Oral Ulcers and Aphthous Like Ulcers

1. ORAL ULCERATION Dr. Hadi Munib
Oral and Maxillofacial Surgery
Resident

2. OUTLINE
•Ulcer vs. Erosion vs. Fissure
•Principal Causes of Oral Ulcers
•Traumatic ulcers
•Recurrent Aphthous Stomatitis
•Causes of RAS
•Systemic Conditions and RAS-like Lesions
•Management of RAS
•Behcet’s Disease
•References

3. ULCER VS. EROSION VS. FISSURE

4. PRINCIPAL CAUSES OF ORAL
ULCERS

5. TRAUMATIC ULCERS
•Physical – Mechanical, Thermal and Electrical.
•Mechanical Ulcers: Sharp Broken Down Teeth, Orthodontic and
Prosthetic appliances, Lip or tongue biting after L.A injection
•Chemical; Aspirin Burn
•Sore, painful to touch, and tend to have an irregular border with
erythematous margins and a yellow base.
•During the healing phase they frequently develop a ‘keratotic halo’

6. MANAGEMENT OF TRAUMATIC
ULCERS
•Elimination of cause
•Antiseptic Mouthwash (0.2% Chlorhexidine) or simple covering agent
•Review after 2 weeks
•If still present  Refer to specialist for biopsy.
•Fictitious Ulcers  Self-Inflicted ulcers

9. RECURRENT APHTHOUS
STOMATITIS
•Most common oral mucosal disease
•20 – 25% of population
•Clinical features: Recurrent bouts of one or several, shallow, ovoid,
painful ulcers, occurring at intervals of a few days or up to 2–3
months.
•Three types:
•Minor – Most common presentation
•Major
•Herpetiformis

10. MINOR RECURRENT APHTHOUS
STOMATITIS
•80% of RAS cases
•Slight Female Predilection
•Second Decade
• 1 – 5 small ulcers (<1cm in diameter) on non-keratinized anterior
areas.
•Healing without scarring in up to 2 weeks (10 days usually)
•Patients can predict ulcers – burning sensation
•Ulcer-Free interval: 3 – 4 weeks

11. MAJOR
RAS
•Less common
•Larger > 1 cm in diameter
•1 – 10 in number
•Keratinized and non-keratinized areas.
•Involvement of posterior areas is diagnostic
•Unpredictable course of onset
•Healing with scarring

13. HERPETIFORMIS
ULCERS
•Morphological resemblance of Herpetic ulcers.
•Small (1 – 2 mm), up to 100 in number.
•Lateral margins and ventral surface of the tongue and Floor of the
mouth.
•Female Predilection, 20 -29 years old
•Very painful and may make eating and speaking difficult.
•A single crop of ulcers may last for approximately 7–14 days.
•Scar formation?
•Spontaneous Remission within 5 years

15. RAS IN CHILDREN
•May affect children less than 7 years old
•Major Aphthous does not seem to affect children less than 7
years old (may begin soon after puberty)
•Frequency and severity diminish with age.
•Herpetiformis ulcers (canker sores) tend to affect older persons.

17. AETIOLOGY
OF RAS
•Trauma
•Smoking Cessation
•Microbial Agents
•Genetic Factors
•Stress
•Menstruation
•Food Hypersensitivity

18. HISTOPATHOLOGY AND
IMMUNOPATHOGENESIS OF RAS
•Pre-Ulcerative phase: CD4+ T-Lymphocytes and Macrophages
•Ulcerative phase: CD8+ T-Lymphocytes and Neutrophils
•Healing phase: CD4+ T-Lymphocytes and Macrophages
•Immune-Mediated

19. SYSTEMIC CONDITIONS AND RAS-
LIKE LESIONS

20. NUTRITIONAL DEFICIENCIES
•Hematinic (iron, folic acid, or vitamin B12) deficiencies have been reported to
be twice as common in RAS patients.
•Up to 20% of RAS patients may have a hematinic deficiency.
•B-complex deficiency (B1, B2, and B6) has been reported in a Scottish cohort
of RAS patients and zinc deficiency has been implicated in a few patients.
•Replacement therapy in RAS patients is not yet successful.

21. GASTROINTESTINAL DISORDERS
•Coeliac disease, Ulcerative Colitis and Crohn's disease.
•The prevalence of coeliac disease in patients who present with RAS is less than
5%.
•Patients with established Crohn's disease frequently report oral ulceration that
is ‘Aphthous-like’.

22. NEUTROPENIA
•A large percentage of patients with cyclical neutropenia present with
‘aphthous-like’ ulceration.
•Other manifestations include: fever, malaise, and susceptibility to bacterial
and fungal infections.
•Patients who are functionally neutropenic (chronic granulomatous disease
or benign familial neutropenia) are also susceptible.

23. HIV-ASSOCIATED APHTHOUS
STOMATITIS
•Crops of five or fewer ulcers, on non-keratinized mucosa.
•Very painful and can cause difficulty in eating
•Myelosuppression.
•Thalidomide has successfully been used to treat HIV-associated RAS.

24. MAGIC; MOUTH AND GENITAL ULCERS WITH
INFLAMED CARTILAGE

25. (P)FAPA SYNDROME
•Periodic fever
•Aphthous ulcers
•Pharyngitis
•Cervical Adenitis)
•Relative IgA deficiency.

26. DRUG REACTIONS
•NSAIDs
•Nicorandil
•Potassium-channel activator
•Methotrexate
•Beta Blockers
•Anti-HIV medications

27. MANAGEMENT OF RAS

29. BEHCET’S
DISEASE
•Rare disease characterized by a classical triad of RAS oral, genital ulceration,
and inflammatory eye lesions.
•Other manifestations include skin, joint, neurological, vascular, and intestinal
disorders.
•90% of affected patients have RAS.
•Women are more commonly affected than men.

30. PATHERGY TEST
•Pathergy test is typically required in patients with Behcet’s disease.
•Intradermal Injection of 0.1 mL isotonic Salt Solution using 20G
needle
•Erythematous papule 24 – 48 hours at prick site

32. MANAGEMENT OF BEHCET’S
DISEASE PATIENTS
•Multidisciplinary approach; Systemic steroids:
•Azathioprine
•Cyclophosphamide
•Colchicine
•Cyclosporine
•Anti-TNFα
•Mycophenolate.
•Thalidomide.

33. REFERENCES
Chapter 5: Oral
Ulceration

34. THANK YOU