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Aphthous Ulcers (Aphthous Stomatitis)

BASICS

  • Definition: Recurrent, painful, shallow ulcerations of the non-keratinized oral mucosa.
  • Synonyms: Canker sores, aphthae, aphthous stomatitis.
  • Natural history: Self-limited, with spontaneous resolution; recurrent in nature.

CLASSIFICATION

I. Clinical Categories

Type Description
Simple aphthosis Episodic (<7 episodes/year), few ulcers, minimal pain, self-limited (1–2 weeks).
Complex aphthosis Frequent/continuous ulcers, major pain, disability, may include genital aphthae, slow healing.

II. Morphologic Subtypes

Subtype Features
Minor (Mikulicz aphthae) <10 mm, 1–5 ulcers, age 5–19, heals in 4–14 days, no scarring.
Major (Sutton disease) >10 mm, 1–10 ulcers, age 10–19, heals in weeks–months, may scar.
Herpetiform 1–2 mm ulcers, cluster in 10s–100s, age 20–29, coalesce into large lesions, no HSV link.

EPIDEMIOLOGY

  • Most common oral mucosal ulcerative condition.
  • Prevalence: 5–85% lifetime, varies by ethnicity and SES.
  • More common in: <40 years, Caucasians, nonsmokers, higher SES.

ETIOLOGY & PATHOPHYSIOLOGY

  • Multifactorial: Genetic predisposition, altered cell-mediated immunity, increased salivary cortisol (stress).
  • HLA associations noted.
  • No association with HSV in herpetiform ulcers.

RISK FACTORS

  • Oral trauma (e.g. sharp teeth, dental procedures)
  • Sodium lauryl sulfate (SLS) toothpaste
  • Stress, anxiety
  • Nutritional deficiencies: B12, iron, folate, zinc, vitamin D
  • Immune deficiency
  • Tobacco cessation
  • Hormonal changes (e.g. menstruation)
  • Associated infections: H. pylori
  • Systemic diseases: celiac, IBD, Behçet syndrome

PREVENTION

  • Avoid SLS-containing toothpaste
  • Nutritional support: Vitamin B12, D, zinc
  • Reduce oral trauma and stress

CLINICAL FEATURES

History

  • Painful oral ulcerations exacerbated by speech, eating, acidic/hot/spicy foods
  • Prodrome: burning/pruritus 2–48 hrs prior
  • Age of onset: typically 5–29 years
  • Recurrent pattern

Physical Exam

  • Round/ovoid ulcer with gray-white base and erythematous halo
  • Common sites: buccal/labial mucosa, ventral tongue, soft palate
  • Evaluate for secondary infection: fever, lymphadenopathy, edema, pus

DIFFERENTIAL DIAGNOSIS

Etiology Distinctive Features
HSV Vesicular, keratinized mucosa, systemic prodrome
HIV Persistent, painful ulcers, advanced disease
Behçet syndrome Genital + oral ulcers, uveitis, arthritis
IBD Aphthae with GI symptoms (Crohn’s, UC)
SLE Systemic features, autoimmunity
Celiac disease Aphthae with malabsorption, dermatitis herpetiformis
Medication Fixed drug eruptions, vancomycin-induced linear IgA
Malignancy Persistent, nonhealing, leukoplakia, lymphadenopathy

DIAGNOSTIC WORKUP

Initial Tests (if severe or recurrent)

  • CBC (anemia), ferritin, folic acid, vitamin B12, zinc
  • Consider biopsy and viral culture if nonhealing
  • Autoimmune/rheumatologic panel for systemic suspicion
  • GI referral if symptoms suggest IBD or celiac

TREATMENT

General Principles

  • Primarily symptomatic management
  • Goal: relieve pain, reduce recurrence, accelerate healing

FIRST-LINE

Category Agents Notes
Topical corticosteroids Triamcinolone 0.1% paste
Fluocinonide 0.05% gel		 Apply 2–4× daily for ≤2 weeks
Topical anesthetics Lidocaine 5% ointment or spray
Hyaluronic acid 2.5%		 Symptomatic relief only
Antimicrobial mouth rinses Chlorhexidine 0.12% or 0.2%
Doxycycline rinses		 Chlorhexidine 3× daily; doxycycline 100 mg in 10 mL water, 4×/day for 3 days
Topical immunomodulator Amlexanox 5% paste (not in U.S.) Apply 4× daily

SECOND-LINE

  • Systemic corticosteroids (for major or refractory aphthae)
  • Prednisone 0.75 mg/kg/day taper
  • Montelukast 10 mg/day
  • Colchicine, pentoxifylline, thalidomide, dapsone (caution: side effects)
  • Levamisole (immune modulator)
  • Penicillin G (short course)

REFERRALS

  • Otolaryngology/dentist for persistent or unusual lesions
  • Rheumatology/GI if suspect systemic disease

ADDITIONAL THERAPIES

  • Vitamin B12 (1,000 mcg sublingual/day)
  • Vitamin C (2,000 mg/day)
  • H. pylori eradication (controversial)
  • Low-level laser therapy (658 nm): may speed healing, reduce pain

FOLLOW-UP

  • Monitor recurrence
  • Reevaluate if nonhealing, new locations, or systemic features
  • Educate on:
  • SLS-free oral hygiene
  • Avoid acidic, spicy, carbonated foods
  • Nutrition and behavior modification

PROGNOSIS

  • Most: self-limited, mild and recurrent
  • Severe cases: potential for scarring, significant pain, and impaired QoL
  • May improve with age

COMPLICATIONS

  • Superinfection
  • Scarring (especially in major aphthae)
  • Functional impairment (e.g., eating, speaking)
  • Psychosocial impact

CODES (ICD-10)

  • K12.0 — Recurrent oral aphthae

CLINICAL PEARLS

  • Most common ulcerative disease of the oral mucosa
  • Painful ulcers on nonkeratinized mucosa = classic feature
  • No HSV association with herpetiform ulcers
  • Recurrent cases may require systemic workup
  • SLS-free toothpaste, B12, and corticosteroids help in prevention and treatment