Talk:Aphthous stomatitis/GA1

GA Review
The edit link for this section can be used to add comments to the review.''

Reviewer: LT910001 (talk · contribs) 06:19, 1 September 2013 (UTC)

Hello! I would be honoured to take this review, and haven't had any part in editing or creating this article. I have previously collaborated with Lesion and would be therefore happy if another person wanted to be the main reviewer.

Overall I found this article very readable, tight and packed full of content. I would support its promotion to GA status.

More specific comments:

Lede

 * Always the hardest section to get right, because it's the most imporatnt.
 * Could be split into two paragraphs for readability, maybe at "The cause is not completely understood." ✅
 * I personally don't think "recurrent aphthous stomatitis, RAS, recurring oral aphthae and recurrent aphthous ulceration" need to be provided. You state RAS is a subtype, not a synonym, and "recurrent" here is adjectival.
 * To clarify, RAS is a synonym, not a subtype. All aphthae are recurrent, there is no non recurrent form. If a mouth ulcer occurs only once, heals and then never comes back, then this diagnosis is not appropriate. Recurrent oral aphthae, and recurrent aphthous ulceration are also commonly enough used that we should list them in the first list of synonyms imo. Any less commonly used term, historic term or term for a subtype, I have not listed here but instead discussed in the History section for want of somewhere better to put it. See also the section above Talk:Aphthous_stomatitis. Lesion  ( talk ) 12:05, 1 September 2013 (UTC)
 * This is a good point. LT90001 (talk) 07:35, 3 September 2013 (UTC)


 * "and non-contagious mouth ulcers (canker sores)". Possibly could remove (canker sores) here, as you state above that canker sores are a reference to this disease and not all mouth ulcers.
 * I see that you read the discussion between myself and Biosthmors (who rightfully is concerned about readability for readers) above Talk:Aphthous_stomatitis. Appears that "canker sores" is not an exact term, it is used both as a synonym of individual mouth ulcers (not necessarily even mouth ulcers associated with this condition), and also other sources use it as a synonym for this condition as a whole. Difficult to say without making its own sentence. Lesion  ( talk ) 12:05, 1 September 2013 (UTC)
 * Oh! Actually I hadn't read that. Perhaps you could reword from "is a common cause of benign and non-contagious mouth ulcers (canker sores). " to "is a common cause of benign and non-contagious mouth ulcers, which are also occasionally called canker sores" or something similar, to remove the ambiguity. LT90001 (talk) 07:35, 3 September 2013 (UTC) ✅


 * "oral cavity (the lining of the mouth)" and several terms below could use the the lining of the mouth to enhance readability and decrease the feeling that this article has been 'translated' from medicine.
 * In the lead, OK agree. Per WP:LEAD, we should be using clear and simple language. However, in the rest of the article, we should not shy away from using jargon. We should use it as the sources do, but all meaning should be derived from the article to explain the jargon. Many editors think it is enough to throw in some jargon as long as it is wikilinked. This is not the case per the MOS. Wikilinking a term is optional and desirable, but explaining it in parentheses is mandatory. The gold standard imo is giving an explanation in brackets AND wikilinking. I have just simplified the end of this sentence to "in the mouth". Can't get more clear than that. When you say, "and and several terms below" I assume you mean throughout the rest of the article, and not in the lead. Please advise if any other wikilinking issues in lead. Lesion  ( talk ) 12:05, 1 September 2013 (UTC)
 * Hi, yep I made a comment below in 'classification' about this wikilinking. LT90001 (talk) 07:35, 3 September 2013 (UTC)


 * Overall this lede is really clear!

Suggested reworked lead based on this feedback: "Aphthous stomatitis (also termed canker sores, recurrent aphthous stomatitis, RAS, recurring oral aphthae and recurrent aphthous ulceration) is a common cause of benign and non-contagious mouth ulcers (canker sores). This condition is characterized by the repeated formation of ulcers in the mouth, in otherwise healthy individuals. These ulcers occur periodically and heal completely between attacks. Symptoms range from a minor nuisance to interfering with eating and drinking."

