 Welcome to yet another session of Oral Medicine and Radiology series. Today we will be dealing with Aptis ulcers. Before we go to an Aptis ulcer, let's see what's an ulcer? By definition, an ulcer is a breach in the continuity of the epithelium of the skin or the mucus membrane to involve the underlying connective tissue as a result of micro-molecular cell death of the surface epithelium or its traumatic framework. These are the various parts of an ulcer. This is the margin or the junction between the surface and the ulcer proper. This part is called as the edge and this is the floor which is visible and this is the non-visible part and it's called as the base. The ulcer actually rests on the base. This what you see here is the epithelium and this part is the connective tissue. So you can see that the connective tissue is involved here. So if the connective tissue was not involved, it was just a superficial area. This could have been called as an erosion. So only since this connective tissue is also involved, it is called as an ulcer. So let's go to the classification of ulcers. So according to the 11th edition of Birkitz, we can classify ulcers into four. The patient with acute multiple lesions. The patient with recurring oral ulcers. The patient with chronic multiple lesions and the patient with single ulcers. Under the patient with acute multiple lesions, we have herpes, simplex virus infections, varicella-softer infections, cytomegalo infections, coxacivirus infections, acute necrotizing ulcerative gingivitis and periodontitis, erythema-multiforme and severe forms of that. That is Steven Johnson syndrome and toxic epidermal necrolysis. Oral hypersensitivity reactions. All these come under patient with acute multiple lesions. And under patient with recurring oral ulcers, we have recurrent apistomatitis So this is what we will be dealing with today. Under patient with chronic multiple lesions, we have a list of vesiculobullous lesions actually. There is pancreas vulgaris, pyroneoplastic pancreas, pancreas vegetans, subepithelial bulus dermatosis, bulus panfegoid, mucosmineran panfegoid, linear IgD disease, epidermolysis, bulosa equisitia. Chronic bulus disease of the childhood. And under patient with single ulcers, we have traumatic injuries causing solitary ulcerations. That is your traumatic ulcers. And traumatic ulcerative granuloma. That is your esnophilic granuloma of the tongue. And then you have three other deep fundal infections. Where the histoplasmosis, gastromycosis and picomycosis. Which also called as mucomycosis. And this is another classification. Just added to make it a little bit simple to understand. This is based on etiology. You can actually divide ulcers or group ulcers based on the etiology part. It is traumatic, infectious, drug induced, ulcers associated with blood discresias, immune mediated, oral ulcers associated with dermatological disorders, oral ulcers associated with GI disorder with gastro-understandal disorders, new plastic oral ulcers and ulcers of uncertain etiology. So the ulcers of the ulcers come under ulcers of uncertain etiology. Coming to recurrent aptis stomatitis or recurrent aptis ulcer. So in short, you can call it as RAS. Short for recurrent aptis stomatitis. So recurrent aptis stomatitis is the most common oral mucosal disease. It is found in men and women of all ages, faces and geographic regions. So it doesn't actually have a particular gender predilection. Because it can be equally seen in men as well as women. It's a disorder characterized by recurring ulcers confined to the oral mucosal in patients with no other signs of disease. So this is why it's called as a recurrent aptis ulcer. The exact etiology is still unknown. Suggested causes of recurrent aptis stomatitis are local factors which include trauma, smoking, salivary gland dysfunction, microbial factors like bacterial and virus diseases, exposure to certain drugs like say, sinusitis, systemic factors like allergic reactions, stress, HIV, besieged disease or syndrome, hormonal influences, celiac disease, counts disease, intravenous ulcers, PFA-PA syndrome, magic syndrome, sweet syndrome. These are actually syndromes associated with oral ulcer formation, apis ulcer formation. Besieged disease. Here you have oral apis ulcer formation along with thing ulcers in your eyes, conjunctiva region, especially you can have also genital ulcers. Okay, that's vicious disease. It's an immediate disease. And then you have PFA-PA syndrome, which is periodic fever apistomatitis, perotitis, sorry, currentitis and agonitis. You can have apis ulcers along with all these other diseases, the conditions. In magic syndrome you have oral ulcers, genital ulcers as well as inflammation of cartilage. In sweet syndrome you have apis ulcers or oral ulcerations along with rashes in various parts of the body like your trunk or arms, etc. Then coming to nutritional and hematological deficiencies. This can also be included in the treatment of the cough. The completion of iron is in folic acid, as in V1, V2, V6, V12, etc. And there are kinetics factors, immunological factors also. Coming to the various clinical features of rheumatoid apistomatitis, mostly it is seen in the second decade of life, that is around 10 to 20 years. The problem of localized burning or stinging or pain can be felt 24 to 48 hours before proper ulcer formation. Localized area of erythema first develops within hours a small white bacterial forms with ulcerates and gradually enlarges over the next 48 to 72 hours. The individual lesions are