Aphthous Ulcer

Information about Aphthous Ulcer

Published on July 14, 2014

Author: sunnieludhwani

Source: authorstream.com

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Aphthous Ulcer - The “Orphan” disease: Aphthous Ulcer - The “Orphan” disease Introduction: Introduction Ulcers is a defect in the epithelium; it is a well-circumscribed depressed lesion over which the epidermal layer has been lost. ( Burkit ‘s Oral Medicine 10 th edition) The term “ aphthous ” originated with Hippocrates as far back as 460–370 BC in reference to disorders of the mouth. In general usage, the word “ aphthae ” refers to the presence of an otherwise undefined ulcer. Prevalence: Prevalence In Indian Population, patients in the third (20.7%) and fourth (26.5%) decade were most commonly affected. Females (56.3%) were more commonly affected than males (43.7%) A higher prevalence has been found in the higher socioeconomic groups and among individuals with stress, such as students at the time of examinations. Prevalence of recurrent aphthous ulceration in the Indian Population; J Clin Exp Dent. 2014;6(1):e36-40. Classification: Classification The clinical presentations of RAS include Minor, Major, Herpetiform aphthae Based on severity Simple aphthous is described when ulcer recurrences are few and not associated with systemic factors and occur only 2–4 times each year. Complex aphthous is a disorder in which patients develop recurrent oral and genital aphthous ulcers or when there is a continuous disease activity with new lesions developing as older lesions heal, or when ulcers are associate with systemic diseases. Rogers RS. Complex aphthosis . Adv Exp Med Biol. 2003;528:311–316 based on severity and they are associated with systemic factors. Classification: Classification To determine management strategies, it is classified as Type A- RAS episodes lasting for only a few days, occurring only a few times a year. Type B- Painful RAS each month, lasting between 3-10 days Type C- Painful, chronic courses of RAS in which by one ulcer heals, another develop Crispian S cully, The Diagnosis and man agement of recurrent aphthous ulcer; Dentistry & Medicine Minor Aphthous: Minor Aphthous MILD APTHAE, CANKER SORE & MIKULICZ APTHAE Minor aphthous ulcers are the most commonly encountered form. This type usually appears as a (one to over 100) painful, oval ulcer, 2-3mm to 10mm in diameter, that is covered by a yellow fibrinous membrane and surrounded by an erythematous halo Minor ulcers typically involve movable and non keratinized oral mucosa , principally the mucosa of the cheek, lip, floor of mouth, ventral and lateral surface of tongue. The prodromal stage of ulceration is variable, but there is usually a sensation described as “burning” or “prickling ” and “ white papule” for a short period before the ulcers appear Each lesion lasts 10–14 days and heals without scarring . MAJOR APTHOUS: MAJOR APTHOUS PERIADENITIS MUCOSA NECROTICA RECURRENTIS OR SUTTON DISEASE OR MIKULICZ SCARRING APTHAE Major ulcers have an irregular border and a size exceeding 10 mm. These lesions are deeper and larger and they last longer than minor aphthae . They persist longer than minor aphthae and can last for weeks or months and often leave a scar after healing . These lesions cause substantial pain associated with fever, dysphagia , and malaise. They have a predilection for the posterior part of the month, particularly the soft palate and pharyngeal wall or tonsillar fauces HERPETIFORM : HERPETIFORM First described by Cooke in 1960 later by lehner , brooke & sapp Herpetiform aphthae are the least common type comprising about 10% of occurrences. This variety is characterized by multiple recurrent crops of 10 or more (as many as a hundred ulcers may be present at the same time) small ulcers of 2–3 mm in diameter, although they may fuse producing large irregular ulcers. This tendency to coalesce is similar to what is seen in viral infections, thus, the term herpetiform and the subsequent confusion. The herpetiform type, like the other forms of RAS, occurs usually on mobile mucosa and not on attached mucosa like a true herpes infection. RAS Associated syndrome: RAS Associated syndrome Behcet’s Syndrome Magic Syndrome Cyclic Neutropenia Pfapa Syndrome Sweets Syndrome Aids Journal of Research in Medical and Dental Science, Vol. 1;Issue 2, October – December 2013 Pre Disposing Factor: Pre Disposing Factor PowerPoint Presentation: Etiopathogenesis of Recurrent Aphthous Stomatitis and the Role of Immunologic Aspects: Literature Review Investigation: Investigation Vivek , bindhu , nair ; Recurrent apthous stomatitis Current concept in diagnosis & Management; JIAOMR, july-sept , 2011 PowerPoint Presentation: C. Scully, S. Porter / British Journal of Oral and Maxillofacial Surgery 46 (2008) 198–206 Management: Management Type A Type B Type C Do not require any treatment Patient with prodromal symptom should be indentified and treated Should be treated by Oral Medicine specialist only Self management if found effective should be advised Cauterizing drugs Azathioprine Vitamins Dapsone Milk of Magnesia Levamisole NSAIDS Pentoxifylline