1. Recurrent Aphthous Stomatitis- Current Perspective Dr. Prabhakar M Sangolli Dept of Dermatology Dept of Dermatology Dr.B.R.AMBEDKAR MEDICAL COLLEGE Bangalore

2. Canker Sore Canker Sore b Recurring ulcers in the oral mucous membrane with no signs of systemic disease. b Common manifestation of haematological, immunological and psychological disorders.

3. Aetiopathogenesis Aetiopathogenesis b Genetic ( HLA)-40% cases b Nutritional-Iron,folic acid,B 1,B 2,B 3, B 12,C b Endocrinal-Premenstrual,pregnancy b Infective-Strep.sanguis(Hsp), HIV b Stress b Smoking cessation b Trauma b Immunological(ADCC)

4. Clinical Features Clinical Features b -20% of general population b -Precipitated by trauma,menses b -Prodrome 2-48 hrs b Pre ulcerative b Ulcerative b Resolving

9. TYPES

10. DISEASES SIMULATING RAS b Behcet’s: oral, genital, neuro-ocular b Sweet’s syndrome b Blood dyscrasias b GIT malabsorption ( Coeliac disease,IBD ) b Collagen vascular diseases b Cyclic neutropenia b Reiter’s Disease b Recurrent Intra oral Herpes

11. MANAGEMENT b History : Stress Trauma Trauma Smoking Smoking Premenstrual flare Premenstrual flare b Clinical examination: Eye Genital Genital Rectal Rectal CNS CNS

12. Investigations Investigations MaRAS,onset >25yrs age,pt with syst.symptoms b CBC b Serum iron,B 12 b Serum iron,B 12,RBC folate levels,ferritin b b ANA

13. GENERAL MEASURES b Stress avoidance b Nicotine patches b Soft tooth brush b B 12 supplements:1000mcg twice wkly-6wks 1000mcg once a month-1 yr (low serum B 12 level) b Folic acid, Iron, B-complex, C supplements b Pre & Probiotics

14. TOPICAL THERAPY b Mild cases - To promote healing, use b 0.1% Triamcinolone with orabase, qid b 2% xylocaine viscous to relieve pain b Severe cases :Clobetasol, Flucinolone b Tetracycline in 30 ml water q.i.d & b 5% Amlexanox paste-Accelerate healing.

15. SEVERE CASES b Prednisolone 1mg/kg/day, taper over 2 weeks b Azathioprine - 50mg b.i.d b Watch for Candidiasis

16. PREVENTION OF RECURRENCE b Oral Pentoxyfylline : 400mg t.i.d-3mths b Colchicine- 0.5mg t. i. d b S/E: Myopathy, neuropathy, nausea,diarrhoa, blood dyscrasias.Potent teratogen b DDS+Colchcine

17. Prevention of recurrence (contd..) b Thalidomide 100mg t.i.d, tapering to 50mg /d as maintenance. b Teratogenic, neurotoxic b STEPS-(System for Thalidomide Education Prescribing Safety) b Other measures: b Topical tacrolimus b Levamisole

18. Points to ponder Points to ponder b H.Pylori b CMV,EBV b Handedness b Glutein free diet b Non enzymatic AOs b Iontophoresis b Detergents in toothpaste

19. SUMMARY b Stress avoidance b Soft tooth brush b Supplements-B 12,folic acid,B 3,C,iron b Steroids with orabase b Local anaesthetic, tetracycline mouthwash b Systemic steroids-severe cases

20. Summary (contd..) Summary (contd..) b Pentoxyfylline,Colchicine & Dapsone- severe relapsing patients b STEPS Assisted Thalidomide