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SGD 3 REPORT

RECURRENT APTHOUS STOMATITIS

BY :
1. Febrianto Dwilaksono
2. Aniska Cattleya S
3. Claudia Nur Rizky J
4. Hafid Nur Arzanudin
5. Karunia Budi Handoko
6. Maharani Tri Nishindri
7. Nifarea Anlila Vesthi
8. Putri F
9. Shita M
10. Wahyu Lusiana H
11. YF. Indah Permata Sari
12. Yoghi Bagus Prabowo

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( 112110213 )
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( 112110234 )
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( 112110238 )

FACULTY OF DENTISTRY
UNIVERSITAS ISLAM SULTAN AGUNG
2012

FOREWORD
Bismillahirrahmanirrahim
Alhamdulillahirabbil'alamin, we pray to God who has bestowed His grace and
guidance to us, so we can finish the report SGD 3 LBM 1 BLOCK 10 on "Recurrent Apthous
Stomatitis". This report was prepared to fulfill the duties that have been implemented SGD.
Despite the many hurdles and obstacles that we experienced in the process of reporting,
Alhamdulillah we managed to finish well.
Do not forget we thank the lecturers who have helped us in doing this report. We
would also like to thank my friends who have taken the trouble to help make this report either
directly or indirectly.
We recognize that there are still many shortcomings in the preparation of this report.
Therefore, we will accept with open criticism and suggestions from readers.
Obviously there are things we want to give to the readers of the results of this report.
Therefore, we hope that this report can be something that benefits us all. In the final section,
we will examine the opinions of the experts. Therefore, we hope this can be useful for us.
Hopefully this report will make us achieve a better life. Aamiin.
Jazakumullahi khoiro Jaza '

Semarang, November 2nd 2012

Publisher

LBM 1

: RECURRENT APTHOUS STOMATITIS

Scenario
A male 24-year-old, a bank employee who had just fired about 6 months ago,
came to the RSGM with ulcers symptoms that never healed since 5 months ago and
tend to more frequent and severe. Initially the ulcers arises merely when it is bitten, but
lately it often arises. According to the patient, since the last 1 month the ulcer has not
healed but it has already appeared again. The number of ulcer is 1-3, pretty sick and
usually on the inside of the lower/upper lips, sometimes is in the corner of the mouth.
History of treatment was obtained: albothyl, kenalog in orabase, enkasari, but without
the benefit. Diet history: chocolate, coffee ( 2 glasses), beans, pempek, cola, bad in
digestive, sleep derivation, systemic disease: stomach ulcer. Oral check-up: lesion is in
inside of the lower lip as seen in the picture. Hurt when it is touched. Lymph gland of
the neck quite swollen and sick. OH is quite bad. The upper front teeth are crowded.

INTRODUCTION
A. Background
It is known that the number of students who do not understand on "Recurrent
Apthous Stomatitis" and the difficulty in finding the right learning resources and
trustworthy. In fact indicates that not many students who would bother to look for
answers or learning resources in detail and clearly. Therefore, it needs to be pursued to
improve the learning ability of students to understand and get the learning resources
on "Management of Pain" is good in order to solve problems of learning.
Efforts to improve students' ability to locate the source of an effort to learn the
most logical and realistic. Lecturer or Tutor as one important factor in the success of
efforts to improve education at the University, especially the increase in activity and
learning outcomes, should play an active role and can choose appropriate learning
strategies to improve student learning outcomes. Lecturers should also consider the
use of instructional media appropriate to the material that will help students to solve
problems and understand the material or the concept of "Recurrent Apthous
Stomatitis" given by the lecturer.

B. Problem Formulation
1. What is the definition of the Recurrent Apthous Stomatitis?
2. What type of Recurrent Apthous Stomatitis?
3. What are the clinical appearance of the Recurrent Apthous Stomatitis?
4. What are the treatment of Recurrent Apthous Stomatitis?

C. Aim
1. Being able to know and understand Recurrent Apthous Stomatitis.
2. Being able to know and understand about the type of Recurrent Apthous Stomatitis.
3. Being able to know and understand about the clinical appearance of Recurrent Apthous
Stomatitis.
4. Being able to know and understand about the treatment of Recurrent Apthous
Stomatitis.

