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Non-Infective Stomatitis - Part 1 — Transcript

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0:01Let's go back to the concept of
0:02ulceration. What does an ulcer mean? It
0:05is a break in a lesion. Its floor is
0:08the connective tissue. Right? Okay.
0:12Actually, we have several causes for
0:14the break. Right? We have infection.
0:17Infection induces apoptosis in cells.
0:20And cells undergo disintegration or,
0:23for example, necrosis. What do necrotic
0:26agents induce in cells? Disintegration.
0:29All these causes can lead to ulceration
0:32. Mechanical irritation can also occur.
0:34Right? Such as trauma. It can cause
0:40mechanical disintegration. Or it can
0:43cause a break in the epithelial
0:45continuity.
0:48>> Usually, oral ulcers heal, as we agreed
0:51, within
0:53>> a few days.
0:54>> A few days, at most
0:57>> two weeks, okay. A few days, at most
0:59two weeks. After two to three weeks, if
1:02there are no signs of healing, it is
1:04classified as non-healing. And we start
1:07thinking about what lesions are
1:09classified under non-healing ulcers. We
1:12need to ask ourselves. Also, when we
1:14see an oral ulcer, we look at the
1:16characteristics of that ulcer. Is it a
1:18recurrent ulcer that comes and goes, or
1:20has it never appeared before? Is it
1:22about the number? The number of ulcers:
1:26is it single? Is it multiple? Does it
1:28appear? Like crops of a large group of
1:31ulcerations. We also need to ask about
1:33its size. Is it small, tiny? More than
1:38tiny, 3 to 7 mm. Large ulcers, more
1:42than 1 cm ulcer. Okay. All these
1:45questions help us categorize it under
1:47the diagnosis. Or narrow down the
1:49differential diagnosis. We also ask
1:51patients if there is a triggering
1:53factor. Did you have this stomatitis or
1:55ulceration after something happened?
1:59Did you eat something, for example, and
2:00then start feeling pain? Are you, for
2:02instance, under a lot of stress lately?
2:05Did you get pain in your mouth
2:07afterwards? Did you have the flu, for
2:09example? Did you get sick? We are...We
2:17are a very small group. Please, if you
2:21don't feel like being in the mood,
2:24attend the lecture. And there are
2:26things. More entertaining things you
2:29want to do, please, honestly, Fahd, I
2:31don't have a problem, I don't find it
2:34offensive or anything like that, it's
2:36fine. Okay, but I'm very. I get very
2:40distracted when I see someone laughing
2:41or talking. I mean, a simple smile is
2:44fine. I let it slide, but continuous
2:46smiling. Don't laugh, I swear, they
2:49don't laugh. Okay? She is laughing at
2:53me. Either you are distracted by
2:54something else, the diseases are not
2:56funny. Okay? In any case, if you don't
2:59feel capable of controlling yourself,
3:00please. Go let out your laughter. Come
3:05in whenever you're comfortable, no
3:06problem. Okay? Well. Traumatic reaction
3:13. Local trauma, okay? Causes
3:18ulcerations. What kind of things can
3:21cause local trauma? What can cause us
3:25injuries?
3:25>> Biting, the simplest thing we do often.
3:28Right, we chew while we eat, and while
3:30we talk, by mistake. The buccal mucosa
3:33gets caught in the cusps of the
3:35posteriors. Okay, it causes biting or
3:37traumatic ulceration on the lateral
3:39border of the tongue. It causes
3:42ulceration on our lips. It causes
3:44ulceration, right.
3:47>> Orthodontic treatment is also
3:49considered, of course, a traumatic
3:51cause. But what? It's not iatrogenic,
3:54you didn't cause it yourself. Okay. I
3:57can cause unintentional injuries to
3:59myself, like biting, accidental biting.
4:02Okay. And other things can also cause
4:04me injuries. Okay. What kinds of things
4:07cause injuries? Like orthodontic
4:09treatment. The brackets, the wires of
4:11orthodontic treatment, can cause
4:14ulcerations. Patients who get braces,
4:17especially the first few months, the
4:20patient isn't comfortable, okay. The
4:23denture flanges, the plastic of the
4:25denture that sits on the buccal and
4:27lingual mucosa, usually isn't 100%
4:29seated correctly. It is usually too
4:31long, okay. Now, being longer than
4:34normal, every time the patient eats,
4:36opens their mouth, or speaks, it’s
4:38like a knife hitting the vestibule.
4:41>> It causes ulceration. Okay. Try to
4:47arrive on time. Okay. Go ahead. So,
5:00there are things that cause me trauma.
5:02I have iatrogenic trauma. I cause it to
5:04myself. There are other things that
5:06cause me trauma. Like we said, dentures
5:08and orthodontic treatment. Also, I have
5:10chemical trauma. Where a certain
5:12chemical drops down. It causes
5:13irritation and ulceration. Like the
5:16etchant I use for composites. When
5:18preparing a tooth for a composite. It
5:22can cause a burn that appears on me.
5:26Couldn't it be, for example, a bur? Of
5:29course, an accident can cause
5:31ulceration. Right, I could have—
5:37Someone doing boxing. Nothing is easier
5:40than boxing to cut their lips. Okay, so
5:44, Falling on the ground. Especially
5:48young children who are still teething.
5:51Okay, and young children who still have
5:53a very high overjet. Their overjet is
5:55very large, they are like this.