"The cause is not completely understood, but may involve a T cell mediated immune response which is triggered by a variety of factors. Different people may have different triggers, including nutritional deficiencies, local trauma, stress, hormonal influences, allergies, and a genetic predisposition. The condition is very common, affecting about 20% of the general population. There is no cure, and treatments are aimed at reducing pain and speeding the healing process. Often, the onset of the condition is during childhood or adolescence and usually lasts for several years before gradually disappearing, with or without any form of treatment."
 * Looks great and reads well. LT90001 (talk) 07:35, 3 September 2013 (UTC)

Classification

 * Given there's a picture in the lede, I think it would be better to move the picture to the symptoms section to illustrate what's written in the text. ✅
 * Major
 * I think it would enhance readability to change instances of "major apthae" to "major apthous ulcers" ✅
 * Remove "(major apthous ulcers)"
 * All GAs and FAs have a unique style and on reflection I think that these parentheses in moderation don't detract from the quality of the article, so I've got no further objections to these. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * Again, back of throat may enhance readability for that one.
 * Herpetiform
 * You state "also known as herpatiform ulcers". That could be removed as it's the title of that subsection.
 * "As with all types of aphthous stomatitis, it is not contagious." I like... very reassuring.
 * Move "Recurrent oral ulceration associated with systemic conditions is termed "RAS type ulceration", "RAS like ulceration" or "aphthous-like ulcers".[3] " up one sentence to improve flow ✅
 * "However, this definition is not strictly applied. " I think you could leave it at that: "E.g., many sources would refer to oral ulceration caused by anemia and/or nutritional deficiencies as aphthous stomatitis. Some consider Behçet's disease to be a variant of aphthous stomatitis.[4]" is not of the same quality as the article and I think it could be removed or rephrased. If you decide to keep it, perhaps "This definition is not strictly applied. For example, as many sources refer to oral ulceration caused by anemia and/or nutritional deficiencies as aphthous stomatitis, some also consider Behçet's disease to be a variant." ✅

Signs and symptoms

 * Could do with a picture, particularly when you say " An erythematous "halo" surrounds the ulcer" the halo picture would be good here. ✅
 * "Persons with aphthous stomatitis have no clinically detectable systemic symptoms or signs." Not too sure I agree, as there is a visible physical ulcer there should be at least one symptom. Perhaps you could add "Apart from presence of one or more ulcers, "
 * "(i.e. outside the mouth)" could be removed, as from my understanding a sign is something that can be elicited or noticed by a medical practitioner, but not necessarily a patient.
 * Hang on, you state "Signs are limited to the lesions themselves." I guess that ties in with my first comment.
 * Comment: in oral medicine and dentistry as a whole, "systemic" is often used to mean "not in the mouth". I have realized this could be confusing for many readers. Maybe "constitutional symptoms" or something would be better here? Lesion  ( talk ) 13:48, 1 September 2013 (UTC)
 * Looks good. Your inclusion of 'systemic' makes all the difference. Suggest change the next sentence "Generally, symptoms " to "Generally, localised symptoms" to highlight this separation. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * "virtual" -> "virtually" ✅
 * "reddened, flat area of mucosa". Wikify link to remove the erythematous tag (too many parentheses)
 * "which develops" -> "which develop" ✅
 * "which can"->"that can" not too sure about the exact grammar on this one but "that can" feels better ✅
 * Remove "(see the classification section)." as this precedes the Signs and symptoms section. ✅

Causes

 * Very clear
 * Remove "(T lymphocyte)," that's not mentioned anywhere else in the article.
 * Well, we do say CD4+ T lymphocytes ... I just thought it would be helpful to say that we mean the same thing ... Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * That's a good point, and it also helps disambiguate when you refer to the collective group 'lymphocytes'. I also can't help but notice you alternate in referring to "T cell" and "T lymphocyte". I think "T cell" is easier to read and you could probably stick to that for consistency. LT90001 (talk) 07:35, 3 September 2013 (UTC) ✅


 * "the generation of T cells" I'm not sure if it's standard terminology to describe T cells as "generated" by an immune response. Maybe "stimulated T cells"? ✅ good point. Just removed entirely since we begin this sent saying T cell-mediated. Kind of implied that T cells are involved by this imo. Lesion  ( talk ) 12:19, 3 September 2013 (UTC)
 * "altong " -> "along" ✅
 * "Persons with aphthous stomatitis have circulating lymphocytes which react with peptides 91-105 of heat shock protein 65-60.[3] " could do with a little bit of context.
 * Beyond removing it entirely, not sure what is best. I've checked the source, it doesn't give any more detail. Suspect that it is in turn based on primary sources, in vitro studies etc. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * All right, I guess somebody will know what this means. LT90001 (talk) 07:35, 3 September 2013 (UTC)