RECURRENT APTHOUS STOMATITIS

UNUNDERSTANDING WORDS
1.ULCER

Pathologist condition because of epithel to lamina propria tissue is


broken. Loose of tissue because of broken tissue on the ephitelium
surface due to rid off the necrotic tissue and extend to lamina
propria.

2. LYMPH GLAND :

A lymph node is an oval-shaped organ of the immune system,


distributed widely throughout the body including the
submandibule, armpit and stomach and linked by lymphatic vessels

LEARNING ISSUES
1. How is the structure of skin layers?

(1) stratum basalis, (2) stratum granulosit, (3) stratum spinosum, (4) stratum
korneum
2. What is the diagnosis of the scenario. Give the reason.
The diagnosis is recurrent apthous stomatitis (RAS). RAS consists of recurrent
bouts of one or more painful, rounded or ovoid ulcers. Most aphthous ulcers
last for 10-14 days. It is a common mouth condition affecting up to 20% of the
population at any given time. The severity and frequency of RAS tends to
decrease with age.

In the scenario there is an ulcus that show in oral mucosa. The lession appear
as round or oval ulcerations of variable depth, with a raised red border. The
center of the ulcer is appear white, yellow. The ulcers are larger than 1 cm in
diameter.
3. What is the pathophysiology of recurrent apthous stomatitis?
Because of the enzyme laktoperosida (naturally in the body) is disturbed,
causing the bacteria to multiply faster with uncontrolled. Decreased immune in
the mouth is affected by the use of detergent to toothpaste, which will damage
the tissue and decrease immune saliva in the mouth. But it could be a pathogen
in the mouth if it increases by the same dosianat hydrogen peroxide is
bakteriosid. If the defense Lactoperoxidase damaged, it will cause bacteria to
multiply uncontrolled. Caused by the consumption of preservatives, dyes, and
pesticides from food substances. The use of antiseptics can destroy all the
bacteria that resides in the oral cavity that also damaged. Damaging stimuli
that enter the body should be dealt with locally or systemically. Actually, the
body tries to react to protect, but will end up damaging the body itself.
Start with erythema makula that will be necrotic. It will becomes vesicle which
is broken because of trauma and formed ulcer. And at the end it will become
cicatrix.
4. What is the clinical appearance of recurrent apthous stomatitis?
Aphthous lesions generally appear as round or oval ulcerations of variable
depth, with a raised red border. The center of the ulcer is often covered by a
pseudomembrane that can appear white, yellow, or gray. They most often
develop on mobile non-keratinized mucosal surfaces in the mouth, though in
HIV-infected patients, they may also occur in the esophagus and anogenital
region. The oral lesions typically cause intense pain and can interfere with
eating, speaking, and swallowing, even leading to significant anorexia and
weight loss in some patients. The ulcers are generally classified as minor,
major, or herpetiform. Minor aphthous ulcers, the most common form, measure
less than 1 cm in diameter, are shallow, have a surrounding erthematous halo
and are often covered with a pseudomembrane. The aphthous minor lesions
usually heal spontaneously within 1-2 weeks without scarring. Major ulcers are
larger than 1 cm in diameter (often exceeding 3 cm in diameter), may develop
into very large necrotic lesions, and in some instances extend to keratinized
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surfaces. Major aphthous ulcers are seen more commonly in HIV-infected than
non-infected patients, especially in individuals who have a CD4 count less than
100 cells/mm3. The rare herpetiform variant is defined by multiple (up to a
hundred) pinpoint lesions that may coalesce to form large, irregular
ulcerations.
5. What are the treatment of recurrent apthous stomatitis?
Treatment for RAS aims to relieve discomfort, prevent or reduce secondary
infection and encourage healing.
o Topical corticosteroids are the main treatment for RAS. They can be
applied locally to the mouth and are effective for most patients. These
