Final Task Modul 1 (Critical Thinking)

STOMATITIS APTHOUS RECURRENT (SAR)

By

PBL 6 (Group E)

Maidel Salsabila 021611133055

Aqil Fadhilah KL 021611133056
Adecha Ekalipta P 021611133057
Sherina W 021611133058
Tiara Sukmawati 021611133059
Amelia Virginia W 021611133060
Kemal Alif A 021611133061
Eksa Arinda P 021611133062
Putri Dea A F 021611133063
Anggita Devina A 021611133064
Radinda Graceluivia 021611133065
Ajeng Dyah R 021611133066
Brenda Regina C 021611133067

FACULTY OF DENTISTRY
UNIVERSITAS AIRLANGGA
SURABAYA
2016
 PREFACE

First of all, thanks to Allah SWT because of the help of Allah, writer finished
writing the paper entitled “Stomatitis Apthous Recurrent (SAR)” right in the
calculated time.

The purpose in writing this paper is to fulfill the assignment that given by Mrs Dr.
Susy Kristiani, drg., M.Kes.

In arranging this paper, the writer trully get lots challenges and obstructions but
with help of many indiviuals, those obstructions could passed. writer also realized
there are still many mistakes in process of writing this paper. Because of that, the
writer says thank you to all individuals who helps in the process of writing this
paper. hopefully allah replies all helps and bless you all.the writer realized tha this
paper still imperfect in arrangment and the content. then the writer hope the
criticism from the readers can help the writer in perfecting the next paper.last but
not the least Hopefully, this paper can helps the readers to gain more knowledge
about Stomatitis Apthous Recurrent (SAR).

Surabaya, December 2016

PBL 6
 TABLE OF CONTENTS

COVER ............................................................................................................ ….i

PREFACE ............................................................................................................. ii

TABLE OF CONTENTS ...................................................................................... iii

TABLE OF FIGURES .......................................................................................... iv

CHAPTER 1 : PRELIMINARY

1.1 Background ..................................................................................................... 1

1.2 Formulation of the Problem ............................................................................ 2
1.3 Purpose ............................................................................................................ 2
1.4 Benefit ............................................................................................................. 2

CHAPTER 2 : LITERATURE REVIEW

2.1 Definition of Stomatitis Apthous Recurrent ................................................... 3

2.2 Classification of Stomatitis Apthous Recurrent .............................................. 3
2.3 The Symptoms of Stomatitis Apthous Recurrent............................................ 5
2.4 The Cause of Stomatitis Apthous Recurrent ................................................... 6
2.4.1 Internal Cause ..................................................................................... 6
2.4.2 External Cause.................................................................................... 8
2.5 The treatment of Stomatitis Apthous Recurrent ............................................. 9

CHAPTER 3 : DISCUSSION

CHAPTER 4 : FINALE

3.1 Conclusion ...................................................................................................... 10

3.2 Suggestion ....................................................................................................... 10
BIBLIOGRAPHY ................................................................................................. 11
 TABLE OF FIGURES

Figure 2.1 Stomatitis Apthous Recurrent .............................................................. 4

 CHAPTER 1

PRELIMINARY

1.1 Background

Healthy teeth and oral cavity is very important for children age into
adulthood. This is demonstrated by the many dental problems and oral cavity are
felt by children and adults of small case until the case is complex.

One example of cases related to oral health is the presence of canker sores.
Sprue is a situation that often occurs repeatedly or recurrent oral mucosa someone,
it can be said that everyone must have experienced thrush that both light and heavy
until thrush interferes with the physiological function of the oral tissues and can
cause a person with impaired speech , chew, swallow even this disorder can result
in reduced body condition when it occurs in a long time with the frequency of
occurrence is frequent.

Among ordinary people who almost routinely experience pain in the form
of injuries in his mouth, they call it by name sprue or heartburn. While the medical
community of this disease known as Aphtous Stomatitis Recurrent or SAR.

Stomatitis is the inflammation of the soft tissue structures lining anything in

mouth. Stomatitis is usually a painful condition, associated with redness, swelling,
and occasional bleeding from the affected area. Bad breath (halitosis) may also
accompany these circumstances. Stomatitis occurs in all age groups, from infants
to older adults.

Sprue or SAR is an oral disease is relatively common in the community.

The disease is relatively mild and do not endanger the safety of human life, but can
degrade the quality of life of sufferers, especially in patients who experience
repeated SAR.

1.2 Formulation of the Problem

1. What is Stomatitis Apthous Recurrent?

2. How is the classification of Stomatitis Apthous Recurrent?
3. How is the symptoms of Stomatitis Apthous Recurrent?
4. Who may be affected by Stomatitis Apthous Recurrent?
5. Where the usual areas exposed to Stomatitis Apthous Recurrent?
6. What causes Stomatitis Apthous Recurrent?
7. How to prevent Stomatitis Apthous Recurrent?

