26 April 2017
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Recurrent Aphthous Stomatitis

Recurrent Aphthous Stomatitis

 

This article is by Navdeep Kumar who is a Fourth Year student at Liverpool School of Dentistry

 

What is RAS?

  • Painful, rounded or ovid ulcers that can reoccur and can present anywhere in the mouth
  • Occur in intervals of a few days or up to 2-3months
  • Last 10-14 days and is common and present in 20% of the population

Aetiology of RAS

  • Unknown
  • Possible aetiological associations with RAS
    • Anaemia
    • Vitamin deficiencies
    • Stress
    • Menstruation
    • Trauma
    • Smoking cessation
    • Microbial agents
    • Genetic factors
    • Food hypersensitivity

Clinical features

There are three types

  • Minor recurrent aphthous stomatitis (MiRAS)

    • Most common occurs in 80% of the population with ulcers
    • Each bout may contain 1-5 ulcers
    • <1cm in diameter
    • Found commonly on the buccal or labial mucosa, the floor of the mouth or the tongue
    • Grey/yellow with slightly raised red margins
    • Duration is 7-14days
    • Heals without scarring
  • Major recurrent aphthous stomatitis (MjRAS)

    • Occurs in 10-15% of the population with RAS
    • Each bout may contain 1-3 ulcers
    • >10mm in diameter
    • More severe than MiRAS
    • Found anywhere in the oral cavity, including the soft palate and tonsillar region
    • Duration is 2-3weeks-3months
    • Heals with scarring
  • Herpetiform

    • Occurs in 5-10% of the population with RAS
    • Each bout may contain 5-20 (up to 100) ulcers
    • 1-2mm in diameter
    • Found on commonly on the lateral and ventral surface of the tongue and the floor of mouth
    • Grey without delineating erythematous border
    • Ulcers may coalesce to form larger ulcer
    • Duration 7-14days
    • Heals without scarring (unless a number of ulcers coalesce)

Management of RAS

1)      History

  • At what age did you first experience these ulcers?
  • Does another member of your family suffer from these?
  • How often do they occur?
  • How long does each occurrence of ulcers last?
  • How many ulcers appear?
  • Where in the mouth do they occur?
  • How big and what shape are these ulcers?
  • Are there any associated medical condition(s)
  • Have you experienced genital ulceration?
  • Have you experienced skin problems?
  • Have you experienced any gastrointestinal disturbances?

2)      Examination

  • Number of ulcers
  • Size and shape of ulcers
  • Size of ulceration
  • Edge of ulcer
  • Base of ulcer
  • Surrounding tissue
  • Scarring
  • Consistency

3)      Investigations

  • Haemoglobin and full blood count
  • ESR/CRP
  • Serum B12
  • Serum/red cell folate
  • Anti-gliadin and anti-endomysial autoantibodies

4)      Treatment

Type Therapy Therapeutic effect
Topical antiseptics/analgesics Chlorhexidine gluconate 0.2% (Corsodyl or Chlorohex mouthwash)

Dose: rinse 10mL for 1minute twice daily

 

Benzydamine Hydrochloride 0.15%

(Difflam mouthwash or spray)

Dose: rinse 15mL every 1.5-3hrs as required

Spray: adult 4-6 sprays onto affected area every 1.5-3hrs

Child under 6yrs 1 spray/4kg body weight every 1.5-3hrs

 

Lignocaine gel 2%

Dose: rub sparingly and gently on affected area every 2-3hrs

 

Lignocaine hydrochloride 0.66% and aminoacridine hydrochloride 0.05%

(Iglu covering paste)

Dose: apply sparingly directly to the affected area(s)

Reduces symptoms. Reduce infection

 

 

Reduces symptoms

 

 

 

 

 

 

Reduces symptoms

 

 

Forms a protective barrier over the ulcer and reduces discomfort and pain

Topical corticosteroids Hydrocortisone hemisuccinate 2.5mg(Corlan pellets)

Dose: adult and child 1 lozenge 4 times daily allowed to dissolve slowly in the mouth in contact with ulcer

 

Triamcinolone acetonide 0.1%

(Adcortyl in Orabase adhesive paste)

Dose: adult and child apply a thin layer 2-4 times daily

 

Beclomethasone dipropionate 50mg

(Beconase spray)

Dose: 2 sprays onto affected area

 

Budesonide 100mg

(Rhinocort Aqua spray)

Dose: 2 sprays daily onto affected area

 

Betamethasone 0.5mg

(Betnesol mouthwash)

Dose: dissolve one tablet in 5-10mL water

Useful firstline treatments if the ulcer-free period is longer than 1month

May reduce frequency in some patients. Encourages healing.

 

 

May reduce frequency in some patients. Encourages healing. No longer available

 

 

 

Hospital prescription. May reduce frequency in some patients. Encourages healing

 

Hospital prescription. May reduce frequency in some patients. Encourages healing.

 

 

GDPs can prescribe. May reduce frequency in some patients. Encourages healing.

Topical antibiotic Chlortetracycline 2%(Aureomycin mouthwash)

Dose: dissolve in 5-10mL water and rinse

Rapid response to herpetifom ulcers. Effectively reduce the ulcer size and alleviate ulcer pain

 

If the ulcer persists for more than 3 weeks then refer the patient urgently!

References

Tyldesley, William R., and E. Anne Field. Oral medicine. Oxford University Press, 1995.

Odell, Edward W., ed. Clinical problem solving in dentistry. Elsevier Health Sciences, 2010.

Joint Formulary Committee, and Royal Pharmaceutical Society of Great Britain. British national formulary (bnf). Vol. 64. Pharmaceutical Press, 2012.

Preeti, L., et al. “Recurrent aphthous stomatitis.” Journal of oral and maxillofacial pathology: JOMFP 15.3 (2011): 252.