A 65 yr old female non DM non HTN with no known addictions, came to me with h/o painful ulcerations over the tongue,soft palate and buccal mucosa since 1yr...on and off...she received multiple treatments...including multivitamins, short courses of steroids twice in this one year..subsided in between.But this time she is having it since 1 month,not subsiding with treatment and severe pain along with difficulty in swallowing. I diagnosed it as recurrent aphthous stomatitis and adv workup. HIV negative,RBS normal,UGI endoscopy-Normal.ANA sent report awaited. There are no other signs and symptoms suggestive of malignancy or autoimmune or behcets disease. I suspected HSV stomatitis and so started her on acyclovir, but did not send tzanck smear...also put her on triamcinolone 0.1% buccal paste, amlexanox and lignocaine ointment and also started pentoxyfylline 400 tid...she came after 3 days with no improvement and so i added defcort 6 mg bid. what is the next course of action,should i get a biopsy. Need expert opinion pls

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The strong contender under the clinical setting described above is BECHET'S SYNDROME, though it is said to have been eliminated. Now there are clear cut crireria like ISG and ICBG Which assaign points to differrent findings of the syndrome with 2 points to oral apthous ulcers and 2 points to ocular manifestations with one point for each of other manifestations. The diagnosis is acceptable if 3 points exist in favour..luckily here 2 points are already there and if we can rope in one more point, the diagnosis is clinched.This calls for deligent search for other systems involment by referring to respevtive specialists. For instance presence of posterior uveitis is enough to clinch but do we search our necks that much as to make a thorough exm of each system involved. This perticular case presence of genital apthosis is enough to clinch, but how honestly we have looked not asked for this finding? An apthous looking ulcer which is not an apthous ulcer is the lead point. The real apthoys ulcer has a red halow around the ulcers and some lymphadenitis of c. glands exist which is not the case here. Though the llok will disqualify, diagnoses like candiduasis, herpes, LP etc were considered and even treated- perfect example of shot gun therapy. But without result as expected. try for just one more finding by all means, and the efforts might be rewarding. All diseases should fall in the known spectrum, the failure to unearth is due to ourself rather than a mysterious disease . This may not be taken as an afront on any person but a soul searching attempt of self. Thanks for wasting ur valuable time. u may continue.

This is surely a chronic case of aphthous stomatitis. U have already done the relevant tests but probably serum iron and related tests with B12 and vitamin A and D3 should also be done along with bone marrow for malignant cells if not already done. Chronic constipation or worm infestation should be ruled out. l have treated a number of such cases with the following regime. Zocon50 --1 tab daily Supradyn --1 daily, Astimin MForte -1 tab Dail, BIFILAC cap 1BD, Medrol 4 --1BD Cetzine -1 daily, dilosyn tab 1 - bedtime and oral application of Metrogyl Gel +Tess Gel + Zytee Gel (all mixed in the ratio of 1:1:1 and apply 3 to 4 times a day orally and keeping mouth shut for 5 minutes each time

I agree to Dr Ashok.... chronic constipation n worm infestation.
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Gastrointestinal disordersare sometimes associated with aphthous-like stomatitis, e.g. most commonlyCeliac disease, but alsoinflammatory bowel diseasesuch asCrohn's diseaseorulcerative colitis.[5]The link between gastrointestinal disorders and aphthous stomatitis is probably related to nutritional deficiencies caused bymalabsorption.[13]Less than 5% of people with RAS have Celiac disease, which usually presents with severe malnutrition, anemia,abdominal pain,diarrheaandglossitis(inflammation of the tongue).[8]Sometimes aphthous-like ulcerations can be the only sign of celiac disease.[8]Despite this association, agluten-free dietdoes not usually improve the oral ulceration.[13] Other examples of systemic conditions associated with aphthous-like ulceration includeReactive arthritis(Reiter's syndrome),[5]and recurrenterythema multiforme.[5]

sir from which site
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Sir as I can see there is halo around the ulcer. So it looks like Aphthous ulcer , I understand there is a long history but also to be considerd is itbis on off, so may be just recurrent aphthous ulcer

sir we strongly support ur advise
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I too think its apthous and not herpetic , continue triamcinolone , multivitamins and give short course of oral steroids

sir ,since u have entered the fray, how many pemphigus cases have come under observation in ur dental practice that could b confused with apthous like ulcers, it is just an idle curosity question for self satisfaction sir.

Sodium lauryl sulphate(SLS), adetergentpresent in some brands of toothpaste and other oral healthcare products, may produce oral ulceration in some individuals.[1]It has been shown that aphthous stomatitis is more common in people using toothpastes containing SLS, and that some reduction in ulceration occurs when a SLS-free toothpaste is used.[8]Some have argued that since SLS is almost ubiquitously used in oral hygiene products, there is unlikely to be a true predisposition for aphthous stomatitis caused by SLS.[8]

sir can u please provide the references e.g. [1] [8] which article or net source u used??
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chronic case of aphthous stomatitis folic acid bcom with zinc and choline salicylate gel application ( pansoral / gelora or hexigel ).Rull out local cause eg. sharp edge of tooth and calculus ( tarter) on lingual surface of lower teeth. systemic cause any drug therapy long time lastly food habit work In my practice one pt suffering from apthous stomatitis since 25 yrs He spend more than 3 lacs rs for tratment. simply food habit and business working style changed and subside without medicines

sir ur advise is clinical and valuable we strongly support ur experience
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If you haven't ruled out oropharyngeal candidiasis then go for it, this can be painful in some cases. Can give empirical course of fluconazole. If still doesn't work then this can be labeled Complex aphthosis which is recurring multiple aphthus ulcers without the other criteria of Bechet's.

she received antifungals,steroids,multivitamins,probiotics before coming to me
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However, there are many factors that are thought to be involved with the development of canker sores, including: Weakened immune system.Allergies to food such as coffee, chocolate, cheese, nuts, and citrus fruits.Stress.Viruses and bacteria.Trauma to the mouth.Poor nutrition.Certain medications.

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