usu labial and buccal mucosa, floor of mouth, ventral surface of tongue • Rarely occur on hard palate or gingiva • Heal spontaneously in 10-14 days

  9. APHTHOUS ULCERS:CHARACTERISTICS • Less common Major, >/= 1cm diameter, same locations as Minor • Third form, even less common “herpetiform ulceration”-ulcers which are initially multiple and pinpoint, may coalesce into single larger ulcers • Major and Herpetiform-pts seek medical care more frequently than for minor b/c: more painful, last several weeks, can affect dorsum of tongue, hard palate, buccal and lip mucosa

  10. APHTHOUS ULCERS:DEMOGRAPHICS • Female • Under 40 yo • Caucasions • Nonsmokers • High socioeconomic status • Affects up to 25% general population at some time

  11. ETIOLOGY • Unproven but some suggestions • Hereditary predisposition • Environmental • Vitamin and mineral deficiencies associated-iron, vitamin B, folate, supplements do not help • Infectious etiologies unproven • Are factors that increase risk of outbreaks in predisposed people: oral trauma, d/c smoking, emotional stress/anxiety, food sensitivities(food preservatives), hormonal changes related to menstrual cycle.

  12. EVALUATING THE PATIENT:CLINICAL SCENARIOS • 1.Oral Ulcers and persistant diarrhea • Crohn’s Dz or UC • 2.Weight loss, anemia, oral ulcers, and abdominal pain after eating wheat-rich meals • Gluten sensitive enteropathy • 3.Oral ulcers, genital ulcers, erythema nodosum, h/o uveitis • Behcet’s Syndrome

  13. EVALUATING THE PATIENT • 4.An otherwise healthy 20 yo woman has had recurrent painful oral ulcers for the past 10 years. She denies genital or anal ulcers, skin lesions, GI or joint problems. PE shows several ulcers, 3mm in diameter, all on her buccal mucosa. • Aphthous Ulcers or Cancker Sores

  14. EVALUATING THE PATIENT:MEDICATIONS CAUSING APHTHOUS ULCERS • NSAIDS • Beta-blockers • Fosamax • Patients may also have a drug rash • Ulcers should resolve with withdrawal of medication

  15. WHEN TO REFER • Any clinical situation that seems to be a chronic and systemic illness • Any ulcer persisting for more than 3 weeks needs to be referred for evaluation for cancer, or for other infectious etiology(usu CMV, HSV).

  16. APHTHOUS ULCER:TREATMENT • Multiple treatments available • Base choice on severity of pain, frequency of ulceration, potential of adverse effects of medications • Minor Ulcerations-less painful, goal should be prevention. • Avoid oral trauma-limit use of hard toothbrushes, avoid acidic foods and drinks which worsen pain and may precipitate ulcers. • OK to use topical analgesics though efficacy unproven e.g.lidocaine or bioadhesives e.g.carmellose. • Antimicrobial mouthwashes may be beneficial-Chlorhexidine containing(e.g.Peridex), or Triclosan containing(e.g.Plax)

  17. APHTHOUS ULCER:MAJOR OR PAINFUL ULCERS-TREATMENT • Topical corticosteroids may speed healing and reduce pain. BE CERTAIN the patient does not have oral candidiasis prior to using!! • FDA approved • 1% triamcinalone dental paste called Adcortyl or Kenalog in Orabase • Other stronger preps are not approved and may be harmful

  18. APHTHOUS ULCER:MAJOR OR PAINFUL ULCERS-TREATMENT • Topical antiinflammatories also FDA approved • 5% amlexanox paste(Aphthasol, Aphtheal) • Double blind controlled trial: applied BID x3d showed signif reduction in ulcer size on day 5 when compared to placebo • RCT: applied QID during prodromal phase vs once ulcer was evident. Use during prodromal phase decreased the liklihood of having an ulcer on d 3. Early tx also redued size, pain, and duration of ulcers as compared with late or no treatment tx.

  19. APHTHOUS ULCERS:TREATMENT OF RECURRENT AND SEVERE STOMATITIS • Option 1:systemic corticosteroids: Prednisone 30-60mg po daily for one week, then tapered over a second week. No data demonstrating better efficacy than topical steroids. • Option 2:Thalidomide:very toxic! Neurotoxicity and teratogen, so use as last effort. Not FDA approved for this indication. • Thalidomide 100mg po daily for 2 months. 45% of patients taking had fewer ulcers or none but only while taking tx, as compared with 3% given placebo.

  20. APHTHOUS ULCERS:TREATMENT RECS FROM U.S. NATIONAL GUIDELINE CLEARINGHOUSE • Take a thorough history: should be consistant with recurrent aphthous ulcers since childhood in an otherwise healthy patient • Do a good PE. Ulcers should be round or ovoid, have a red halo, be on oral mucosa only, esp non-keratinized surfaces such as buccal and labial • Rec:avoid irriants:oral trauma, acidic food/drink

  21. APHTHOUS ULCERS:TREATMENT RECS FROM U.S. NATIONAL GUIDELINE CLEARINGHOUSE • TX:first line:topical lidocane or protective bioadhesives • TX:second line:RCT support use of topical corticosteroids in a paste or 5% amlexanox paste for 2 weeks or until ulcers heal • All patients may benefit from mouth rinse like chlorhexidine gluconate which may speed healing and reduce pain • Repeat treatments PRN as ulcers recur

  22. BIBLIOGRAPHY • NEJM: 355/2 7/13/2006 Aphthous Ulceration, Crispian Scully, MD • NEJM:341/17 10/21/1999 Behcet’s Disease, Sakane, Takeno, Suxuki, et al.

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