5:59>> Okay, the position of the front teeth
6:01is still forward, and as soon as they
6:02fall, what happens? They get a lower
6:06lip laceration because the upper
6:08incisors press on the lower lip. And in
6:11most cases, we get a tooth fracture.
6:14And part of the broken tooth enters the
6:16lip. Okay.
6:19>> Doctor, when you spoke about the
6:20denture, what do you mean it's high?
6:22>> It's long.
6:23>> Long, like that.
6:24>> Long, meaning the denture, right?
6:27>> It has flanges, it has plastics,
6:29whether it's a complete denture or an
6:31RPD.
6:32>> Okay, the RPD can also have flanges and
6:36plastic.
6:37>> Okay, when it's longer than the
6:40vestibule. Or the length of the
6:42vestibule wasn't measured correctly.
6:43Which is, I have movement. When we do
6:46border molding for a complete denture
6:49and an RPD. We move the soft tissue. We
6:52move the vestibule and the frenum. Why
6:54do we record it? So it won't be too
6:56long. And cause denture ulcerations.
6:58Okay. Dentures that haven't been
7:03smoothed out.
7:05>> Those with sharp edges and sharp
7:07particles, they are like knives or
7:09needles to the patient and cause
7:10ulcerations, okay.
7:13>> Well, what other chemical trauma, we
7:15mentioned the etchant. What else causes
7:21chemical trauma? Sodium hypochlorite
7:24that we use in endodontic treatment for
7:29irrigation. In endodontic treatment, if
7:32a drop falls, it can cause burns. Okay,
7:36what else can cause a burn that appears
7:39as an ulceration? Food, hot food.
7:42>> Okay, like pizza, very hot pizza on the
7:46palate.
7:46>> On the palate. When someone eats very
7:49hot pizza, the melted cheese holds all
7:51that heat. Okay, once you eat it and
7:55there is direct contact with this
7:57melted cheese. It acts on where? On the
8:02palate. It leaves this, it makes...what
8:06bursts for us? Okay, it can be put
8:10within...What did you ask?
8:20>> They are only traumatic, we will take
8:22them now.
8:23>> What was it that you asked?
8:24>> Does vitamin deficiency cause
8:26ulcerations? I told her it causes
8:28ulcerations, but not traumatic ones.
8:30>> Okay.
8:32>> I will teach it in this lecture, it
8:34will be uploaded. Uh.
8:38>> I am now, because we are not finished
8:40yet, the second part of the lecture is
8:42not 100%complete, again, for me, the
8:44study is from the book.
8:46>> Doctor.
8:47>> Book, meaning the exam comes from the
8:49book.
8:51>> Study from the book.
8:52>> But there is nothing outside of your
8:53explanation, right?
8:55>> Study from the book. Now, I put these
8:57slides for myself, so I remember what I
8:59want to say. It gives me direction. I
9:00put extra pictures in them. I put
9:02histopathology that is not in the book,
9:04to help you understand. Okay. But the
9:07study is from the book, fine. You can
9:10take this as a guide. You can take this
9:12to focus the information. But for me,
9:15the study is from the book. I will
9:16upload the slides, okay. But study from
9:18the book.
9:19>> Doctor, is that ulcer below...
9:21>> That ulcer below.
9:22>> Yes, but it is not a traumatic ulcer,
9:24but within the eosinophilic ulcerations
9:26, you will see that it is...
9:27>> Ah.
9:28>> Among the following ulcers. Well, what
9:30is the most common site where traumatic
9:33ulcers occur? Lips.
9:35>> Buccal mucosa, lateral border of the
9:37tongue, those are the most common
9:40places where they occur. Okay. We don't
9:58have...It won't be induration.
10:06>> Which is the hardness in Arabic, we
10:08call it induration. Okay, how sometimes
10:11, for example, a cyst is inflamed, you
10:13feel it, you feel it hard.
10:15>> We have a cyst that remains soft.
10:17>> Traumatic ulcers do not have induration
10:21. Okay. Now I will tell you which one
10:23has induration. So, what characterizes
10:27traumatic ulcers in terms of the
10:29characteristics of their border? Their
10:33border, but they are ragged ulcers,
10:36ragged ulcers are irregular. Okay. Why
10:40are they irregular? Because the cause
10:43is a mechanical break. Okay. It is not
10:46a vesicle that burst and left behind a
10:49circular ulcer. Okay. Regular borders?
10:53No, the borders in traumatic ulcers are
10:56...
10:56>> Ragged. Okay. As you can see in this
11:00picture, we forgot to mention that one
11:03of the most common causes of an ulcer
11:05is anesthesia. Okay. Which is
11:08anesthesia. Patients come, and we give
11:10them an inferior alveolar nerve block.
11:12With the nerve block, we numb half of
11:14the lower jaw. We are effectively
11:16numbing the inferior alveolar nerve, to
11:18numb the dental branches of the
11:20alveolar nerve. And because we numbed
11:23the trunk, the mental nerve also gets
11:25numbed. As a result of the inferior
11:27alveolar block, the chin and lips of
11:29the affected side or of the anesthesia
11:32get numb. Okay. Young patients who are
11:36five or six years old, taking the
11:38inferior alveolar block for the first
11:41time, the lack of sensation and
11:43anesthesia in this area bothers them a
11:45lot. Okay. So they keep checking if
11:48their lip is there. How do they check
11:50if their lip is there? They start like
11:52this, then...
