This document discusses recurrent aphthous stomatitis (RAS), commonly known as canker sores. It describes the characteristics of RAS including its clinical presentations, types, causes, associations with other conditions, histopathology, and management approaches. RAS presents as recurring oral ulcers that can be minor, major, or herpetiform. It most commonly affects females between ages 20-40 and has associations with stress, genetics, infections, nutritional deficiencies, and immune dysregulation.

4.  Defect in the epithelium or loss in continuity
of epithelium is called as ulcer.
 The term “ aphthous ” was first coined by
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.

5.  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.

6.  The individual ulcer begins as a round or oval area of
erythema which develops a pin-point central area of
white ulceration.
 Over the next 3-7 days the ulcer enlarges laterally and
becomes saucerized or cupped out.
 As healing commences, the red halo diminishes and
small punctate red areas dot the white ulcer bed
(representing blood vessels from the underlying
granulation tissue which have reached the surface).
 Over several days the white color of the bed changes to
red or pink and the area heals without scar formation in
the minor type and with scar in major type.

7.  1.Simple
 2. Complex

8.  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 associated with systemic
diseases.

9. The clinical presentations of RAS include
 Minor,
 Major,
 Herpetiform aphthae based on severity

10.  To determine management strategies, it is
classified as
 TypeA- 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

12.  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

13.  Each lesion lasts 10–14 days and heals
without scarring .

15.  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.

16. First described by Cooke in 1960 later by lehner , brooke & sapp

17.  Herpetiform aphthae are the least common type.
 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.

18.  They have a predilection for the posterior
part of the mouth, particularly the soft palate
and pharyngeal wall or tonsillar fauces

20.  Behcet’s Syndrome
 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.
 Cyclic Neutropenia

21.  Pfapa Syndrome : Periodic fever, aphthous
stomatitis, pharyngitis and adenitis
or periodic fever aphthous pharyngitis and
cervical adenopathy.
 in which high feveroccurs periodically at
intervals of about 3–5 weeks, frequently
accompanied by aphthous-like
ulcers, pharyngitis and/or cervical adenitis
(cervical lymphadenopathy).

22.  Sweets Syndrome: acute febrile neutrophilic
dermatosis
 AIDS

23.  Genetic
 Systemic disease
 Stress
 Mechanical injury
 Hormonal
 Microelement deficiency
 Bacterial

25.  recurrent aphthae appear more frequently in
patients with gastro-intestinal disturbances,
mainly those from the group of chronic
inflammatory bowel diseases (Crohn’s
disease, ulcerative colitis) and celiac disease

26.  In some patients with RAS, the deficiency in
hematins (iron, folic acid, vitamin B12) was
revealed
 some food ingredients, e.g., chocolate,
gluten, cow milk, preservatives, nuts and
food coloring agents may induce the pro-
inflammatory cascade in RAS

27.  There is also the correlation between the
serum levels of sexual hormones and the
course of RAS.
 Exacerbations of the condition were
observed mainly in the luteal phase of the
menstrual cycle and during the menopause,
while the remissions seem to appear often
during pregnancy and in women on
contraceptives

28.  In many RAS-predisposed patients, the
lesions appear on the oral mucosa shortly
after mechanical irritation of the area;
however, the mechanism of this reaction
remains not fully understood

29.  Psychogenic effects modify the immune
response also in the other conditions with a
suspected autoimmune background, like
lichen planus and chronic inflammatory
bowel diseases

30.  bacteria (Streptococcus oralis, Helicobacter
pylori) and virus (herpes simplex virus,
varicella-zoster virus, cytomegalovirus,
adenoviruses) antigens.

31.  There is an increased secretion ofTh1 which
causes increased cytokine release
 This observation confirms that the imbalance in
pro- and anti-inflammatory cytokines’
production may contribute to the development
of autoimmunisation and RAS in predisposed
subjects.
 decreased expression of heat shock protein 27
was observed in the oral mucosa of the RAS
patients

32.  lower incidence of aphthae in smokers
compared to non-smokers due to increased
hsp

33.  Anitshkow cells: Pathognomic for rheumatic
heart disease.The cells are also called caterpillar
cells, as they have a large amount of clear
cytoplasm surrounding a rod-
shaped nucleus that to some resembles a
caterpillar.
 Squamous epithelial cells with nuclear changes
resembling Anitschkow cells have also been
observed in recurrent aphthous stomatitis, iron
deficiency anemia, children
receiving chemotherapy, as well as in healthy
individuals