1.3 Purpose

To find out more about Stomatitis Apthous Recurrent and its classification,
symptoms, causes, and treatment.

1.4 Benefit

Benefit for Writer

The author can understand more about the Recurrent Aphtous Stomatitis

Benefit for Public

The public can understand what is meant by Recurrent Aphthous Stomatitis at once
understand the symptoms and treatment
 CHAPTER 2

LITERATURE REVIEW

2.1 Definition of Stomatitis Apthous Recurrent

Aphthous stomatitis (canker sores) is the recurrent appearance of mouth

ulcers in otherwise healthy individuals. The cause is not completely understood, but
it is thought that the condition represents a T cell mediated immune response which
is triggered by a variety of factors. The individual ulcers (aphthae) recur
periodically and heal completely, although in the more severe forms new ulcers
may appear in other parts of the mouth before the old ones have finished healing.
Aphthous stomatitis is one of the most common diseases of the oral mucosa, and is
thought to affect about 20% of the general population to some degree. The
symptoms range from a minor nuisance to being disabling in their impact on eating,
swallowing and talking, and the severe forms can cause people to lose weight. There
is no cure for aphthous stomatitis, and therapies are aimed at alleviating the pain,
reducing the inflammation and promoting healing of the ulcers, but there is little
evidence of efficacy for any treatment that has been used.

2.2 Classification of Stomatitis Apthous Recurrent

Aphthous stomatitis has been classified as a type of non-infectious

stomatitis (inflammation of the mouth). One classification distinguishes "common
simple aphthae", accounting for 95% of cases, with 3–6 attacks per year, rapid
healing, minimal pain and restriction of ulceration to the mouth; and "complex
aphthae", accounting for 5% of cases, where ulcers may be present on the genital
mucosa in addition to mouth, healing is slower and pain is more severe. A more
common method of classifying aphthous stomatitis is into three variants,
distinguished by the size, number and location of the lesions, the healing time of
individual ulcers and whether a scar is left after healing (see below).
 Figure 2.1 Stomatitis Apthous Recurrent

Minor aphthous ulceration

This is the most common type of aphthous stomatitis, accounting for about
80–85% of all cases. This subtype is termed minor aphthous ulceration (MiAU), or
minor recurrent aphthous stomatitis (MiRAS). The lesions themselves may be
referred to as minor aphthae or minor aphthous ulcers. These lesions are generally
less than 10 mm in diameter (usually about 2–3 mm), and affect non-keratinized
mucosal surfaces (i.e. the labial and buccal mucosa, lateral borders of the tongue
and the floor of the mouth). Usually several ulcers appear at the same time, but
single ulcers are possible. Healing usually takes seven to ten days and leaves no
scar. Between episodes of ulceration, there is usually an ulcer-free period of
variable length.

Major aphthous ulceration

This subtype makes up about 10% of all cases of aphthous stomatitis. It is

termed major aphthous ulceration (MaAU) or major recurrent aphthous stomatitis
(MaRAS). Major aphthous ulcers (major aphthae) are similar to minor aphthous
ulcers, but are more than 10 mm in diameter and the ulceration is deeper. Because
the lesions are larger, healing takes longer (about twenty to thirty days), and may
leave scars. Each episode of ulceration usually produces a greater number of ulcers,
and the time between attacks is less than seen in minor aphthous stomatitis.[4] Major
aphthous ulceration usually affects non keratinized mucosal surfaces, but less
commonly keratinized mucosa may also be involved, such as the dorsum top
surface) of the tongue or the gingiva (gums). The soft palate or the fauces (back of
the throat) may also be involved, the latter being part of the oropharynx rather than
the oral cavity. Compared to minor aphthous ulceration, major aphthae tend to have
an irregular outline.

Herpetiform ulceration

Herpetiform ulcers, (also termed stomatitis herpetiformis, or herpes-like

ulcerations) is a subtype of aphthous stomatitis so named because the lesions
resemble a primary infection with herpes simplex virus (primary herpetic
gingivostomatitis). However, herpetiform ulceration is not caused by herpes
viruses. As with all types of aphthous stomatitis, it is not contagious. Unlike true
herpetic ulcers, herpetiforme ulcers are not preceded by vesicles (small, fluid filled
blisters). Herpetiforme ulcers are less than 1 mm in diameter and occur in variably
sized crops up to one hundred at a time. Adjacent ulcers may merge to form larger,
continuous areas of ulceration. Healing occurs within fifteen days without scarring.
The ulceration may affect keratinized mucosal surfaces in addition to non
keratinized. Herpetiform ulceration is often extremely painful, and the lesions recur
more frequently than minor or major aphthous ulcers. Recurrence may be so
frequent that ulceration is virtually continuous. It generally occurs in a slightly older
age group than the other subtypes, and females are affected slightly more frequently
than males.