are available as mouthwashes, sprays, and small dissolvable pellets.
o Anaesthetic (analgesic) mouthwashes, sprays or over-the-counter
sugar free throat lozenges can be used if your mouth becomes sore and
are particularly helpful if used before meals.
o Use of an antiseptic alcohol-free mouthwash, spray or gel (e.g.
chlorhexidine gluconate) maybe recommended to help reduce any
secondary infection and control plaque levels on teeth if toothbrushing
is difficult or uncomfortable.
o Tetracycline mouthwashes may be of value for some types of RAS.
o Covering agents work by forming a mechanical barrier against
secondary infection and further mechanical irritation. These are
available as pastes and soluble pellets for application to ulcers.
o Severe cases of RAS may require treatment with a short course of
systemic corticosteroids (i.e. taken in tablet form). Long-term treatment
with these drugs is not recommended because of the potential side
effects.
o Other types of oral (systemic) therapy are reserved for severe cases of
RAS (especially the major type) and various drugs have been used as
management options to suppress the ulcers by altering the bodys
immune system. These can be associated with a number of side effects
which should be discussed with your specialist. Regular blood tests are
required when taking most of these drugs, particularly during the early
stages of treatment.
6. What are the classification of recurrent apthous stomatitis?
RAS is classified into three types:
o Minor
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o Major
o Herpetiform
Minor ulcers are the most common type affecting the majority (80%) of people
who suffer from mouth ulcers. Minor ulcers occur in crops of about 1 to 5 at a
given time and are usually 10mm or less in diameter. These usually appear
inside the lips and cheeks, on the tongue and sometimes the floor of the mouth.
The ulcers tend to last between 10-14 days and heal without scarring.
Major ulcers are less common and affect 10-15% of patients with RAS. Major
ulcers tend to be larger and typically greater than 10mm in diameter. They can
occur singly or 2-3 can appear at a time anywhere in the mouth. If the soft
palate is involved, swallowing can be difficult. The ulcers may last up to 3
months and some of the larger ulcers leave a scar when healed.
Herpetiform ulcers are the least common type affecting 5-10% of cases. The
ulcers are small (1-2mm in diameter) and can occur in clusters of more than 20
at a time which can merge to give larger ulcers. Can come from 10-100 ulcers.
They tend to occur in the front of the mouth particularly under the tongue and
on the edges of the tongue. These tend to heal within two weeks without
scarring. Despite their name, they are not caused by a herpes virus.
7. What are the symptoms of recurrent apthous stomatitis?
The main complaint is pain. This can be made worse by hot, salty, spicy or
hard/abrasive food. Eating and drinking can therefore become difficult.
Depending on the site of ulcers, speech can also be affected. The ulcers occur
in recurrent bouts, heal and reoccur with varying time intervals. A few people
are never free from ulcers.
There are two symptoms. subjective symptoms (pain does not correspond to
the size of ulcers in the mouth, according to the movement of the mouth, pain
when chewing is when erosion began to be closed by new epithelial cells.
Sometimes it does not cause a fever) and objective symptoms (yellowishwhite looks erosion tends to inspection, shaped round oval, about the erosion
of the surrounding colored red).
8. What are the etiology of recurrent apthous stomatitis?
There is no proven etiology for recurrent aphthous stomatitis. Immunecomplex mediated vasculitis and autoantibodies against the oral mucosal
membranes have been suggested due to the histopathological features.
Precipitating factors include trauma, stress, chemical irritants, hormones, and
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heredity. Local trauma frequently leads to non-recurrent solitary ulcers which