 * "Furthermore, the ratio of CD4+ T lymphocytes to CD8+ T lymphocytes in the peripheral blood of individuals with aphthous stomatitis is decreased.[4]" Not a comment but a thought, does that have implications for HIV/AIDS or EBV sufferers?
 * Yes, HIV is associated with aphthous-like ulceration. Not heard of any link with EBV, but I could be wrong. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * "the common " -> "common" ✅
 * "meaning that aphthous stomatitis is not a classical autoimmune disease" remove. This implication is clear from what you state in the sentences prior. ✅ Rephrased this whole paragraph in a more structured way. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * "T cell mediated " -> "T cell-mediated" ✅
 * Primary immunodysregulation
 * "aphthous stomaitits " -> "apthous stomatitis" ✅
 * "(see Effect of stress on the immune system)" could be silently wikilinked.✅ I think
 * Would prefer "E.g." replaced by "For example," in all circumstances, as I think it's more suitable not to use this shorthand. ❌ is this personal preference or supported by policy? I'm not sure, but I see e.g. and i.e. used very commonly in articles and I've never seen it get corrected. Happy to correct if this is policy. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * Yep, just a personal preference. I think it makes an article flow more if there aren't too many abbreviations or parentheses but I don't think it detracts from overall quality. LT90001 (talk) 07:35, 3 September 2013 (UTC) ✅ In this instance. Lesion  ( talk ) 12:19, 3 September 2013 (UTC)


 * This statement "although this would be by the decreased mucosal barrier mechanism described below" should be stated or removed as original research ✅ I wanted to talk about stress all in the same place, but the theories to explain this correlation do not neatly fit into any single mechanism alone. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * Decrease of the mucosal layer
 * "The thickness of the mucosa ...thickness of the oral mucosa (atrophy)." is uncited. ✅ both these short paragraphs were supported by Neville 2008, but the refs were hidden. I think I must have felt that Neville was cited too much, but it is a great source and I've not found a more complete or well structured discussion of the etiology of RAS to date. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * "all can " -> "can all" ✅
 * "In a small subgroup of females with aphthous stomatits, there are " reads a little strange. Suggest reword to "In one study, a small group of females with apthous stomatitis had fewer occurences of apthae..." ✅
 * Suggest apthae -> apthous ulcer. ✅ for readibility sake, but technically "aphthous ulcer" means "ulcerous ulcer", but it is a widely used term nonetheless. Lesion  ( talk ) 13:03, 1 September 2013 (UTC)
 * Hah, well what about 'blue nevus'? I'm sure there's a lot more. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * Don't understand. "Nevus" = mole/birthmark? You mean it's not actually blue? Lesion  ( talk ) 12:19, 3 September 2013 (UTC)


 * Increase in antigenic exposure/Heightened antigenic sensitivity
 * Suggest " e.g"-> "with implicated triggers including " ✅
 * Systemic disease
 * I'm liking the table! (I like tables too. Lesion  ( talk ) 13:03, 1 September 2013 (UTC))
 * Table "Systemic disorders Associated with aphthous-like ulceration" -> decapitalise "associated" ✅
 * Table "immunocompromise" -> "Immunocompromised states" ✅
 * " (e.g., the conjunctiva or the genital mucous membranes)" -> "such as the conjunctiva... membranes." ✅
 * "a decreased frequency" remove "a" ✅
 * "Silk Road, (i.e. " -> "Silk Road (between..." ✅
 * Suggest integrate " (inflammation of the lymph nodes in the neck-- cervical lymphadenitis)." as a wikilink. (tidied a bit. Lesion  ( talk ) 13:03, 1 September 2013 (UTC))


 * Lately noticed " (often they accompany each other)," is given it's own clause. Suggest remove parentheses, or commas. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * Only just noticed because it is a new addition. ✅ Lesion  ( talk ) 12:19, 3 September 2013 (UTC)