11:54>> Now, when we bite our lip by mistake,
11:56we avoid biting that area again because
11:58it starts to hurt us, right? But they
12:00don't feel it.
12:01>> They don't feel it because they are
12:02numbed, and they literally keep eating
12:04their lip. Okay, God bless you. Yes,
12:10that's why one of the most important
12:12things to consider when administering
12:14local anesthesia that numbs the lips,
12:17whether upper or lower. In this area,
12:20we must give an indication to the
12:22patient to be careful not to bite their
12:24lip. For children, we place a cotton
12:26roll to keep them away from the teeth
12:28so they don't bite them. Okay. Well,
12:35for traumatic ulceration, we must
12:38remove. The cause; as long as the cause
12:42exists, the ulcer will regenerate and
12:44will not heal. Once you remove the
12:47cause of the ulcer, the trauma, the
12:50source of the trauma, the ulcer will
12:52begin to heal, okay. So, remove the. If
12:56I have a broken tooth with a sharp edge
12:58, round it off, or extract the tooth.
13:01If I have a long flange on a denture,
13:04shorten it and round it off. If I have.
13:09Orthodontic treatment, apply wax, or go
13:11to the doctor and have them trim. The
13:15long wire.
13:17>> Yes.
13:18>> Doctor, didn't we say that? Even if
13:24it's not well, it doesn't go away on
13:26its own.
13:27>> It goes away on its own, unless it's a
13:29very severe ulcer.
13:32>> Okay, it goes away on its own once the
13:34anesthesia wears off, but it takes
13:35three hours for the anesthesia to wear
13:37off. Imagine chewing on your lip for
13:40three hours; what happens? A severe
13:42ulcer.
13:45>> To what? To alleviate what?
13:51>> I mean, does something hot remove the
13:52anesthesia? Anesthesia must take its
13:53time, according to the dose the doctor
13:55gave. Pharmacokinetics, you know, the
13:57half-life of it. It's fixed. Okay. I
14:01always keep an eye on my young child. I
14:04keep the cotton roll here and give them
14:05an indication not to bite. Even if they
14:08bite once, the patient shouldn't keep
14:09biting. I mean, those who don't follow
14:12these instructions, a child might chew
14:15their whole lip, cutting it off. Do you
14:18understand what I mean? This causes
14:20scarring, which is a problem. I mean, a
14:23small ulcer will heal. But if it's very
14:26large, it will take a very long time.
14:28The patient will be in a lot of pain.
14:30Okay. Well, after I remove the cause, I
14:35need to reassess. Once the cause is
14:38gone, the symptoms will subside and it
14:40will heal. Do you understand? Do we
14:44raise a red flag? We raise a red flag
14:47when the traumatic ulcer lasts for more
14:50than 10 days. I need to see, is it
14:52actually—I have to reassess once more
14:55. Is it trauma, cancer, or trauma that
14:59got infected? A traumatic ulcer that
15:02got a bacterial or fungal infection,
15:04for example, which delayed the healing.
15:07Or, okay, I go back and do a biopsy. I
15:13might take. Okay, with this biopsy, I
15:17can see if there is dysplasia, if there
15:19is carcinoma, or if there is secretion.
15:23Alright. Okay, we've discussed all
15:28these things. Another type of traumatic
15:30ulcer is the eosinophilic ulcer. Okay.
15:33So, the eosinophilic ulcer is a
15:35traumatic ulcer. Then why did we
15:37classify it separately? Because there
15:39are actually differences between them.
15:41The first difference in the
15:42eosinophilic ulcer is that the cause of
15:44the ulceration remained; it didn't go
15:46away. We didn't treat the cause of what
15:48.
15:49>> Of the ulceration, fine. It remained
15:52chronic for a very long time. So it
15:54turned from a regular traumatic ulcer
15:57into an eosinophilic traumatic ulcer,
16:00which is the ulceration. Well, what
16:03characterizes it? What characterizes
16:05this ulcer? Because the histopathology
16:08of an eosinophilic ulcer is actually
16:10different from a normal traumatic ulcer
16:12. In a normal trauma, any injury...The
16:16first immune response is lymphocyte
16:18infiltration, macrophages, and
16:21monocytes. They infiltrate the site
16:23where I have the ulcer. This is normal
16:26to protect it and stimulate healing.
16:28This is normal, okay. In an
16:30eosinophilic ulcer, because it remained
16:32chronic for a very long time...The
16:33cause continued, continued, and
16:35continued for a very long time. The
16:37immune response shifted from a normal
16:39immune response to an abnormal one. We
16:42had infiltration with eosinophils, okay
16:45. It was no longer neutrophils and
16:47macrophages. I had eosinophil
16:49infiltration. As a result of eosinophil
16:52infiltration, it brings with it, or
16:54creates, granulation tissue. Okay, this
16:58granulation tissue is accompanied by
17:01scarring. That is why eosinophilic
17:05ulcers persist for weeks as a
17:07non-healing ulcer. There is nothing to
17:10stimulate it to heal. I do not have the
17:12normal immune response that secretes
17:15cytokines and initiates healing. I have
17:17...Eosinophils, and eosinophils
17:19stimulate granulation tissue. I have a
17:24scar. And it doesn't heal for weeks. It
17:26doesn't heal, okay. For weeks, it
17:29doesn't heal. And if it happens, it
17:31happens. Okay. So...The immune response
17:43shifted from normal to abnormal. On
17:48that. It brought...Along with it,
17:52granulation. Okay, granulation. Created
17:56an ulcer. Here we have induration.