2.3 The Symptoms of Stomatitis Apthous Recurrent

The clinical features of RAS consist of recurrent bouts of one or several

rounded, shallow, painful oral ulcers at intervals of a few months to a few days.
RAS has 3 main presentations-minor (MiRAS), major (MaRAS), or herpetiform
(HU) ulcers (Table 1). Minor recurrent aphthous stomatitis (MiRAS) is the common
variety, affecting about 80% of RAS patients, and is characterized by round or oval
shallow ulcers usually less than 5 mm in diameter, with a grey-white
pseudomembrane enveloped by a thin erythematous halo. MiRAS usually occurs
on the labial and buccal mucosa and the floor of the mouth, but is uncommon on
the gingiva, palate, or dorsum of the tongue. These lesions heal within 10-14 days
without scarring. MiRAS is the most common form of childhood RAS (Field et al.,
1992). Major recurrent aphthous stomatitis (MaRAS) is a rare, severe form of RAS,
also known as periadenitis mucosa necroticarecurrens. These lesions are oval and
may exceed 1 cm in diameter; indeed, they may approach 3 cm. MaRAS has a
predilection for the lips, soft palate, and fauces, but can affect any site. The ulcers
of MaRAS persist for up to 6 weeks and often heal with scarring. MaRAS usually
has its onset after puberty and is chronic, persisting for up to 20 or more years
(Scully and Porter, 1989). The third and least common variety of RAS is
herpetiform (HU), characterized by multiple recurrent crops of small, painful ulcers
that are widespread and may be distributed throughout the oral cavity. As many as
100 ulcers may be present at a given time, each measuring 23 mm in diameter,
although they tend to fuse, producing large irregular ulcers. HU may have a
predisposition for women and have a later age of onset than other types of RAS
(Lehner, 1977; Scully and Porter, 1989) or may represent a spectrum of oral
disorders manifesting as recurring ulcers (Porter and Scully, 1991).

2.4 The Cause of Stomatitis Apthous Recurrent

2.4.1 Internal Cause

1. Nutritional Deficiency

Patients who experience a nutritional deficiency has a relationship

with the SAR. Most patients with SAR estimated deficiency of vitamin B1,
B2, B6 and B12. case report by Volkov (2005) against the three SAR patients
with vitamin B12 deficiency states that the SAR could be due to lack of
nutritional intake of animal products such as meat causes low levels of serum
vitamin B12, but it is still doubtful because of the mechanism of the SAR with
vitamin B12 deficiency is still unclear, experts estimate that has to do with
the suppression of cellular immunity (cell mediated immunity) on the cell
mukosa.

2. Trauma

Ulcers can form on areas of scar. It usually can cause ulcers on the
surface of the oral cavity. Ulcers generally occur due to being bitten while
talking, bad habits such as bruksism, chewing, as a result of dental care, and
consuming food or drink that is too hot.

3. Allergies

Allergies are the body's immune response to the changes in the

existing materials in their daily living environment hari. SAR may occur
because of the sensitivity of tissues of the mouth of some staple in toothpaste,
mouthwash, lipstick, chewing gum, artificial tooth materials or fillings, as
well as groceries. After contact with some materials that cause sensitivity to
the mucosa, it gets inflamed mucosa. These symptoms are accompanied by a
burning sensation, itching sometimes arise, may also be preceded by the
formation of vesicles that are temporary and then will rupture forming regions
small erosion and ulcers which later evolved into SAR.

5. Stress

Stress is alleged to constitute one of the factors that contribute

indirectly to SAR. Stress can cause trauma to the soft tissues of the oral cavity
associated with parafungsional habits such as biting the lip or cheek mucosa
and trauma can cause oral mucosa susceptible to the occurrence ulserasi.
 Research conducted by Farmaki et al (2008) concluded that anxiety
may be a factor contributing to the SAR. Patients often feel anxious to have
high levels of serum cortisol at the time suffering from SAR.

6. Hormonal

Hormonal state menstruating women can be attributed to the hormone

SAR. deemed important role is estrogen and progesterone. In some women
the SAR reported to be more severe during the luteal phase of the menstrual
cycle, which is associated with increased levels of progestogen and estrogen
decline. The decline in estrogen results in decreased blood flow to the main
blood supply to peripheral declining balance disorder that causes cells
including oral cavity, slowing down the process of keratinization causing an
overreaction to oral tissues and are vulnerable to local irritation so easily
happen SAR. Progesterone is considered a role in regulating the turn of the
mucosal epithelium of mouth.

