Stomatitis Aphtosa

Dr Dewi Priandini, drg, Sp.

Pm
Department of Oral Medicine
Faculty of Dentistry
Universitas Trisakti
 Definisi
⚫ Inflammation of the mucous lining of any
of the structures in the mouth, which may
involve the cheeks, gums, tongue, lips, and
roof or floor of the mouth.
⚫ The word "stomatitis" literally means
inflammation of the mouth.

Etiologi
Penyebab belum pasti
 suatu peradangan mukosa
stomatitis mulut yang ditandai dengan
erosi atau ulserasi rekuren,
berbentuk oval, berbatas jelas,
aphthae
dikelelilingi daerah eritema,
ditutupi oleh pseudomembran
canker sores
berwarna putih keabuan baik
soliter maupun multiple
STOMATITIS AFTOSA REKUREN
? pada
Insidensi SAR terjadi Lokal:
2-66% dari populasi di dunia genetik
Sistemik :
Faktor Etiologi : Tidak
Imunosupresion
Diketahui
Psikogenik
Faktor Predisposisi
defiesiensi
Self Limiting disesase nutrisi/ vitamin
Faktor Predisposisi
⚫ LOKAL • SISTEMIK
•
Alergi
• Behcet’s D
•
Trauma • Crohn’s D
•
mkn./Mnm • Coeliac D
•
Disfungsi sal pencernakan • Cyclic Neutropenia
• Endocrine Dist D.M
•
Genetik
• Nutritional Def
•
Mikro Organisme • Immuno Suppresion HIV
• Steptoccocus Infection,
• Virus :VHS,Cytomegalo V Aids
• Haematologic Def
Epstein B V, .Fe, Folate, Vit B12
Var.Zoster • Stress
• Hormonal :
Haid,Menopause,
Kontrasepsi
 Tipe stomatitis aphthosa

APHTOSA MINOR APHTOSA APHTOSA

HERPETIFORMS
• 85% paling sering • MAYOR
Jarang
• Berbentuk bulat • Lesi bersifat
• Lesi berbentuk
atau oval multipel (10 hingga
• Diameter < 1 cm,
bulat atau oval
• Diameter > 1 cm 100 ulser),
• Lesi sembuh
• Penyembuhan lesi diameter 1-3 mm,
10-14 hari tanpa
meninggalkan dari ulser mayor dan dapat
jaringan parut dapat beberapa bergabung
• Biasa terjadi pada minggu hingga 1 membentuk ulkus
mukosa rongga bulan dengan/ tanpa yang tidak
mulut yang tidak meninggalkan beraturan
CLINICAL FEATURES OF SAR
 Mekanisme
Rasa panas/gatal Makul/papul merah
pd daerah lesi

Jaringan nekrotik Pemucatan di bgn tengah

Ulserasi dangkal
Putih kekuningan Membesar
Penyembuhan
Bulat/oval/ bertahap 2-3 hr Tepi Tengah
tdk beraturan Lengkap 10-21 hr
Kelim /tepi merah + Dgn/tanpa pengob
sakit
SA Minor
SA Mayor
SA Herpetiform
 MASALAH

Penyebab ≠ pasti Banyak peny mirip SAR

Pengobatan ≠ St. herpetika Kars sel

spesifik/ skuamosa
tak tuntas
menular fatal

Tata laksana
sering salah
 Mengurangi rasa
sakit

TUJUAN PENGOBATAN Mempercepat

penyembuhan

Mencegah
infeksi sekunder
Working diagnosis
DIAGNOSIS * Anamnesa * Gamb Klinis * Pem. Lab

The correct diagnosis of RAS is dependent on a

detailed and accurate clinical history and
examination of the ulcers. The main points to be
elicited in the clinical history are shown in Table 1.