18:04Because I have granulation tissue. Okay
18:07. Normally...An ulcer shouldn't have
18:10induration.
18:12>> Here, because I have granulation due to
18:14the eosinophils. It became indurated.
18:17How do I make it heal, exactly? If the
18:19cause is present, I must remove it. The
18:21cause, now, is possible. Remove the
18:23cause, and after a while, healing is
18:24stimulated. However, the healing will
18:26take a very long time. Until we have,
18:28you know, acceptable healing. And
18:31always with healing, we have scarring.
18:33I don't have a 100%healing process.
18:37Okay. Well, I have a lesion or an ulcer
18:41here for a very long time. Could it be,
18:45you know...
18:45>> Cancer.
18:46>> Cancers, okay. So I might take samples
18:49from these. From these. What do I see
18:58in it? I see in it...I don't see it,
19:07okay. Well...What else stimulates
19:13healing in eosinophilic ulceration?
19:15Excision. I mentioned that we have
19:18granulation tissue. And even if I
19:20remove the cause, it takes a very long
19:21time. And if healing occurs, it will be
19:23accompanied by a scar. So how do I
19:24stimulate healing? I remove it, okay. I
19:28perform an excision, I remove it to
19:30stimulate the healing. Well, we have...
19:43This...Who is affected by it? Which is
19:50the neonates, who are newborns.
19:53Neonates develop, they can develop what
19:56are natal teeth, okay. Not any neonates
20:00, not all neonates get this disease.
20:02But those who have natal teeth. Well,
20:05why those who have natal teeth?
20:08Actually, these patients, their feeding
20:11method is through the skin of the
20:13mother, whether they are breastfed or
20:15bottle-fed babies. To create suction,
20:18they must create an oral seal, okay.
20:22This oral seal is not created unless
20:24the tongue rests on the ridge and the
20:26lips. Well, what has emerged on the
20:28ridge?
20:30>> You know how baby teeth are quite sharp
20:32, okay? And imagine these newborns
20:36nursing 10 to 12 times a day, with each
20:39session lasting half an hour to an hour
20:41until the baby is full. So, imagine how
20:46much they are exposed to this trauma
20:48for a very long time. It transforms
20:50from a normal situation. It gets named.
20:58Because it effectively formed while the
21:00baby was nursing. Okay.
21:05>> Doctor, about the ulceration, we
21:08discussed what changes it from
21:10traumatic to a persistent cause.
21:13Meaning, the thing that causes the
21:15trauma. For example, you keep biting
21:17your tongue. You keep biting, biting,
21:20biting, biting, biting. Even if you're
21:22wounded, you keep biting. You have a
21:23broken tooth, and this broken tooth
21:25keeps causing irritation and ulceration
21:27for months, and you don't remove it.
21:29>> It transforms from trauma to...
21:31>> It’s the same cause, but the duration
21:33persists; the cause remains.
21:34>> Yes, and the patient also has a
21:37susceptibility here, so the cause
21:40remains. How do we remove the cause?
21:44>> Excellent. How do I treat a patient who
21:47has an ulcer caused by teeth?
21:49>> If it’s supernumerary, extract it.
21:51>> Okay.
21:52>> If it’s permanent, round it off.
21:55>> Okay.
21:56>> If even rounding off doesn’t solve
21:57the problem, extract the permanent...no
21:59, extract the primary teeth, okay, not
22:01permanent, extract the primary.
22:03>> Isn't there something we can put over
22:04it to insulate it?
22:05>> This is only days old.
22:07>> When do permanent teeth come in? At six
22:10months?
22:11>> It’s impossible to put a prosthesis
22:13on a small child, even up to the age of
22:15two, three, or four. No. They barely
22:20have enough space to even put anything
22:22inside. Okay. I prefer we don't put
22:25anything, even if there is malalignment
22:27of the teeth. And once they grow up, we
22:29perform orthodontic treatment. And have
22:31it fixed. Okay.
22:34>> Could we, perhaps because it's the
22:35first year, start feeding them
22:37something else, stop the nursing?
22:39>> The problem is in the first six months.
22:41>> Impossible.
22:42>> Six months, ten times, half an hour
22:44each time at minimum—it’s too much
22:46for this child.
22:48>> But they will get a scar here, right?
22:51>> And the tooth shouldn't even be
22:52erupting.
22:53>> It’s not normal for it to erupt in
22:54this location. Nor is their mouth ready
22:57to create an oral seal while they have
23:00teeth. Be careful. Young children might
23:03nurse up to two years old. They have
23:05all their primary dentition erupted.
23:07But they have stronger jaw development.
23:11They can rest on their teeth without
23:13wounding themselves. Okay, here, no.
23:16Here, no.
23:19>> Doctor, you mentioned if it were
23:20permanent, extract it, even if it was
23:23...
23:24>> It’s going to erupt before the
23:25primary one.
23:25>> No, she meant permanent/primary.
23:28>> I meant primary, not supernumerary,
23:30okay.
23:31>> Supernumerary are permanent, right? No,
23:34I’m wrong.
23:35>> She means it's one of the original
23:36teeth.
23:36>> Yes, the original teeth, which are the
23:38primary set. Okay, it could be
23:40supernumerary, meaning an extra tooth
23:42beyond the primary and permanent. Okay,
23:44it could be that the one erupting is
23:46primary dentition, which is one of the
23:48original teeth. Okay?
