From the Guidelines
For a patient with recurrent canker sores, negative ANA results, and elevated sedimentation rate, I strongly recommend a comprehensive diagnostic work-up and treatment approach, prioritizing the reduction of inflammation and prevention of recurrences, as outlined in the expert consensus guideline for diagnosis of difficult and complicated oral ulceration 1.
The patient's symptoms and laboratory results suggest a complex case of oral ulceration, which may be attributed to a combination of local and systemic causes. The elevated sedimentation rate indicates ongoing inflammation, which is common in recurrent aphthous stomatitis, while the negative ANA helps rule out autoimmune conditions like lupus.
Key considerations in the management of this patient include:
- Prescribing topical corticosteroids like triamcinolone dental paste 0.1% applied directly to sores 3-4 times daily to reduce inflammation
- Using benzocaine 20% gel or lidocaine 2% viscous solution for pain management before meals
- Considering systemic therapy with colchicine 0.6mg twice daily or dapsone 100mg daily to reduce inflammation and prevent recurrences in severe cases
- Avoiding triggers such as spicy foods, acidic beverages, and SLS-containing toothpastes
- Addressing nutritional deficiencies by testing for vitamin B12, folate, iron, and zinc levels
- Using a mouth rinse with equal parts diphenhydramine, antacid, and viscous lidocaine (magic mouthwash) for additional relief
According to the expert consensus guideline 1, a comprehensive diagnostic work-up should include a detailed clinical medical history inquiry, histopathological examination, and screening for ulceration-related systemic diseases. This approach can improve diagnostic efficiency, avoid misdiagnosis, and missed diagnosis, ultimately leading to better outcomes and survival for patients with oral ulceration caused by systemic precursors.
If symptoms persist beyond 2-3 weeks or worsen, further evaluation for underlying systemic conditions like inflammatory bowel disease or Behçet's syndrome is warranted, as suggested by the guideline 1.
From the Research
Negative ANA Results with Elevated Sed Rate on Patient with Reoccurrence of Canker Sores
- The patient's symptoms of reoccurring canker sores, also known as recurrent aphthous stomatitis (RAS), can be related to various factors, including genetic predisposition, viral and bacterial infections, food allergies, vitamin and microelement deficiencies, systemic diseases, hormonal imbalance, mechanical injuries, and stress 2.
- The elevated sed rate (erythrocyte sedimentation rate) may indicate an underlying inflammatory process, which can be associated with RAS 3, 2.
- A thorough history and review of systems can assist in determining whether the RAS is related to a systemic inflammatory process or truly idiopathic 3.
- The negative ANA (antinuclear antibody) results may help rule out certain autoimmune disorders, but it is essential to consider other potential causes of RAS, such as vitamin deficiencies, including vitamin B12 deficiency 2, 4.
- Management of RAS typically involves topical medications, such as corticosteroids, anti-inflammatory drugs, antibiotics, and antiseptics, as well as systemic therapies in more severe cases 5, 6.
- Vitamin B12 supplementation has been proposed as a potential treatment for RAS, with some studies suggesting that it can reduce the frequency and duration of ulcers 4.