round, symmetric, shallow, but no tissue tags are present. Multiple lesions are seen, but the number, size and frequency of these varies. So according to these, actually you can subdivide apis ulcers into three, that is minor, major and property form ulcers. It is usually seen in the freely movable oral ulcers, that is your non-characterinal mucus. The ulcers are mostly seen involving the leading and the muscle mucosa, but also occur on the tongue, the mucobacal fold, the little mouth and the soft palate. The characterized part of the lip mucosa, the hard palate and the vinge are fairly involved. So as I told you, these are the various features of apis ulcers. This here can be considered to be a minor apis ulcer, moving to its size, which seems to be less than one centimeter. This could be considered as a major apis ulcer, because it looks like it's more than one centimeter, or almost one centimeter in size. So this can be considered as a major apis ulcer. These here look like herpetiform ulcers. So here you can see small ulcers, but a lot of ulcers. So these can range from around 50 to 100 ulcers. So such a presentation of apis ulcer is called as herpetiform ulcer. As time proceeds, you can actually see that these minor ulcers or maybe small small ulcers, they can squarely form larger ulcers. Coming to the three subtypes of apis ulcers in detail. So when you check for the numbers, you can see that minor apis ulcers can range from 1 to 10. It's usually multiple. Major, it's usually one or two. You can go up to five. In herpetiform, you always have a huge range, that is from five to 100. You can have almost 50 or 100 regions in one particular area. You can have colonies or crops of ulcers. Coming to the size, you can see that it's around five to 10 millimetres. That's less than one centimetre. Major is always more than one centimetre, or it can be one centimetre. Herpetiform ulcer is always less than 0.5 centimetres. Coming to the pain sensation, the major apis ulcer, since it occupies a large area, there's a lot of nerve-indexing water, and the pain attributed can be severe. Whereas in your minor and herpetiform ulcers, it can range from 1 to 100. Coming to the duration, you can see that the major apis ulcer takes a little bit more to heal. It takes more than two weeks to heal. Whereas your minor and herpetiform ulcers, take less than two weeks. Regarding scarring, the major apis ulcer heals with scarring, whereas the other two variants don't form scars. The location is almost similar. It's usually the clay bale, or the soft palate region, or the non-catanus, the ulcer, which is in the water. Coming to the incidence, you can see that the minor apis ulcer forms the major scar, or the minor apis ulcer, which is always usually seen when compared to the major apetiform radians. The diagnosis doesn't actually require a particular lab procedure to form a definitive diagnosis. It is kind of a diagnosis of exclusion. That is, you rule out all the other conditions, including zero in on apis ulcers. You can also always see the clinical presentation and a bit of history and then you can go for this particular diagnosis. There's no particular requirement for a biopsy to provide a definitive diagnosis. You may rule out malabsorption and eliminate nutritional causes. That is, you know, replacement of iron or correlate with vitamin B-tel or keratin stores. And again, you can go for biologically mitigations if you suspect herpetic involvement. Herpetic involvement. But again, this is not really required. You can just go for the clinical presentation and exclude all the other conditions. You can just exclude nutritional states and the viral states or the viral species, you think. So this is not a definitive diagnosis, but a diagnosis of exclusion. Coming to the various differential diagnosis, a proper detailed history and a proper examination of the requisites for diagnosis of oral apis ulcers. All these can be considered to be differential diagnosis for apis ulcers. Traumatic ulcers. So here you can find a traumatic agent, maybe a sharp tooth, a jack border of a denture, a broken piece of oak, something like that. So you always have a traumatic agent. In coming to oral apis infection, you could have fever or the ulcer could be preceded by a small vasectomy or a blister. So that's how you can roll out herpes infection. In cyclic neutropenia, you have ulcers forming every 21 days. So if you go for a little bit of history, you can find out this. And then you can go in for certain flap procedures where you can check the neutrophil count during this particular day as well as the other days. So you can compare both those states and then zero in on cyclic neutropenia. In ertyma multiformae, as the name suggests, multiformae, we have various types of license. Ulcer is also one of the forms that we could find ertyma multiformae present in the oral character. So you could have blisters, or you could have ulcers, you could have vesicles, bullies, apioles, erosions, all those forms can be seen. But in ertyma multiformae, you could also have skin lesions. You could see that we have the relations of bulls-eye lesions. So that could easily help you to roll out this form of the ulcers. Coming to tubercular ulcers, usually it's seen as a salt reels. It's painless. It's seen in the tongue or the heart palate. And you will have history of a cough or something which actually brought in the infection from the lungs to the oral palate. Then again you can go for your lymph nodes and check. And then coming to sephilitic ulcer, the