General Info
Contemporary Oral Medicine A Comprehensive Approach to Clinical Practice Annotations
Epidemiology
- 10 -20% of population
- Minor, major, herpetiform and severe
- Severe
- New ulcers come up as old ones are healing
- chronic and severe pain
- All mucosa can be effected
- take weeks to heal often have scarring
- Severe
- Usually develops in patients between 10 and 19 yoa
- if becomes more severe with age could indicate an underlying systemic condition
In relation to p/t
- the ulcers are small but take 4-6 weeks to heal so are is it severe recurrent apthous stomatitis?
- probably the Referral Back to External pretty much just repeats the main symptoms of severe stomatitis, everything except for ulcer size!!!
- Also atypical because it developed in an older patient
criticism of case management
Seems that they could never get the patient in early enough to catch an ulcer at peak/ they don’t have any photographic records from the referring clinicians
Etiopathogenesis
- not well understood
- Could be due to past diseases:
- VSV, CMV, HHV6 and 7 , oral streptococci and heliobacter pylori but none have been confirmed
- Common risk and triggering factors
- local
- smoking
- trauma
- hematologic
- immunologic
-
- Immunoglobuluin serum levels and NK clles are within range in RAS patients
- “Studies have shown defects of cell-mediated immunity with an alteration in the CD4+:CD8+ T lymphocyte ratio (Preeti et al. 2011). Specifically, CD4+ cells are more frequent in the pre-ulcer and healing phases, while CD8+ cell levels are higher when the ulcer is present (Bachtiar et al. 1998; Sun et al. 2000).” (“Contemporary Oral Medicine: A Comprehensive Approach to Clinical Practice”, 2019, p. 1037) (pdf)
-
- genetic
- “Heredity may play a role as both twins and children with parents affected by RAS are more prone to develop the disease (Miller et al. 1980).” (“Contemporary Oral Medicine: A Comprehensive Approach to Clinical Practice”, 2019, p. 1037) (pdf)
- Other:
- Nutritional deficiencies
- psychological stress
- anxiety
- hormonal fluctuations
- allergy to certain foods
- SLS toothpaste
- local
in relation to p/t
- History says no infections other than hapatitis in the past
- pts brother also suffers from RAS so could be cool to mention
- ! Does the blood test tell us anything about CD4 and CD8 levels?
- How does thyroid removal affect the immunologic factors, the Patient details cites potential cyclic neutropenia?
- pt denies being stressed and doesn’t smoke or drink but has poor sleep qualityReferral Back to External
- Do any of the patients current medications affect this ? External Referral To OCHWA
- candesartan
- cyclosporine
- denosumab
- thyroxine
- vitamin c
- calcium
- zinc
- Aside from the cyclic neutropenia do any of her other conditions have potential implications?
- Hypertension
- Rheumatoid arthritis
- Osteoarthritis
- Osteoporosis
- Dry eye and blepharitis
- T-cell large granular lymphocyte leukaemia
- Papillary thyroid carcinoma
Criticism of case management
- Was a diet analysis ever done to rule out any nutritional deficiencies or food allergies?
- “patient appeared well nourished Patient Notes”
- Trigger foods include:
- dairy
- tomatoes
- nuts
- most fruits except banana
- Do these ever have anything in common? allergens or acidity? Why bananas!?
- Did they ever figure out what kind of toothpaste she uses?
Management
- Depends on frequency and severity of the lesions
- “The main therapeutic goal for severe and painful cases is to reduce the frequency of the episodes and control the pain.” (“Contemporary Oral Medicine: A Comprehensive Approach to Clinical Practice”, 2019, p. 1039) (pdf)
Criticism of case
- Could it be “aphthous sotmatitis associated with systemic conditions ”
- GI disordrs
- Behcet syndrome
- Food allergy !!
- Why was p/t not given any topical anesthetics for pain control? Referral Back to External
- Why are amphotericin lozenges and curasept given (check Aussie management guidelines, textbook is american?)