Topical Steroid Thalidomide Systemic Steroid Management: Management Symptomatic Treatment : Symptomatic Treatment Local Anesthetics ( Dologel ) Pain relief may be achieved with 2 percent viscous lidocaine applied with a cotton swab several times daily, as needed. Antiseptic and Anti-inflammatory Therapies Topical application of diclofenac 3% in hyaluronan 2.5% ( Solaraze ) reported a significant reduction in pain. Combination of over-the-counter magnesium hydroxide antacid and diphenhydramine hydrochloride (5 mg per mL), mixed half and half, will bring about some symptom relief. Food Carrot, celery and cantaloupe juices also have been reported as helpful complementary agents Specific Treatment : Specific Treatment Tetracycline and minocycline are the agents most commonly used. A 250-mg antibiotic capsule of tetracycline can be dissolved in 180 mL water and used as a “swish and swallow” or “swish and spit” treatment four times per day for several days. Minocycline ( Minoz ) can also be used this way, with a 100-mg tablet dissolved in 180 mL water and swished twice per day Topical 50mg penicillin G potassium troches ( Cankercillin ) applied 4times/day for 4 days-significant rapid healing and pain relief Corticosteroids : Corticosteroids Action- It use is mainly intended to limit inflammatory process. Directly acts on T-lymphocytes and alter the response of effector cells to precipitants of immunopathogenesis and also shortens the healing time. Topical Systemic 0.05% fluocinonide gel ( Flucort ) Prednisone ( Wysolone ) 40 mg/day for one week 0.1% triamcinolone acetonide ointment ( kenacort ) 0.05% clobetasol proprionate gel ( Powercort cream) 0.5 mg/ 5ml dexamethasone elixir ( Decadron ) Role of Corticosteroid in Dentistry-A review; Archives of Dental Sciences, 2010, vol 1 (1) Immunomodulator: Immunomodulator Cyclosporine A ( Imusporin ) Cyclosporine A, at a dosage of 3-6mg/kg, was shown to be effective in about 50% of Bechet Disease patients with respect to aphthosis Azathioprine ( Azioprin ) An imidazoyl derivative of mercaptopurine often used for immunosuppression in human. It is started at 50mg/day and can be given upto 150mg/day. The toxic effect of azathioprine is bone marrow depression and hepatic dysfunction Methotrexate ( Trexall ) Methotrexate (7.5-20mg/week) has been proven to be effective in severe orogenital aphthosis . While on therapy, folic acid should be administered intermittently. Others: Others Thalidomide ( Oncothal ) TNF-alfa blocker, may be effective in treatment of RAS It may induce healing and re epithelization as it can improve human keratinocyte migration and proliferation. The recommended dosage 100 to 200mg/day to start with and to be continued till remission . Amlexanox ( Aphthasol ) Amlexanox 5% paste has been examined in several studies of the treatment of aphthous ulcers. The paste was applied to ulcers two to four times a day Pentoxifylline ( Trental ) It inhibits TNF-alpha productions and 400mg, 1-3 times/day was shown to be effective Vivek , bindhu , nair ; Recurrent apthous stomatitis Current concept in diagnosis & Management; JIAOMR, july-sept , 2011 Others: Others Levamisole ( Vermisol ) Levmisole (150mg/day), an immunotherapeutic drug is believed to reduce pain, number, duration and frequency in major RAS Dapsone ( Dapsone ) It is widely used drug for leprosy has been tried with a limited success in oral apthous ulcer Dapsone is given in 100mg orally in divided doses and may be increased at the rate of 50mg/day per week maximum upto 300mg/day. Vivek , bindhu , nair ; Recurrent apthous stomatitis Current concept in diagnosis & Management; JIAOMR, july-sept , 2011 Others: Others Low level laser therapy 50-55mw is used as main stay of treatment these days Local Cauterization Applications of hydrogen peroxide 0.5% solution, silver nitrate 1%-2% solution, or a silver nitrate caustic stick represent several older therapeutic methods that can reduce the duration of solitary aphthae . Drug: zinc sulphate 220mg/day in one dosage in RAS is also in clinical trails Milk of Magnesia - used as a mouthwash. Provides temporary relief from pain. Vaccination with cow pox virus, lactobacillus containing material and nutrient supplements have been tried. Curcumin gel can reduce pain intensity and size of aphthous ulcer. Curcumin Gel in the Treatment of Minor Aphthous Ulcer: a Randomized , Placebo- Controlled Trial; Journal of Medicinal Plants Others: Others Honey adsorbs toxins from the mucous membrane and precipitate protein, so the pus and inflammatory exudates are adsorbed by the natural honey, thus protecting the underlying tissues and enhanced normal healing and the epithelialization. Recently researched treatment- Shark liver oil Ultrasound Nicotine Natural honey as healing agent for apthous ulcers; Pakistan Oral & Dental Journal Vol 32, No. 3 (December 2012) References: References Burkit -Text book of Oral Medicine-10th edition Shafer-textbook of Oral Pathology- 6 th edition A manual on Clinical Surgery-S. Das-9 th edition CIMS Annual Updated Prescribers Handbook 2013-14 Thank you : Thank you Thank you

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