Recurrent Apthous Stomatitis

Resident’s Name: Brian Schmid Date: 7/17/2009
Article title: Recurrent Apthous Stomatitis
Author(s): Jonathan Ship DMD, Elisa Chavez DDS et al
Journal: Quintessence International
Month, Year: 2000
Major topic: Review of recurrent apthous stomatitis
Type of Article: Review
Findings: RAS is the most common oral mucosal disease in humans with an incidence of 5-25% and much higher in selected populations (50-60% in med/dent students). Minor RAS consists of small (<10mm) painfululcers with a necrotic center and a gray-white pseudomembrane. They typically heal within 10-14 days without scaring and is typically located on nonkeratinized oral mucosa. Major RAS (aka Suttons Disease and periadenitis mucosa necrotica recurrens comprises 10-15% of RAS cases). These lesions are larger than 10mm and often scar. They can also last for months and be a major cause of dysphagia. Major RAS has a predilection for lips, tongue, soft palate and the palatal fauces. It is frequently found in HIV patients. Multiple small clusters of pin point ulcers characterize Herpetiform RAS.
The most common differential for RAS is herpes simplex, which differs from RAS in that the primary form causes fever and erythema and it typically occurs on attached tissue. Varicella Zoster virus can be differentiated by its unilateral patter of following the trigeminal nerve and a prodrom of pain and tingling/burning sensation. Herpangina lesions usually have correlated systemic symptoms like fever and will resolve in 1-2 weeks. Erythema multiforme lesions are accompanied by stargetoid skin lesions and occur on both attached and movable mucosa. Oral lichen planus can resemble RAS but lesions will typically also occur on the gingiva and hard palate, and is often not painful. Systemic lupus erythematosis, Crohns disease, Behcets disease, Reiters syndrome and HIV/AIDS can also present with RAS-like ulcers. While there is no hardline causation of hematological defects with RAS, a significant persentage of patients can be successfully treated with blood elements.
Chronic minor or major RAS can be a concern due to the myriad potential underlying systemic diseases and any chronic RAS patient should be referred for medical workup. Dermatology and internal medicine may be necessary for immunosupressant medications; Otolaryngology for infectious diseases such as pemphigoif and herpangina; GI for IBD and Crohns; Opthamology for Behcets or Reiters disease. Also, allergists, infectious disease and hematology may need to be consulted.
Anti-inflammatory topical gels and ointments are the first line of chemotherapeutic defense. They are most effective when applied early in the outbreak. The topical glucocorticoids of choice is fluocinonide, triamcinolone and clobetasol. These drugs mixed with Orabase can be an effective treatment. 5% amlexanox applied 4 times daily is also an effective and safe treatment. There are also effective topical rinses such as Sucralfate.

Key points/Summary: There are many possible treatments for RAS and even more potential causes. It is essential to cover your medical bases and account for any possible underlying causes.

Assessment of article: A super review of RAS related material.