it is necessary to carry out an external examination

including palpation of the cervical lymph nodes

the investigation tests for patients with persistent

RAS including hemoglobin and full blood count,
erythrocyte sedimentation rate/C-reactive protein,
serum B12, serum/red cell folate, anti-gliadin, and
anti-endomysial autoantibodies
The Important Features to be noted from General Practioners
The investigation tests for patients with persistent recurrent
aphthous stomatitis
 Differential diagnosis
⚫ By the location of the lesion or the presence of an
additional symptom.
⚫ HSV infections may have similar-appearing lesions; primary
HSV infections present with a diffuse gingival erythema and
fever preceding oral mucosal vesicles and ulcers.
⚫ Ulcers of RAS are not preceded by fever or vesicles, and they
occur almost exclusively on movable oral mucosa, such as
the buccal and labial mucosa, tongue, and soft palate.
⚫ SAR be differentiated from varicella zoster virus infections
(shingles) based on clinical presentation (VZV) lesions have
a unilateral extraoral and intraoral distribution pattern
following the trigeminal nerve) and symptoms (VZV )
infections have a prodrome of pain and burning prior to
lesion eruption).
Differential diagnosis
⚫ Recurrent aphthous stomatitis (idiopathic)
⚫ Drug Induced
Fixed Drug eruption, linear IgA bullous dermatosis, drug-
induced bullous pemphigoid, drug-induced pemphigus Stevens-
Johnson syndrome, toxic epidermal necrolysis
⚫ Autoimmune diseases
Crohn’s (orofacial granulomatosis), Behcet’s, Celiac, systemic
lupus erythematosus, Lichen planus Linear IgA bullous
dermatosis, Wegener’s granulomatosis
⚫ Trauma
Dental appliances, necrotizing sialometaplasia
⚫ Hematologic
Anemia, neutropenia, hypereosinophilic syndrome
⚫ Fever syndromes
Cyclic neutropenia, PFAPA (periodic fever, aphthous stomatitis,
pharyngitis, cervical adenitis)
Differential diagnosis
⚫ Vesiculobullous disorders
Pemphigus vulgaris, linear IgA disease, erythema multiforme
⚫ Nutritional Deficiency
iron, folate, zinc, B1, B2, B6, B12
⚫ Viral
Coxsackie A, herpes simplex, herpes zoster, cytomegalovirus,
Epstein-Barr, human immunodeficiency virus
⚫ Bacterial
Tuberculosis, syphilis
⚫ Fungal
Cryptococcus neoformans, Blastomyces dermatitidis
⚫ Inherited
Epidermolysis bullosa, chronic granulomatous disease
⚫ Other
hormonal disturbances, malignancy, smoking, hormonal
(menstrual-associated)
Diagnosis banding

Ulkus kronis
 Kars sel skuamosa St aftosa mayor

- Trtm usia lanjut - Semua usia, trtm 10-19 th

- Berbulan-bulan - Bbrp jam - bbrp hari

- Penebalan tepi nyata - Tepi meradang

- Indurasi jar sekitar lesi - Palpasi ≠ perlu

- Pemb kel getah - Pemb kel getah
bening ≠ sakit bening sakit
- Sakit minim / ≠ - Sangat sakit
- ≠ peradangan - Sering disertai
sekitar lesi edema sekitar lesi
Diagnosa Banding Major Apthae
- karsinoma sel skuamosa
ST. Aftosa Mayor

Karsinoma Sel
Skuamosa
 St aftosa rekuren St herpetika rekuren

- Mukosa mlt melekat

- Mukosa mlt bergerak
periosteum (gingiva,
(bibir, pipi/lidah)
pal keras, ridge alv)
- Setiap usia,
- Setiap usia,
> sering usia
> sering usia muda
pertengahan & lanjut
- Dimulai dgn kemerahan - Berasal dari vesikel yg
yg diikuti pemb jar pecah kd ditemukan
nekrotik ditengah sisa atap vesikel
- ≠ menular - Menular
Herpetiform apthtae
- infeksi primer herpes simpleks
ST. Aftosa Herpertiform
Gingiva sehat

ST.
Herpertika
Gingivitis
menyeluruh
Management
⚫ Identification and elimination etiology and
predisposing factors
⚫ Symptomatic treatment
⚫ Causative treatment
⚫ Supportive treatment
⚫ Education, Motivation and Instruction
 TATA LAKSANA
2 TAHAP

Pengendalian / Obat simtomatik &

eliminasi Faktor perawatan suportif
prediposisi
 Tahap 1 :Pengendalian / Eliminasi
Faktor Prediposisi

Faktor Prediposisi dpt diket dgn cara :

⚫ Pengumpulan data :
Def nutrisi Hormonal
Sensitivitas mkn ttt Sal penc mkn
Stres Kel darah
Genetik Imunologi
⚫ Lanjutkan pemeriksaan lab
Faktor Prediposisi
⚫ Sistemik terutama SAR : usia pertengahan &
lanjut , Jarang usia muda
⚫ Setempat dieliminasi dgn :
Eliminasi tepi gigi / karies / tambalan tajam
Hindari mkn tajam & merangsang
OH
Tahap 2 : OBAT YG BERSIFAT SIMTOMATIK

