Recurrent aphthous stomatitis — Viva

Q1: Define recurrent aphthous stomatitis.

Expected answer: Recurrent aphthous stomatitis is a noninfectious recurrent ulcerative disorder of the oral mucosa, presenting with painful shallow round or oval ulcers with a yellow-white fibrinous base and erythematous halo, usually on non-keratinized movable mucosa. It is classified as minor, major and herpetiform aphthae.^[1]

Probe: Why is "herpetiform" a dangerous name?

Expected answer: It describes clustered tiny ulcers that resemble herpes clinically, but they are not caused by HSV, do not have a vesicular stage and should not be treated with aciclovir unless HSV is proven or strongly suspected.^[1]

Q2: Classify aphthous ulcers.

Expected answer: Minor aphthae are under 1 cm, usually one to five ulcers, heal within 7-14 days and do not scar. Major aphthae are greater than 1 cm, deeper, persist for weeks to months and may scar. Herpetiform aphthae are multiple 1-3 mm ulcers in crops that may coalesce and are not viral.^[1]

Probe: Which type should make you investigate more readily?

Expected answer: Major, herpetiform, complex, adult-onset, treatment-resistant or severe disease should prompt screening for haematinic deficiency, coeliac disease, IBD, HIV, neutropenia and Behçet disease, guided by symptoms.

^{[3] [6]}

Q3: How do you distinguish RAS from HSV?

Expected answer: Aphthae are ulcers from the outset, typically on non-keratinized mucosa such as labial/buccal mucosa, ventral tongue and floor of mouth. HSV usually has grouped vesicles before ulcers and recurrent intraoral HSV favours keratinized mucosa such as hard palate and attached gingiva. If uncertain, especially in immunocompromise, send HSV PCR from an early lesion.

^[5]

Q4: What red flags require referral or biopsy?

Expected answer: Ulcer persisting more than 2-3 weeks, induration, rolled edge, spontaneous bleeding, erythroplakia or leukoplakia, fixation, neck node, dysphagia, odynophagia, weight loss, tobacco/alcohol/betel exposure, solitary progressive ulcer, or diagnostic uncertainty. Refer to oral medicine, ENT or oral and maxillofacial surgery for biopsy-pathway assessment.^[1]

Q5: What systemic associations must be screened for?

Expected answer: Behçet disease, IBD, coeliac disease, HIV or other immunodeficiency, cyclic neutropenia, PFAPA in children, haematinic deficiencies and medication-related ulceration. Behçet clues are recurrent oral ulcers with genital ulcers, uveitis or retinal symptoms, erythema nodosum/acneiform lesions, arthritis and pathergy. Eye symptoms need urgent ophthalmology.

^{[2] [3]}

Q6: What investigations would you order?

Expected answer: No broad tests are needed for classic infrequent minor RAS without red flags. For recurrent, severe, major or atypical disease order FBC with differential, ferritin or iron studies, B12, folate and zinc. Add coeliac serology with total IgA if iron deficiency or GI features, HIV Ag/Ab for severe atypical disease or risk, ESR/CRP/faecal calprotectin or GI referral for IBD symptoms, serial FBC for cyclic neutropenia, HSV PCR if vesicular or uncertain, and biopsy for suspicious persistent ulcers.

^{[7] [5]}

Q7: Outline treatment.

Expected answer: Start with explanation, trigger control, correction of trauma, SLS-free toothpaste trial, avoid reproducible food triggers, chlorhexidine mouthwash, topical benzydamine or lidocaine and simple analgesia. For frequent or painful disease use topical corticosteroids such as triamcinolone dental paste or betamethasone rinse. Consider tetracycline mouthwash for selected recurrent disease in appropriate non-pregnant adults. Treat deficiencies and underlying disease. Severe refractory or complex aphthosis needs specialist therapy such as colchicine, dapsone or thalidomide with monitoring and pregnancy-prevention safeguards.

^{[1] [3]}

Q8: How would pregnancy or immunocompromise change your answer?

Expected answer: In pregnancy prefer conservative and topical measures, avoid tetracyclines and thalidomide, and use systemic drugs only with specialist risk-benefit assessment. In immunocompromise broaden the differential to HSV, CMV, candidiasis-associated erosions, neutropenic ulceration and malignancy before escalating corticosteroids.^[1][3]

References7ShowHide

1. [1]Oral Aphthous: Pathophysiology, Clinical Aspects and Medical Treatment. Archives of Razi Institute, 2021.PMID 35355774
2. [2]Update on the Diagnosis of Behçet's Disease. Diagnostics (Basel), 2022.PMID 36611332
3. [3]Jacobson JM, Greenspan JS, Spritzler J, et al. Thalidomide for the treatment of oral aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group N Engl J Med, 1997.PMID 9154767
4. [4]Jacobson JM, Greenspan JS, Spritzler J, et al. Thalidomide for the treatment of oral aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group N Engl J Med, 1997.PMID 9154767
5. [5]Wray D, Ferguson MM, Mason DK, et al. Recurrent aphthae: treatment with vitamin B12, folic acid, and iron Br Med J, 1975.PMID 1148667
6. [6]Jacobson JM, Greenspan JS, Spritzler J, et al. Thalidomide for the treatment of oral aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group N Engl J Med, 1997.PMID 9154767
7. [7]Koparal M, Ege B, Dogan EI, et al. Evaluation of biochemical variables in patients with recurrent aphthous stomatitis J Stomatol Oral Maxillofac Surg, 2023.PMID 36162803