is different from recurrent aphthous stomatitis. Emotional and physical stress
have been implicated in the pathogenesis which is supported by the
observation that students and military personnel have a high incidence of oral
ulcers. Certain foods, including coffee, chocolate, potatoes, cheese, nuts, figs,
citrus fruits, and gluten-containing foods, have also been implicated.
Deficiencies in iron, folate, and vitamin B-12 have been noted in relation to
these ulcers.
L-forms of streptococci are most frequently isolated from aphthous ulcers. It is
believed that antibody formation and complement fixation induced by these
streptococci may play a major role in the pathophysiology. This theory is also
supported by the rapid clinical response to topical and systemic therapy with
tetracycline, which is very active against streptococci.
Although there is a high correlation of recurrent aphthous stomatitis in
identical twins, genetic considerations tend to point to a polygenic inheritance
pattern, with multiple factors affecting penetrance. No clear association
between recurrent aphthous stomatitis and an HLA antigen has been shown.
Immunopathogenetic studies indicate that the ulcerations might be caused by
cytotoxic action of lymphocytes and monocytes on the oral epithelium with an
unknown trigger.
Recurrent aphthous stomatitis has been noted in patients with systemic
diseases such as inflammatory bowel disease, Crohn\'s disease, HIV and AIDS,
and celiac sprue. Despite theories that implicate certain viruses such as
Coxsackie virus, herpes simplex virus, Varicella zoster virus, Epstein-Barr
virus, CMV or adenovirus, no viral associations have been proven thus far.
B12: Cobalamin serves to produce folic acid. B12 to make red blood cells.
Deficiency can occur because of being pressured by other vitamins such as
excessive consumption of vitamin C. Red blood cells if reduced, wound
healing is also to be reduced.
Can occur due to an increase in IgE, so some of the food alone that can cause
ulcers. Disorders stomach ulcers.
Stomatitis due to allergies: alergica stomatitis.
Nicotin produced tobacco in smokers increased carbon dioxide so boost the
acidity in the mouth.

May be caused by the fungus because the body's defenses down, abnormal
IgA, it will cause hipersensitive ig. Lack of vitamin C will cause rapid
depletion of mucosal so torn.
Ulcers due to medications (stomatitis medica mentosa). For example antiaglina
/nicorandil. Metonindazol antibiotic, penicillin, tetracycline. Clonazepam
anticonvulsant, hydantoin, lamotrigine. Antidepressants imipramine, fluexetin,
etc.
Hormonal Menstrual disorder resulting decrease in estrogen balance oral cells.
Slowing the process of keratinisation causing excessive reaction in the mouth,
vulnerable local irritation, resulting in RAS.
9.

What is the clinical examination of recurrent apthous stomatitis?


The early stages of determining the predisposing factors, a history of recurrent
or primary and clinical examination, no examination of the blood test. Do
blood tests are intended in the event of malignancy in case of malignancy (can
be done if there is a disease that does not heal)
Examination opinion: how long does it hurt? (acute / chronic), the first new or
have been used to suffer? (primary / recurrent), how many lesions? (single /
multiple).

10. What is the differential diagnosis in the scenario?


As always, a careful history is the first and most important diagnostic step.
Elucidation of the timeline, provocative and palliative factors, and association
with other symptoms such as ocular, musculoskeletal, or urogenital symptoms
is important.
The physical exam should focus on the location and nature of the lesions, in
addition to assessing other organ systems for relevant findings. In such
patients, the physician must evaluate and rule out other conditions with similar
features. Aphthous stomatitis ulcers involve the non-keratinized oral mucosa
such as the tongue, floor of mouth, soft palate, and buccal and labial mucosa.
Diagnostic evaluation is usually fruitless, unless vitamin deficiencies are
highly suspect. Most diagnostic tests are useful in ruling out other etiologies,
rather than being specific to aphthous stomatitis.
Herpes simplex virus infection is usually preceded by vesicles and occurs on
keratinized mucosa bound to periosteum, such as the hard palate and attached

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gingiva.