TUJUAN
Mengurangi rasa sakit
Mempercepat penyembuhan

TETAPI
≠ DPT MENCEGAH REKURENSI
Tahap 2 : OBAT YG BERSIFAT SIMTOMATIK

⚫ Obat kumur antimikroba :

Lar tetrasiklin/klortetrasiklin 2%
- rasa sakit pd St aftosa mayor
Klorheksidin glukonat 0.2%
⚫ Kortikosteroid setempat
Kombinasi dgn OraBase
⚫ Obat bersifat anestetik
Benzokain 4% dlm borakgliserin
 Tahap 2 : OBAT YG BERSIFAT SIMTOMATIK

Pemilihan obat tergantung pada:

✔ Keluhan
✔ Lamanya
✔ Keparahan
✔ Faktor prediposisi sistemik

⇨ Bervariasi untuk tiap individu

Tahap 2 : PERAWATAN SUPORTIF

⚫ DIET

⚫ VITAMIN A

⚫ OBAT KUMUR SALIN HANGAT

⚫ ISTIRAHAT CUKUP
APHTOUS L IKE ULCER
Disease and Syndromes associated: HIV
Malnutrition associated RAS
Eosinofilic Ulcer
Neutropenic ulcer
Definition
⚫ Inflammatory ulceration of the oral mucosa
mimicking recurrent aphtous stomatitis
⚫ Commonly associated with systemic condition
Aphtous like ulcer
⚫ Systemic associated RAS
⚫ Eosinophilic ulcer: traumatic ulcerative granuloma
with stromal eosinophilia (TUGSE)
⚫ Cyclic Neutropenia
⚫ HIV associated
⚫ Behcet’s disease
⚫ Crohn’s disease
⚫ PFAPA (periodic fever, aphthous stomatitis,
pharyngitis, cervical adenitis)
Systemic associated RAS
⚫ Recurrent aphtous stomatitis (RAS)
⚫ 20% of the population
⚫ Most common lesions seen in daily practice
⚫ Typically starts in childhood
RAS: Etiology & predisposing
⚫ Etiology: unknown
⚫ Predisposing factor:
⚫ Deficiency of a hematinic such as iron, folate or
vitamin B12
⚫ Coeliac disease
⚫ Menstruation
⚫ Stress
⚫ Food allergy
⚫ Behcet’s disease
⚫ Immunodeficiency
Working diagnosis
Anamnesis
⚫ Recurrent ulcers
⚫ Anemic symptoms
⚫ Very painful
⚫ Malnutrition
⚫ Vegetarian*
Extra Oral
⚫ Pale
⚫ Check : conjunctiva, skin, nails
⚫ Might or might not have limfadenopathy
Clinical features
 Oral Medicine Clinic, Jordan University Hospital, Amman, Jordan

Research : Methods
A full blood examination : Hb, S.Ferritin, S.Vit.B12, S.Folate

⚫ Study group
• 143 RAS patient, ≠ systemic diseases, ≠ drug history
• Male : female = 67 : 76 ; 17-67 years
• Disease duration : 5 – 37 years

' Control Group

• 143 patient having oral condition other than RAS
• No hematinic deficiencies, ≠ systemic diseases, ≠ drug
history
• Age and gender = study group
Result