23:50>> Okay.
23:51>> So, how can I know if it’s
23:53supernumerary or not?
23:54>> Maybe an X-ray.
23:55>> Ah.
23:56>> Yes, normally.
23:59>> Yes, right.
24:00>> Because it’s only days old, so...
24:03>> What do we do?
24:04>> What should I extract?
24:08>> You extract whatever it is, regardless
24:10of the consequences, okay, whether you
24:12lose the primary or the supernumerary,
24:14and you take an X-ray to confirm what
24:16it is.
24:17>> Could rounding help?
24:19>> It might alleviate it. Okay, before you
24:23go on break, one last thing: factitious
24:26ulcers or self-inflicted ulcers. These
24:29are patients who don't hurt themselves
24:31by accident; they knowingly cause
24:33ulcers on purpose, not by mistake.
24:37>> These people have problems, or
24:42psychological disorders. They have
24:45mental health issues. Like those with
24:47severe depression. Like patients who
24:49have bipolar disorder. For example,
24:52they are very prone to having the
24:54tendency to hurt themselves. Okay, but
24:58here the harm is meant to send a
25:00message to others: "I'm suffering, pay
25:02attention to me.""I'm suffering."
25:05That's why self-inflicted oral ulcers
25:07are always in the anterior area. To be
25:11visible. Okay? I want to show people
25:14that I'm suffering. I have a big ulcer.
25:17I have pain. Self-inflicted injury or
25:20trauma could even lead to
25:22self-extraction.
25:25>> Pulling out their front tooth so people
25:28notice them. Okay, self-trauma can also
25:31be with acid, for example. Okay, they
25:36have a condition. They might hurt
25:43themselves and cause self-trauma; they
25:46might have syndromes where they hurt
25:48themselves because of tics or twitches
25:51they experience. Okay?
25:53>> This also includes those who keep
25:55picking at their lips.
25:57>> Those who keep picking at their lips,
25:59we can call that a traumatic ulcer. Now
26:03, if the picking keeps happening in the
26:05same spot and isn't healing, we might
26:07call it self-inflicted, but if it's
26:10stress-related, not because...
26:12>> Yes, not because they want to show
26:15people, it gets classified as...
26:17>> Traumatic ulcer. Here, unfortunately,
26:20every time the patient lets the ulcer
26:22heal, they reopen it.
26:25>> Okay, they keep reopening it; they are
26:27aware of reopening it so that people
26:29will notice them. And unfortunately,
26:31for many patients, reaching
26:32self-inflicted oral ulcers is a step
26:34before suicide.
26:35>> Before the...
26:36>> Before suicide, before the exam. Okay,
26:39so when patients come to you with
26:41ulcers in the oral cavity that seem
26:43like factitious ulcers or
26:44self-inflicted ulcers, take the matter
26:47seriously. You might save the patient's
26:50life.
26:50>> Like in the picture, how they do it.
26:52>> Yes, here in the picture, these are
26:54self-inflicted ulcers. It’s not just
26:56me biting or hurting myself with a
26:58sharp tool; it could be with my
27:00fingernails.
27:01>> I keep picking at the gingiva.
27:05>> Picking.
27:05>> Picking, picking means to gouge.
27:08>> Yes.
27:09>> It could be with a sharp pencil lead.
27:13>> A sharp ink pen, a sharp needle, a
27:16sharp piece of metal. All of these are
27:20considered self-inflicted ulcers. Okay?
27:28Okay, take a break and we’ll return
27:29to Aphthous.
27:31>> Alright, 10-minute break. Okay, let's
27:36continue. By its name. It comes back
27:53several times. It doesn't happen just
27:57once in a lifetime and end. No, it's
27:58recurrent. It comes in...Attacks, I
28:03call them. Okay. It may come or...Next
28:17to each other, like a cluster like this
28:19. On...One of the things to keep in
28:39mind. Incidence: they can occur in
28:42people who don't have any specific
28:45disease. And they can come, they can
28:52come...For example, they come...One of
28:59the diseases. It might come...I have, I
29:09have, I have...It might come...PFAPA
29:18syndrome. I have fevers. I have aches.
29:25I also have pharyngitis. I also have
29:29cervical adenitis. It can also come
29:34from an infection. So, effectively, or
29:40it could be...Okay, or the herpetiform
29:47aphthous syndrome.
29:49>> A type of type we learn about. A type
29:51of herpes. A type of aphthous. Okay. A
29:56very important piece of information. An
29:57important clinical indication in
29:59aphthous stomatitis. In aphthae, I have
30:02ulcerations. Okay. However, these
30:05ulcers are not caused by infection.
30:08This is a very important piece of
30:09information to consider. Because it
30:11helps us with the differential
30:12diagnosis. Between it and other
30:14diseases. Especially viral infections.
30:19>> Who are the people most affected by
30:21aphthous stomatitis? Adolescents, okay.
30:26At the adolescent age, they are the
30:28most affected by aphthae. Then, as they
30:31grow up and become adults, or late
30:34adults, the recurrence of aphthae
30:36decreases significantly. So the peak.
30:40Incidence of aphthae is adults.
30:44Adolescents or teenagers. Then it
30:47decreases as we get older. I mean. For
30:50example, I am one of the people who had
30:52aphthous stomatitis. Actually, its
30:55outbreaks were in my teenage years.
30:57Around 13, 14, then as I got older, it
31:00decreased, decreased, decreased.