34.  A central ulcer with a thick fibrin bed
containing numerous neutrophils
 A lichenoid infiltrate consisting of histiocytes,
lymphocytes, neutrophils and a few
eosinophils
 Widely dilated capillaries in the lamina
propria
 Slight hyperplasia of the surrounding
epithelium

36.  Traumatic ulcer
 Squamous cell carcinoma
 TB ulcer
 Herpetic ulcer
 Pemphigus, pemphigoid.
 ANUG

37.  Cauterizing drugs Azathioprine,Vitamins,
Dapsone, Milk of Magnesia, Levamisole,
NSAIDS, PentoxifyllineTopical Steroid,
Thalidomide, Systemic Steroid.

39.  Behçet's syndrome is diagnosed based on the
finding of recurrent mouth ulcerations
combined with any two of the following:
 Uveitis; eye inflammation,
 Genital ulcerations, or
 Skin abnormalities

41.  Same as RAS
 Autoimmune with trigger e may be either
HSV or Strep, staph or E coli.
 Genetic
 Hsp

42.  Aphthous and genital ulcers:
 Aphthous ulcers are usually the first sign of
Behçet disease.
 These sores occur on the lips and tongue and
buccal mucosa.The ulcers look like common
canker sores, and they typically heal within one
to two weeks.
 About 75 percent of all people with Behçet
disease develop similar ulcers on the genitals.
 These ulcers occur most frequently on the
scrotum in men and on the labia in women.

43.  Skin lesions
 Rashes and vesciculobullous
lesions(resembling acne) on the face, neck,
and arms

44.  Uveitis:
 An inflammation of the eye is found in more
than half of people with Behçet disease.
 Eye problems are more common in younger
people with the disease and
 affect men more often than women.
 Uveitis can result in blurry vision and an extreme
sensitivity to light (photophobia).
 If untreated, the eye problems associated with
Behçet disease can lead to blindness.

45.  Behçet disease can also affect the joints,
gastrointestinal tract, large blood vessels,
and brain and spinal cord (central nervous
system).

46.  To manage symptoms so that there are no
complications
 Tetracycline
 Steroids
 Anaesthetics

48.  The classic triad of ReA symptoms
 (found in only one third of patients) consists of the
following: Arthritis, urethritis and conjunctivitis
 Reactive arthritis, after a GI or GU infection
 genitourinary tract symptoms foll sexual transmission
of chlamydia and
 conjunctivitis.
 Lesions of the skin resembling psoriasis and mucous
membranes also develop in some patients.
 Pus-filled sores on soles, palms, and penis. May also
include mouth sores.

49.  Common in AIDS patients

50.  Antibiotics to eliminate original bacterial
infection, especially if genitourinary
 Nonsteroidal anti-inflammatory drugs
(NSAIDs) to reduce joint inflammation and
pain
 Drainage of swollen joints then corticosteroid
injections into painful joints

52.  Unknown etiology that manifests as non
caseating granulomas,
 predominantly affects the lungs and
intrathoracic lymph nodes.

53.  it's due to an overactive immune system that
responds too strongly to an invading organism.
 Other researchers think sarcoidosis may be
inherited,
 caused by an infection, or
 caused by allergens that are breathed in or
toxins found in the environment.

54.  Age: People in their 30s or 40s
 Sex: F>M

55.  Common symptoms, which tend to be vague, include
 fatigue (unrelieved by sleep; occurs in 66% of cases),
 lack of energy,
 weight loss,
 joint aches and pains (which occur in about 70% of
cases), arthritis (14–38% of persons), swelling of the
knees
 dry eyes, blurry vision,
 shortness of breath, a dry, hacking cough. Less
commonly, people may cough up blood.
 or skin lesions.

56.  Nearly all organs like skin, eyes, nervous
system, joints are affected.

57.  A noncaseating granuloma

58.  Increased ESR
 Neg Mantoux test.
 Kveim's test (intradermal injection of splenic
material from a confirmed case of
sarcoidosis, and histological examination of
any nodule formed) has fallen out of favour
due to the risk of transmission of new-variant
Creutzfeldt-Jakob disease (nvCJD), and the
several weeks it takes to get a diagnosis.

59.  About half of all people with sarcoidosis get
better without needing treatment.
 For others, medications such as
corticosteroids may help reduce lesions