Such

lesions

usually

respond

to

acyclovir,

especially

in

immunocompromized patients.
Shingles and herpangina are other examples of oral vesiculo-ulcer conditions
with viral etiologies. Varicella is distinguished by its dermatomal distribution
along the respective branch of the trigeminal nerve. Herpangina, caused by the
Coxsackie virus, is common in children and usually is seen in the posterior
region of the mouth and pharynx.
Behcet\'s syndrome is characterized by similar ulcerations as discussed above,
but also includes uveitis, urethritis, and arthralgia, in addition to skin, vascular,
and neurological involvement. These findings usually are not present
simultaneously, thus a careful history is integral to the evaluation.
Crohn\'s disease is an idiopathic chronic inflammatory disease that can involve
any part of the gastrointestinal tract. Oral ulcers can be seen, but biopsy reveals
characteristic chronic granulomatous inflammation.
Squamous cell carcinoma should be entertained in the initial presentation of a
solitary ulcer that does not resolve in a timely manner. This is of higher
concern in the patient with a history of tobacco use and/or alcohol
consumption.
Mouth and genital ulcers with inflamed cartilage characterize MAGIC
syndrome. As part of this syndrome, patients can also have fever, pharyngitis,
and aphthous ulcers.
FAPA syndrome was described by Marshall and colleagues based on a group of
12 pediatric patients with periodic fever, aphthous stomatitis, pharyngitis, and
adenitis.8 Several possible cases have been described in adults, but no
definitive tests exist for the diagnosis of this condition, further research is
necessary.
Mucocutaneous diseases such as erythema multi-forme, erosive lichen planus,
cicatricial pemphigoid, and pemphigus vulgaris should also be considered.1
These conditions are commonly accompanied by typical skin lesions which
can be evaluated by biopsy.

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The differential of recurrent apthous stomatitis and herpes simplex.

11. There is an ulcers, but why is it hurt when its being touched?
There is inflammation in the ulcer and the injury upto the lamina propria which
it is contains many free nerve pain
.
12. Why the lymph glandula hurt and swollen?
Lymph nodes are part of our immune system. Our body has approximately 600
lymph nodes, but only in the submandibular area (the lower mandible; sub:
bottom; mandible: the lower jaw), armpit or groin that felt normal in healthy
people. Encased in a fibrous capsule that contains a collection of cells forming
the body's defenses and is a screening antigen (foreign protein) of the lymph
vessels that pass through it. Lymph vessels that flow to the lymph nodes. the

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location of lymph nodes will be known flow of lymph vessels that pass
through it.
Because bypassed by the flow of lymph vessels that can carry antigens
(microbes, foreign substances) and has immune cells so if there is an antigen
that infect the lymph nodes can produce immune cells that much more to
overcome antigen so that the lymph enlarged nodes. Enlarged lymph nodes can
be derived from the addition of immune cells derived from the lymph node
itself such as lymphocytes, plasma cells, monocytes and histiocytes, or because
the arrival of inflammatory cells (neutrophils) to overcome the infection in the
lymph nodes (lymphadenitis), infiltration (entry) of malignant cells or
accumulation of metabolites disease macrophages (Gaucher disease)
By knowing the location of enlarged nodes then we can mobilize to the
location of the possibility of infection or cause enlargement of the lymph node.
13. Is there any relation between ulcers and crowded tooth?
Dealing with oral hygene, it could be from how to brush your teeth.

CONCEPT MAPPING

PASIEN

PEMERIKSAAN

SUBYEKTIF

OBYEKTIF

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DX: RECURRENT
APTHOUS
STOMATITIS

TREATMENT

BIBLIOGRAPHY

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Warwick, Roger; Peter L. Williams (1973) [1858]. "Angiology (Chapter 6)". Gray's
anatomy. illustrated by Richard E. M. Moore (Thirty-fifth ed.). London: Longman. pp.
588785.

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Assoc. 1992 Oct;123(10):83-86.

Petersen MJ, Baughman RA. Recurrent aphthous stomatitis: primary care


management. Nurse Pract. 1996 May;21(5):36-40, 42, 47.

Fischman SL. Oral ulcerations. Semin Dermatol. 1994 Jun;13(2):74-77.


Schneider LC, Schneider AE. Diagnosis of oral ulcers. Mt Sinai J Med. 1998 OctNov;65(5-6):383-387.

Porter SR, Scully C, Pedersen A. Recurrent aphthous stomatitis. Crit Rev Oral Biol
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MacPhail L. Topical and systemic therapy for recurrent aphthous stomatitis. Semin
Cutan Med Surg. 1997 Dec;16(4):301-307.

Rogers RS 3rd. Recurrent aphthous stomatitis: clinical characteristics and associated


systemic disorders. Semin Cutan Med Surg. 1997 Dec;16(4):278-283.

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