31:04Currently, it maybe happens once every
31:07two years. Well, we said it is
31:11recurrent, so it comes at intervals and
31:14is periodic. Okay, it comes every now
31:16and then. There might be things that
31:19trigger aphthous stomatitis. Like, for
31:23example, the seasons, change of seasons
31:25, temperatures might trigger it. Okay.
31:28Menses every month in females. Before
31:32the menstrual cycle, they get aphthous
31:34stomatitis.
31:35>> Immune system drop has a relation.
31:37>> Immune drop is a trigger.
31:39>> Now we have this table comparing the
31:41phenotypes. Before we talk about it,
31:44let's look at the pictures. I have. The
31:55first type. It is. There are, of course
32:00, these. Or conditions. There are small
32:07ulcers from 3 to 7 mm. Okay. Their age,
32:12they reach more than 1 cm or 10 mm.
32:15They are from 3 to 7 mm. They can be
32:18solitary. They can be multiple. But how
32:20many? Multiple, several. Meaning from 3
32:23to 9 maximum in an attack. Okay. Most
32:28of the time they come solitary or two.
32:33Let's talk about its characteristics.
32:35One of the characteristics of minor
32:37aphthous stomatitis. Its size is small.
32:42We have. Okay. It has, its
32:48characteristics are with regards to.
32:55Okay. It creates for us. Meaning where
32:59does aphthous stomatitis appear? The
33:03most common place for aphthous
33:05stomatitis is the non-keratinized
33:07mucosa. It is. Unlike whom? Unlike
33:18herpes. It likes...Meaning it does not.
33:41Its.
33:43>> Now, talking about the cause. Okay, of
33:45the ulceration. Okay, a break occurs
33:50for us. Degradation, the epithelium
33:53enters into apoptosis. It leaves an
33:56ulceration underneath it. This ulcer
33:57has a normal reaction to the ulcer.
34:00Neutrophils and macrophages and mono.
34:02There is nothing distinctive about it.
34:04It has no cause. Okay, we talked about
34:08the first phenotype. Let's go to the
34:11second phenotype, which is major
34:13aphthous stomatitis. Major aphthous
34:16stomatitis, the ulcerations in it are
34:19large in size. We classified it as
34:23major because the ulcer in it is more
34:25than 1 cm in diameter. Okay. The
34:32character. It is. In terms of. In terms
34:40of. And it is in terms of. We have a
34:48self. We have a halo. And we have its
34:54borders. They can be well-defined. They
34:57can be ill-defined in major stomatitis.
35:00Okay, unfortunately, in major
35:02stomatitis, the healing process takes
35:05more than a month. Okay, it takes four
35:09weeks plus to enter the healing phase.
35:11Here, it normally takes 10 days to two
35:14weeks to enter the healing phase. Okay,
35:16here a month, and it might enter the
35:18healing phase. It might be delayed even
35:21more. And the healing in it is what,
35:23with a scar. And this is the healing of
35:26the minor. Its healing is without
35:28scarring. Here, the healing is with a
35:31scar. Here, it takes days. Here, it
35:34takes more than a month. It might heal,
35:36and it might not.
35:37>> Okay doctor, around it there was like a
35:40fill, a little raised. The ulcer is
35:47there, okay, not filled.
35:51>> Okay. So, what are the sites that major
35:55stomatitis affects? It affects
35:57keratinized and non-keratinized tissue.
35:59But major can affect keratinized and it
36:02can...We might see major affecting the
36:04tongue, okay. The minor and the
36:10herpetiform, okay. Only on
36:12non-keratinized. So let's come to the
36:17third type of aphthae, which is
36:20herpetiform aphthous stomatitis.
36:23Herpetiform, why is it named
36:24herpetiform? It resembles primary
36:27herpetic gingivostomatitis, okay. In
36:30terms of ulceration, let's look at them
36:32, there is ulceration. Its size is a
36:39few millimeters in character. We have
36:42several. We have, it actually resembles
36:47primary gingivostomatitis. So what is
36:51the difference between them? First
36:52thing, primary gingivostomatitis has
36:55systemic symptoms. I have a fever. I
36:57have lymphadenopathy. Okay, I have
37:00malaise. Here, I don't have these
37:02things. This is one. Two, the systemic
37:06or herpes infection is accompanied by a
37:10very important sign or symptom.
37:19>> Wait.
37:22>> It is accompanied by desquamative
37:25gingivitis. But in herpetiform aphthous
37:28stomatitis, it is not accompanied by
37:31gingivitis. Okay. Here I can
37:33distinguish even if I didn't take a
37:35good history. I see if I have
37:37gingivitis or don't have gingivitis.
37:39Okay. It is one of the important things
37:41. The third thing that differentiates
37:43between them is the initiation. Herpes
37:46has vesicles before the ulcer. Here we
37:49have...They are similar in number, in
37:55size, in shape. They differ in the
37:58things we mentioned before. All right.
38:01Here it affects only non-keratinized.
38:06Herpes. But it affects keratinized and
38:08non-keratinized. All right. The cause,
38:17What is the reason? I don't know why it
38:19happens to people suddenly. Okay. It is
38:25not contagious. A thing, okay, why did
38:27he get it? We don't know. However, we
38:33have things that trigger the appearance
38:36of these. Those. I have aphthae, my
38:45father has it. Honestly, I have aphthae
38:47and my father has aphthae. My mother
38:49doesn't, for example. My mother, I have
38:51never heard her complain that she has
38:52ulcers in her mouth. Me and my father,
38:54always. Okay. We have a genetic
38:57predisposition. So trauma and stress
39:00come under the same category. Trauma
39:04causes stress. Pain causes stress.