Diagnosis

 * Suggest split into two or three paragraphs for readability, perhaps at the "blood tests" and "histology" areas of the paragraph. ✅
 * "(e.g. to exclude anemia / deficiencies of iron, folate or vitamin B12 or celiac disease)." remove parentheses and "eg." ✅
 * "conenctive tissue " -> connective tissue ✅ my bad, Lesion  ( talk ) 13:43, 1 September 2013 (UTC)
 * I feel "Many of the systemic diseases cause other symptoms apart from oral ulceration, e.g. genital ulceration in Behçet's syndrome, which is in contrast to aphthous stomatitis where there is isolated oral ulceration. " has by now been mentioned a few times.
 * Distinguishing isolated oral ulceration from oral ulceration with systemic signs and symptoms is one of the key points in the differential diagnosis of recurrent oral ulceration ... rm at least mention of Bechet's again. Lesion  ( talk ) 13:43, 1 September 2013 (UTC)
 * Looks good. LT90001 (talk) 07:35, 3 September 2013 (UTC)


 * One small thing, "anemia / deficiencies of iron" is not the same style as your other common language/med language separations, which use parentheses. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * ✅ Used a comma instead. Anemia and hematinic deficiency closely related but not equivalents. Lesion  ( talk ) 12:25, 3 September 2013 (UTC)

Treatment

 * Suggest removal of parentheses " (the pain is tolerable with simple dietary modification during an episode of ulceration)" and addition of ", with the pain tolerable..." ✅
 * Table - suggest you add a title and put the citations there. (OK, this is a big task so pending, Lesion  ( talk ) 13:43, 1 September 2013 (UTC))
 * After the first line that says "wikitable", you can add a "|+ caption here", that will change the table to display with a caption. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * ✅ But, I'm sorry, I'd definitely call that a title rather than a caption. Lesion  ( talk ) 12:31, 3 September 2013 (UTC)


 * You list "prednisolone" as a systemic agent and not a corticosteroid. (will look into this, Lesion  ( talk ) 13:43, 1 September 2013 (UTC))
 * Comment, the categories are "Topical mild potency corticosteroids", "Topical moderate potency corticosteroids" and "Systemic agents". Because of the topical qualifier, predisolone correctly belongs in the systemic group. Lesion  ( talk ) 13:47, 1 September 2013 (UTC)
 * Fair enough. It's perturbin' my bones to think of prednisone as a systemic agent. Could you put it in its own column? LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * Renamed the "systemic agents" row "orally administered drugs" since all the other categories are topical therapies, this actually makes more sense to me now. Lesion  ( talk ) 12:31, 3 September 2013 (UTC)


 * In paragraph, "Amlexanox " should probably be wikilinked. ✅

Prognosis

 * I think very readable. No comments.

Epidemiology

 * "racial epidemiologic variation" reword to "ethnic variation"; "epidemiologic" has no utility. ✅ Lesion  ( talk ) 13:43, 1 September 2013 (UTC)
 * "e.g. in the United States of America, " -> new sentence, wikilnk to "USA". ✅
 * "white skinned" -> "white-skinned" and same for "black skinned" ✅

History

 * No comment. Would be interested to know where "canker sores" came from, but Wikipedia isn't all about what LT910001 wants.
 * Added some info on this, but it is not an easy word to pin down etymologically I sense. Lesion  ( talk ) 13:43, 1 September 2013 (UTC)
 * Hmm! interesting. This part " In Latin, cancer translates to "malignant tumor" or literally "crab", and in Middle English and Old North French, chancre which now is more usually applied to syphilis. When the word canker is used in the phrase "canker sores", this does not imply that it is a cancerous condition, but rather canker is used to describe the appearance of the sores." is uncited. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * The last sentence was OR. Reworded to "Despite these terms, aphthous stomatitis is not a form of cancer but rather entirely benign."


 * This sentence is also uncited "Stomatitis is also a non specific term meaning inflammation of the mucous membrane of the mouth, and again may describe many different conditions." LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * This is akin to asking for a reference to say "the sky is blue". I went to Stomatitis (which I have been working on a bit recently) but to no avail. These terms are so commonly used it is difficult to find a basic definition in a source even though you already know it. Similar situation on cheilitis, you wouldn't believe how long I had to search for a definition. Lesion  ( talk ) 12:36, 3 September 2013 (UTC)
 * This source was in the ELs of stomatitis (questionable whether this passes MEDRS, referenced but not a publication in a peer review journal...) but it might serve as an indicator that we are not far off with such a definition.

