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10/2/2010 1 A Clinical study on minor recurrent aphthous ulcer among 40 referred cases in Sulaimani city. Clinical presentation and possible predisposing factors. Prepared by Dr.Faiq M.Ameen lecturer B.D.S. MSc Oral medicine University of sulaimani College of dentistry sulaimani iraq Email dfaiq@yahoo.com

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10/2/2010 2 Recurrent aphthous ulcer (RAU) seems to be as old as humanity itself. The father of medicine, Hippocrates (460 to 370 BC) is credited with the first use of the term “aphthai” in relation to focal painful inflammation of the oral mucosa.

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10/2/2010 3 Definition and classification: Recurrent aphthous ulcer (RAU) is one of the most common and poorly understood lesions of the oral mucosa. Aphthous ulcers affect up to 25% of the general population, it is found in men and women of all ages, races, and geographic regions. Types: Aphthous ulcers are classified according to the diameter of the lesion. 1-Minor aphthous 2-Major RAU lesions. 3-Herpetiform ulcers.

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10/2/2010 4 Etiology: Local and systemic conditions, genetic, immunologic, and microbial factors all may play a role in the pathogenesis of RAU. However, to date, no principal cause has been discovered. Factors that provoke them include: Stress, fatigue, illness, injury from accidental biting, hormonal changes, menstruation, sudden weight loss, food allergies, the foaming agent in tooth paste, and deficiencies in vitamin B12, iron and folic acid.

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10/2/2010 5 Diagnosis: Since the etiology is unknown, the diagnosis is entirely based on history and clinical criteria and no laboratory procedures exist to confirm the diagnosis.

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10/2/2010 6 Treatment: There is no curative therapy to prevent the recurrence of this ulcer, and all available treatment modalities can only reduce the frequency or severity of the lesions. The primary goals of therapy for RAU are relief of pain, reduction of ulcer duration, and restoration of normal oral function. Although RAU may be a marker of an underlying systemic illness such as coeliac disease or may be present as one of the features of Behçet's disease , in most cases no additional body systems are affected, and patients remain otherwise fit and well.

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10/2/2010 7 Patients and Method: The study was based on a clinical survey of forty patients; their chief complaint was mucosal pain and discomfort. Due to the absence of a definitive etiology or diagnostic test for RAU, the identification of RAU in a clinical practice usually relies on combinations of a history, and clinical features.

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10/2/2010 8 RAU patients were excluded from the study if they had: A history or manifestation of any systemic illness or immunodeficiency state. 2) Chronic or acute infection such as recent viral illness. 3) Recurrent intraoral herpes simplex virus lesions or other oral mucous membrane diseases. 4) Been taking any medication that might interfere with the study parameters (such as steroids or immunosuppressive drug).

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10/2/2010 9 Because approximately 80 percent of patients with recurrent aphthous ulcers present with minor aphthous ulcers, so in our study we focus only on minor type of recurrent aphthous ulceration and the two other less common types, major and herpetiform were excluded.

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10/2/2010 10 The major criteria for recognizing and diagnosing the condition of minor RAU were: 1. External appearance: 2. Recurrence: 3. The lesion is painful: 4. Self-limitation of the condition: 5. Location of ulcers: 6. Duration of the lesion:

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10/2/2010 11 The case sheet included a full medical and dental information, beside a self report questionnaire about stress. medical and dental information The aim of the study was to find out the possible predisposing and associated factor that causes RAU in Sulaimani patients.

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10/2/2010 12 Results The studied samples included 24 (60%) female and 16 male (40%) with age range of (16-73) years. Females were more commonly affected than males with a ratio (1.5:1). % No. of patients Sex 40% 16 Male 60% 24 Female Sex distribution among 40 patients.

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10/2/2010 13 % No. of patients Age range years 40% 16 16-20 33% 13 20-40 27% 11 40-73 All age groups were found to be affected, The peak was in (16-40) years age group (73%). Distribution of patients among age group.

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10/2/2010 14 All studied patients were non smokers or they stopped smoking. In the present study all patients were with high Socioeconomic status.

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10/2/2010 15 From the history and self report questionnaire, all our patients were under psychological stress. Family history that suggested heredity factor was evident in 40% of our patients..

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10/2/2010 16 The ulcers were present on: lip, Check and Tip of the tongue.

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10/2/2010 17 Discussion: A careful history is the first and most important diagnostic step. The physical examination should focus on the location and nature of the lesions, in addition to assessment of other organ systems for relevant findings. In such patients, the physician must evaluate and rule out other conditions with similar features. C,B

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10/2/2010 18 The high reproducibility and uniformity of the clinical picture and course in all our patients suggests that all the RAU samples that were included in this study represent minor recurrent aphthous ulcers. Round small recurrent painful ulcers, that interfere with eating, speaking, and swallowing .They are seen on non keratinized mucosa and heal in 10-14 days with out scar formation.

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10/2/2010 19 (Rennie et al. 1985). High percentage between ages 16-40 years but less in ages 40-73 years. (Axéll and Henricsson 1985a). Females express higher percentage 60%. (Sircus et al.1957), (Ship 1972). Family history was evident in 40% of our patients. (Cohen et al., 1983), (Sircus et al. 1957, Ship et al. 1960, 1967, Miller et al. 1977a). All our patients were under psychological stress . (Shapiro et al. 1970, Axéll and Henricsson 1985b), (Grady et al. 1992), (Greenspan et al. 1992). All studied patients were non smokers or they quit smoking. (Rodu B, Mattingly G. 1992, Petersen MJ, Baughman RA. 1996). Rivera-Hidalgo F, Shulman JD, Beach MM 2004,Shulman JD2004, Crivelli MR, Aguas S, Adler I, Quarracino C, Bazerque P. 1988.). In the present study all patients were with high Socioeconomic status . All our results In accordance with other studies

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10/2/2010 20 From the results of the present study, we conclude the following: Stress is the main cause of minor recurrent aphthous ulceration in Sulaimani governorate population, who were with high socioeconomic level and they were non smokers or patient quit smoking. Stress

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10/2/2010 21 Prepared by Dr.Faiq M.Ameen lecturer B.D.S. MSc Oral medicine University of sulaimani College of dentistry sulaimani iraq Email dfaiq@yahoo.com Thanks

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