39:07Exams cause stress. Okay. When you go
39:10to take international exams, you go
39:12into a lot of stress. You find that an
39:14ulcer has appeared on you. Okay. How do
39:16you know that an ulcer has appeared?
39:18While you are eating or drinking, you
39:21find that there is an area that hurts
39:23you.
39:24>> You start to have a burning sensation.
39:26>> You go to the mirror. Why is it burning
39:28here? You hold your lip, ah, I have an
39:31ulcer here. Your tongue, ah, here I
39:35have an ulcer. You open your cheek, you
39:37find you have an ulcer. Did you have
39:39trauma here? No, we didn't have trauma.
39:41I am sure that I don't have, meaning I
39:43don't have a traumatic cause. Okay, it
39:46is likely stress. What are the other
39:50causes? Or...When immunity decreases,
39:59the rate increases. They have erection
40:09problems because of, because of,
40:11because of. Okay, all these patients
40:18have absorption problems. Especially
40:23with vitamins, like vitamin B12,
40:25vitamin B2, vitamin B6, they develop
40:30absorption problems. Iron, folic acid,
40:33they have a severe deficiency in them.
40:36This leads these patients to develop
40:39aphthous stomatitis. Who else are the
40:41patients that have problems falling
40:43into this category? Bariatric surgery.
40:47Patients who undergo weight-loss
40:49surgeries, like stomach reduction,
40:51gastric banding, or bypass; all these
40:54affect the absorption process, so these
40:56patients usually get anemia after
40:59losing a lot of weight. They develop
41:01anemia due to malabsorption.
41:03Hematologic deficiencies. Patients who
41:05have, for example, thalassemia.
41:08Patients who have sickle cell anemia.
41:10Those who have...Anemia, B12 or B6
41:14deficiency anemia are also prone to it.
41:17They are also more prone to aphthous
41:19ulcers. Hormonal imbalances also
41:26trigger aphthous outbreaks, which is
41:28why the first incidence of aphthae in
41:30the population or individuals is at
41:33puberty. Okay, when a patient reaches
41:36puberty, you find that they start to
41:38develop aphthous stomatitis. I find
41:41recurrences in females before
41:43menstruation. Before the menstrual
41:45cycle, we find that they have an
41:47outbreak of aphthous stomatitis. I
41:49forgot to tell you a very important
41:51piece of information that it...
41:59>> 25%of the population have suffered or
42:02are suffering from it. If we do a
42:07survey here, with about 60 people, we
42:09have 12 people who have surely been
42:11affected once in their lives. What do I
42:21find in aphthous stomatitis? Before we
42:25have an outbreak of the ulcer and see
42:27it become a real ulcer, we have a
42:29prodromal phase.
42:32>> I feel burning and pain before the
42:35ulcer appears by a few hours; four to
42:38six hours, I have burning in that area,
42:42and then when I look, I find an
42:44ulceration. So I have a prodromal phase
42:48. Who else has a prodromal phase
42:49besides aphthae? Which diseases have a
42:54prodromal phase? You feel it before the
42:57symptoms appear.
42:59>> Herpes, herpes labialis, right?
43:02Shingles.
43:03>> Correct.
43:04>> Herpes zoster, all of them have a
43:06prodromal sensation before the symptoms
43:09appear. Plus, with aphthous stomatitis,
43:11I have a tingling sensation and a
43:13burning sensation. A couple of hours
43:15later, an ulceration occurs. What
43:18happens in this phase? Neutrophil
43:21infiltration occurs where the ulcer is
43:24going to be. Okay? Why? We don't know
43:27why. The infiltration of neutrophils
43:30releases cytokines. It puts the
43:33epithelial cells into apoptosis. And
43:36then the ulceration forms. Okay?
43:40>> Well, once the ulcer occurs, what is
43:42the histopathology or pathophysiology?
43:44What is the typical pathophysiology?
43:47Neutrophil, macrophage, and monocyte
43:49infiltration. To protect the ulcer from
43:52infection, okay. And to help with
43:54healing. There is nothing unique about
43:57the ulcer. When do we take a biopsy? If
44:01the patient has major aphthous
44:02stomatitis. It lasted more than a month
44:04. A month, and there are no signs of
44:06healing. On the contrary, there is a
44:08worsening of the symptoms, okay. The
44:10pain increased. We had bleeding from
44:12the ulcer. The ulcer grew larger. Here
44:14I take a biopsy, firstly to rule out
44:17carcinoma, alright. Or it developed
44:22secondary infection. Or there was a
44:27change in the symptoms, okay. It helps
44:32us in how we approach aphthae from the
44:34history and the clinician's story. It
44:36is the diagnostic feature we have for
44:39aphthous stomatitis. When I take a good
44:42history from the patient, whether
44:43regarding the recurrence or the
44:45frequency of the ulcer. Does it always
44:47come to you? How often does it come,
44:49okay, how much? How long does it last?
44:53Does it last 10 days and then heal?
44:55Where does it appear? Does it appear in
44:56the same place? Does it appear in
44:58several places? Does it come as one, or
45:00several; what is the number? Okay, its
45:03size. All these questions help us in
45:06what the diagnosis is. I can also ask
45:11him if he has any systemic disease.