"Inflammation of mucous lining of any of the structures in the mouth, cheeks, lip, tongue, gingiva, and floor or roof of the mouth."
 * I'll definitely "finish" stomatitis at some point, and I'm assuming I'll have to find a better source then anyway. Lesion  ( talk ) 12:40, 3 September 2013 (UTC)

Overall comments
In conclusion a tight, well-written article. LT90001 (talk) 06:19, 1 September 2013 (UTC)


 * Thanks for detailed review. Agree that table in treatments section needs inline citation. I will do this soon. Lesion  ( talk ) 13:45, 1 September 2013 (UTC)
 * Table now has inline citation. ✅ Lesion  ( talk ) 17:38, 2 September 2013 (UTC)


 * Just to be clear, are you saying that you are not comfortable being the main reviewer for this GA? If so, I'm not sure anyone else knows to take it, because it appears as though the review has already been taken on the GA nominations page. I wonder if there is a way to mark it as needing a reviewer again? Lesion  ( talk ) 17:38, 2 September 2013 (UTC)


 * Hey, sorry for any confusion. I'm quite happy to be the main reviewer. I'll get back you on the commentary today (thought I'd leave a day to space things out a bit). It would be nice if at least one other person lent their support before this article goes to GA, but I think this article's quality stands on its own. LT90001 (talk) 22:41, 2 September 2013 (UTC)
 * Done. LT90001 (talk) 07:35, 3 September 2013 (UTC)
 * OK I'll action the rest of these points. I'll also post on WT:MED to see if anyone else will offer the second opinion that you asked for above. Lesion  ( talk ) 11:28, 3 September 2013 (UTC)

Hi folks; I read through this yesterday after I heard that you'd like a second opinion. I'd like to point out that the image File:Behcets_disease.jpg appears to have an incorrect license. The image is taken from a paper that the source URL indicates is copyrighted. It is unclear why the image is tagged at Commons as CC BY-SA. It doesn't appear that the uploader (who self-identifies on a subpage of his userpage here) is one of the paper's authors. I think the image should be removed unless we can get some source for the purported licensing status. ✅ -- It looks very similar to the other pictures of ulcers we have here already anyway. Lesion ( talk ) 14:43, 4 September 2013 (UTC)

I'd like to point out a few very minor, not-actionable-for-GA quibbles that I noticed because I mostly review at FA:


 * No need to link United States of America. ✅
 * Please use a consistent style when listing page numbers (we have 323–8 but 53–56, for example). ✅
 * Seems to have definitely been an error here "pp 220–224195" let me recheck that. Lesion  ( talk ) 14:43, 4 September 2013 (UTC)
 * Please make an effort to link on first use of a term (see for example systemic, systemic condition/disease, Behçet's disease).
 * I personally feel that sometimes the first occurrence of a term is not always the best place for the link, but this view is probably against MOS. I have partially corrected this issue for Behcet's, but it is still linked twice in both the table and the article, which is probably wrong too. Also corrected for systemic disease.
 * The table in Treatment could use some punctuation attention (lists currently end with either no punctuation, comma, or full stop but should be consistent; there should be a comma not a full stop after sulodexide). ✅
 * We try not to use full stops after incomplete sentences, but I notice you've used them in the table names; do you feel that the bolded name is insufficient on its own? Perhaps put them in a table row instead, to clarify? ✅ -- I think I put in a period just to separate the title from the reference. Lesion  ( talk ) 14:43, 4 September 2013 (UTC)
 * The Commons category link goes to a nonexistent category; should it go to Category:Aphthous ulcer instead? ✅

I would be happy to support promotion to GA after resolving that single image issue. Nice work. Maralia (talk) 14:15, 4 September 2013 (UTC)


 * Thanks for feedback. Lesion  ( talk ) 14:43, 4 September 2013 (UTC)
 * No problem. I haven't done a GA review in many years so I'll leave the technical aspects of closing to LT (or you). Well done! Maralia (talk) 00:09, 5 September 2013 (UTC)

I have concluded this review and promoted to GA. Well done! LT90001 (talk) 03:05, 5 September 2013 (UTC)