2.4.2 External Cause

There are causes of minor stomatitis aphtous. There is an abnormal

immunologic form (T - cell mediated), inflammatory neurogeric (neuropeptide
induced, such as substance P), a defect of mucosal healing (inhibition by cytokines),
microbiological (viruses, bacteria), nutritional deficiencies (vitamin B12, folic acid,
iron ), chemical (toothpaste) (Simamora, 2015). In addition, if it is connected with
the case were obtained, minor stomatitis aphtous recurrent on children can be
caused by activities such as frequently bitten.
2.5 The Treatment of Stomatitis Apthous Recurrent

Treatment for RAS is symptomatic; the goals being to decrease pain,

healing time, number and size of the ulcer, and to increase disease-free periods.
Current treatment options include topical agents, systemic and topical steroids,
corticosteroids, cauterization, antibiotics, mouth rinses containing active enzymes,
laser treatments and combination therapy. Given the prevalence of RAS, primary
care physicians and dentists should become familiar with its presentation and
management and be able to offer therapeutic options that meet their patients’ needs.
The report serves as an educational medium for health professionals, so that they
may become equipped 2 with the knowledge to manage patients who present with
RAS. Since aphthous minor is the most prevalent form of RAS, this report focuses
specifically on its treatment options. The findings of this report may not be
generalizable to patients with major or herpetic aphthae or those with forms of RAS
that are manifestations of systemic disorders. For other forms of RAS, therapy
should be individually tailored to the patient depending on the severity of the ulcer
and the patient’s health.
 CHAPTER 3

DISCUSSION

"A 12 years old boy with his mother came to the Hospital Dental Dentistry
Airlangga University with complaints of frequent canker sores. According to his
mother no family record who have allergies. Currently there are 2 canker sores on
the tongue and had never been treated. "

From the case can be taken three key words: 12 years, frequent canker sores, and
no record of allergies.

Stomatitis has many kinds, such as aphthous stomatitis, Generalista stomatitis,

mycotic stomatitis, Herpetiformic stomatitis, and Medicamentosa stomatitis. If the
age is 12 years, it is likely that those patients suffering from canker sores is
aphthous stomatitis because this type of stomatitis can be suffered by all ages. In
addition, there are also stating that canker sores occur frequently, then it can be
said patients suffering from recurrent aphtous stomatitis. Moreover, the other fact
that support is overactivity are usually owned by children of 12 years can cause
trauma to the oral mucosa, which is one of the cause from recurrent aphthous
stomatitis. The way to treat it is by eating foods nutritionally adequate and avoid
excessive physical activity.
 CHAPTER 4

FINALE

3.1 Conclusion

From explanation which is already written, then the writers may conclude
that “Stomatitis Aphtosa Recurrent”(SAR) papers which is discussed with
involving certain problem, writers may say that SAR phenomenon can be happened
by many things and can be suffered by anyone. In fact, SAR disease can be a
symptom of other disease occured. The less precise handling and treatment for SAR
can worsen the condition of patient. Therefore, SAR is necessary to be investigated
beforehand according to its type and cause to choose the suitable treatment action.

3.2 Suggestion

After writing this papers, writers have a better understanding about

Stomatitis Aphtosa Recurrent disease from various aspect, which are affecting and
also affected aspects. Knowing that writers’ work are still far from perfect, in the
future, writers will try to work up the references and completeness needed for
deeper understanding. Writers desire to give suggestion to readers, in treatment of
SAR, don’t treat SAR disease with the identical treatment. It’s better to investigate
what is the factor that causing, after that we can finally decide which treatment suits
best. With this method, treatment will work better and more effective. Of course,
the prevention according to its cause will help preventing SAR of coming back and
bring uncomfortable feeling to patient.
 BIBLIOGRAPHY

Brocklehurst P, Tickle M, Glenny AM, Lewis MA, Pemberton MN, Taylor J,

Walsh T, Riley P, Yates JM. 2012. Systemic interventions for recurrent
aphthous stomatitis (mouth ulcers. Cochrane Database of Systematic
Reviews.
Field EA, Brookes V, Tyldesley WR. 1992. Recurrent aphthous ulceration in
children-a review. Int I Paed Dent 2: 1-10.

Neville BW, Damm DD, Allen CM, Bouquot JE. 2008. Oral & maxillofacial
pathology (3rd ed.). Philadelphia: W.B. Saunders.

Porter SR, Scully C. 1991. Aphthous stomatitis-an overview of aetiopathogenesis

and management. ClinExpDermatol 16:235-243.

Preeti L, Magesh KT, Rajkumar K, Karthik R. 2011. Recurrent aphthous stomatitis.

Journal of Oral and Maxillofacial Pathology.

Scully C. 2013. Oral and maxillofacial medicine: the basis of diagnosis and
treatment (3rd ed.). Edinburgh: Churchill Livingstone.

"International Classification of Diseases-10". World Health Organization.

Retrieved February 16, 2013.