45:14Okay, he might have Behçet's disease,
45:16and he knows he has Behçet's disease.
45:18But he doesn't know that with Behçet's
45:21disease, he gets aphthous stomatitis.
45:23So I ask him about his health. Do you
45:25have any of these diseases: one, two,
45:27three, four? Okay, it helps me confirm
45:31my diagnosis. Blood tests also give us
45:36an indication of any blood
45:38abnormalities. That stimulate or act as
45:43an associated factor for RAS or
45:46systemic aphthae. Like the Mean
45:50Corpuscular Volume, when it is high,
45:53that means I have. And the RBCs are low
45:58, it means I might have iron deficiency
46:02anemia. Okay. Well, when I have it
46:07small, low MCV. It means I have
46:11microcytic anemia. Which means I might
46:13have a B12 deficiency.
46:14>> What is MCV?
46:16>> It's just
46:17>> Mean Corpuscular Volume, which is the
46:19size of red blood cells.
46:21>> Okay.
46:21>> Okay.
46:25>> Doctor, what causes necrosis to the
46:27epithelium or makes it undergo
46:29apoptosis?
46:32>> What makes it undergo it is the
46:33infiltration of neutrophils.
46:35>> Neutrophils secrete cytokines.
46:37>> Yes.
46:37>> Neutrophils came to this place, it's
46:39not known why they come, okay.
46:41>> They secreted cytokines, these
46:44cytokines stimulate cells to enter,
46:47okay, so an ulceration is created.
46:49>> Okay. Management of RAS, first of all.
46:54Because I made the correct diagnosis, I
46:56can reassure the patient. I reassure
46:58them not to worry, this aphthae comes
47:00and goes. A quarter of the world has it
47:03, okay. When I say a quarter of the
47:04world, it's because actually a quarter
47:06of the world has it. Okay. Well, then I
47:08want to alleviate. The symptoms. I have
47:11two goals for the treatment of aphthae.
47:14Control the pain. And do what? Heal. I
47:21want to relieve the pain and accelerate
47:24the healing. Okay, he has minor aphthae
47:28. What can I help him with? I can give
47:30him a corticosteroid. Very famous here
47:33in the country, which is Oracort E.
47:35Okay. This Oracort E is an ointment. It
47:38is cortisone with vitamin E cortisone.
47:41It creates a very viscous layer that
47:43protects. The ulcer from secondary
47:46infection. And protects the ulcer from
47:48direct friction. Because it is a thick
47:50layer, you know, on the ulcer. It is
47:52cortisone, so it reduces inflammation.
47:54Okay, it stimulates healing. And
47:56vitamin E stimulates basal cells to
47:58proliferate, and it closes the ulcer.
48:00It also stimulates healing, okay, in
48:03the context. Of treating RAS, okay.
48:10Well, what else besides topical
48:12corticosteroids? I give an indication
48:16for the patient to rinse with
48:17chlorhexidine and tetracycline
48:19mouthwash. Okay. Or, fine. Either
48:22chlorhexidine. Or tetracycline
48:24mouthwash. Especially when? When the
48:26patient has major aphthae or
48:28herpetiform aphthae. Major aphthae are
48:32very large. We are afraid of. It
48:34getting an infection. Okay. As for
48:36herpetiform, they are very numerous.
48:38And spread across all our mucosa. So
48:42the patient is also at risk of
48:44secondary infection. So we help them
48:47with adjunct treatment. I give them
48:50antimicrobial and antibiotic agents. I
48:54could use topical salicylic acid, which
48:57is like aspirin. Topically applied to
48:59the site of the major aphthous. It
49:01relieves the pain. Also, I can use a
49:04local analgesic, like BabyGel. Okay, it
49:07is a topical analgesic. Applied, it can
49:11relieve the pain. Well, if I have a
49:13major aphthous ulcer and it's resistant
49:15to treatment. How can I treat the
49:18patient? I could give them
49:20immunosuppressives. I could give them
49:22azathioprine. I could. Dapsone, or
49:25perhaps. Then we talk, and I can also
49:28give them colchicine as an
49:30anti-inflammatory drug. Okay, once
49:33again. The goal of treatment is for me
49:36to control the pain. To favor healing.
49:42Okay, here I have a summary of
49:44recurrent aphthous. Finally, we have a
49:47video for the aphthous ulcer types.
49:54Hours. Here the patient starts to feel
49:57the prodromal sensation. At the fourth
49:59to sixth hour, the outbreak of the
50:01ulcer begins. Okay, we have a complete
50:05ulcer now. It will continue until the
50:08sixth or seventh day. Then you will see
50:11how the redness will subside. And the
50:13fibrin layer will fade. Okay. By day 13
50:20, healing begins for us. It disappears
50:23just as it came, it goes away.
50:25>> It remains painful throughout all these
50:27days, but only the first two days.
50:29>> No, not the first two or three days, it
50:31lasts until the fourth or fifth day.
50:33Now, from the fifth day, the symptoms
50:35subside significantly. The symptoms
50:37subside a lot, but the first four or
50:38five days are really, really painful,
50:40truly painful, it goes away on its own.
50:43>> It goes away on its own even if you
50:45don't apply corticosteroids, even if
50:47you don't wash it with anything. Minor
50:50ones go away as they came, okay.
50:53>> Well, does anyone have any questions?
51:02Let me take attendance.

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