secondary stage, that is not the Shangri or the Gamma, but the mucocutinous lesions. They kind of resemble the apis ulcer, but again you can roll out the proper history. Coming to the treatment aspect, so as we discussed the probable causes or the etiology for the apis ulcers, this is not a very specific treatment vision. You can see that it's a more generalized kind of a treatment offer for apis ulcers. First of all, you would try to eliminate all the local factors. Try to reduce the stress, avoid acidic or salty or spicy food, abstain from alcohol or carbonated beverages or any other possible causes which can cause apis ulcerations. Then the next step is topical therapy. So we can go for analgesics or anti-inflammatory drugs, anti-microbials or cortical steroids. Under analgesics and anti-inflammatory drugs, we have lidocaine or bignocaine, diphenhydramine, benzythymine, hydrochloride, milk of magnesium, etc. So usually a lidocaine or lidocaine gel or ointment is given. It's applied topically. You can also use benzythymine mouthwash. This is a particular drug which is best given as a mouthwash. So in areas where you cannot place your finger or the applicator, there may be extreme parts like the oral cavities, peripheral part or areas where your finger cannot reach or penetrate or can cause nausea. You can use this particular formula. Gargle form or mouthwash form. You can actually gargle and apply the medication into a particular area. Then you have anti-microbials like chloroxidin gluconate, which is available under the commercial list. Or tetracycline or all these can be used. This again can prevent secondary infection. You can see that it is not a specific treatment. It just prevents secondary infection thereby reducing the feeling of the particular ulcer. Then when you have severe lesions which doesn't actually heal very fast include for corticosteroids, topical corticosteroids. Usually triamcinolone, epitaminosuronic, clobitazole, propionate are usually given. The most commonly used corticosteroids in the topical form is triamcinolone, etc. It is available by the name canocortortes. 0.1% is usually given. Clobitazole propionate can also be given which is actually more long-standing. But usually it is given in the dermatological lesions rather than oral lesions. But along with the norobase it can be used for oral lesions also. Then long-acting steroids like that some of this one can also be given in the form of elixes. Then in case where these ulcers do not respond to normal topical application you can go for installation injections. This is mostly given for the calcitrine cases which doesn't respond to normal medications. These again are corticosteroids given in injection form. Then there are others like amyloxenox, acentralophen, cyclosporine which are immunomodulatives or drugs which are used for cancer therapy. Cyclosporine, cyclosporine, etc. Amyloxenox is another drug which is a recent drug not very recent but considerably recent and it has given very promising results and used as a 5% paste of ointment gives very promising results in oral cavity. It has been earlier used as a dermatological medication but now along with oral base it has been very successful in treating oral ulcers especially it helps in reducing the pain increasing the time when the next ulcer appears and the frequency is also reduced. Then you have ulcer protectants like sukhalphic which actually coats the ulcer this can also be used and then you have other natural products like aloe vera which helps in soothing in soothing sensation this can also be used on top of ulcers as topical therapy. In where topical therapy doesn't really work very well you go in for systemic therapy you see that immunomodulators are given they include levomazole, thaliumide, colchicin, petoxyfilin, papstone, santerpin, etc. you also have antioxidants, vitamin V12, folic acid so here it's actually a mixed bunch it's not actually a proper immunomodulator the levomazole is not a proper drug which can be included in an immunomodulator it is actually an anti-helmet but when used in a particular formulation in a particular dosage it can act as an immunomodulator again here, pentoxyfilin it is a vasodilator, colchicin again used for treatment of gout but when used in a particular dosage it can act as an immunomodulator and reduce the formation of apricus ulcers then again here anti-oxidants can be given to reduce oxidative stress calving and pre-radicals and then detoxify prevent ulcer formation vitamin V12 and folic acid again nutrient supply apricin faster healer then again others like trednisalone, pramsinone, decimicosone decimicosone can be given as systemic drugs where it does not actually respond to topical therapy and then you have rebomopied which is recently successfully used for treating both gastric as well as oral ulcers this has been recently used nowadays in clinics but you have to understand as well as oral ulceration together you have also other therapies like ultrasounds and laces of tissue laces where T's have been proven to reduce the healing time so the healing time is very fast and again the pain has also been reduced so all these modalities have been tried after ulcers increasing successfully so there is no exact magic wand or proper treatment we actually have to tailor make each treatment for a particular patient depending on how it presents how the frequency of each ulcer or each other claims of ulceration that is how you create apricots so with that we will end this session today thank you stay safe and stay enlightened