⚫ Vit B12 deficiency : 26.6%

⚫ Iron deficiency : 16.9%
⚫ Folate deficiency :4.9%
Clinical Features

Burgan et al, 2006

Further examination
⚫ Complete blood count
⚫ Abnormalities count on Hb, Ht, RBC
⚫ Abnormalities on MCV, MCH, MCHC
⚫ MCV : mean corpuscular volume
⚫ MCH : mean corpuscular hemoglobin
⚫ MCHC : mean corpuscular hemoglobin concentration
Management
⚫ Identification and elimination etiology and
predisposing factors
⚫ Symptomatic treatment
⚫ Causative treatment
⚫ Supportive treatment
⚫ Education, Motivation and Instruction
Management
⚫ Identification and elimination etiology and
predisposing factors
⚫ Unknown etiology
⚫ Predisposing factors : hematinic deficiency
Management
⚫ Symptomatic treatment
⚫ Covering agent
⚫ Hyaluronic acid 0.5%
⚫ Chlorhexidine gluconate 0.1% / 0.2%
⚫ Tetracycline mouthwash
⚫ Topical steroid : triamcinolone acetonide 0.1%
Management
⚫ Supportive treatment
⚫ Vitamin A
⚫ Referral Hematologist Internist
⚫ Education, Motivation and Instruction
⚫ Vegetarian* food variation
Eosinofilic Ulcer
⚫ traumatic ulcerative granuloma with stromal
eosinophilia (TUGSE)
⚫ Benign ulceration due to chronic trauma, such as
dental caries, dental appliances
⚫ Do not heal, mimicking oral malignancy
⚫ Can occur at any age:
⚫ Infants : Riga-Fede disease
Working diagnosis
Anamnesis
⚫ Painless ulceration
⚫ Occur for a long period
⚫ Unresponsive on any treatment
Clinical features
⚫ Most common site : lateral or ventral tongue and
buccal mucosa
⚫ Solitary ulcer
⚫ From few millimeters to 2 cm
⚫ Margins of ulcers often raised and indurated
⚫ Yellowish base
Clinical Features

dental.washington.edu
www.scienceopen.com
Clinical Features

www.intechopen.com
Further examination
⚫ Histopathology Examination
⚫ Biopsy : band of eosinophil
Management
⚫ Identification and elimination etiology and
predisposing factors
⚫ Etiology : trauma
⚫ Symptomatic treatment
⚫ Topical steroid : triamcinolone acetonide 0.1%
⚫ Supportive treatment
⚫ Vitamin A
⚫ Education, Motivation and Instruction
Cyclic Neutropenia
⚫ Rare hematologic disorder: severe neutropenia
⚫ Characterized by
⚫ Periodic fever
⚫ Mouth ulcer
⚫ Infection
Clinical Features

www.hindawi.com
Management
⚫ RAS remedies
⚫ Caution on steroid usage
⚫ Referral
HIV associated
⚫ Oral manifestation of HIV infections
⚫ Consensus classification of orofacial lesions
associated with Pediatric HIV infection (Ramos-Gomez et al, 1999)
⚫ Lesions commonly associated with pediatric HIV
infection (Group 1)
⚫ Consensus classification of orofacial lesions
associated with Adult HIV infection (EC-Clearinghouse, 1993)
⚫ Lesions seen in HIV infection (Group 3)
Clinical Features

dentosca.wordpress.com
Shiboski et al, 2009
Management
⚫ RAS remedies
⚫ Caution on steroid usage
⚫ Referral
Behcet’s disease
⚫ Multisystem inflammatory disorder
⚫ Oral ulcer, genital ulcer and eye involvement
⚫ Others manifestation : join, neuro, cardiac, renal,
pulmo
⚫ Autoimmune disease
 International Study Group (ISG) of Behçet’s disease
Minor aphthous, major aphthous, or herpetiform
Recurrent oral ulceration ulceration observed by physician or patient, which
recurred at least three times in one 12 month period
And two of the following :

Aphthous ulceration or scarring, observed by

Recurrent genital ulceration
physician or patient
Anterior uveitis, posterior uveitis, or cells in
Eye lesions vitreous on slit lamp examination; or retinal
vasculitis observed by ophthalmologist
Erythema nodosum observed by physician or
patient,
Skin lesions pseudofolliculitis, or papulopustular lesions; or
acneform nodules observed by physician in post
adolescent patients not on corticosteroid treatment

Positive pathergy test Read by phycisian at 24–48 hours

All clinical findings are applicable to the diagram of BD only in absence of other clinical explanation.
Clinical Features
Management
⚫ RAS remedies
⚫ Referral
PFAPA
⚫ periodic fever, aphthous stomatitis, pharyngitis,
cervical adenitis
⚫ Rare disease, tends to occur in young children
⚫ Self-limiting
⚫ Non recurrent
Clinical Features
Simple vConCons complex
Simple aphtous Complex aphtous
Common Uncommon
Episodic Episodic or continuous
Short-lived lesions Persistent lesions
Few lesions Few to many lesions
Frequent or continuous
Three to six episodes per year
ulceration
Prompt healing Slow healing
Pain Marked pain
Little disability Disability
Limited to oral cavity May have genital ulcers
CONCLUSION
CONCLUSION
CONCLUSION
CONCLUSION
CONCLUSION
dpriandini@gmail.com