Aphthous Stomatitis

Background

• Aphthous ulcers, commonly called canker sores, are painful, shallow, recurrent oral ulcers in the absence of systemic disease.
• The cause is unknown but possible precipitating risk factors include local oral trauma, foods (such as nuts, acidic foods, and seasonings), medications, and stress.

Evaluation

• Diagnose aphthous stomatitis with observation of painful recurrent round or ovoid oral ulcers with white, yellow, or gray pseudomembrane located on the labial or buccal mucosa, ventral or lateral tongue, floor of mouth, soft palate, or oropharynx.
  • Minor aphthae (small ulcers < 1 cm) and herpes-like aphthae (crops of small 1-3 mm ulcers) resolve spontaneously within 10-14 days and usually have their first presentation in childhood.
  • Major aphthae (ulcers > 1 cm) may take > 6 weeks to resolve, may develop secondary bacterial infection, lead to scarring, and usually have onset at puberty with chronic recurrences.
• Consider alternative diagnoses of infectious origin.
  • Consider oral herpes if lesions appear as clusters at vermillion border or on lips. (See Oral herpes.)
  • Consider herpangina if there is an associated fever, especially in children < 5 years old with oral lesions usually more concentrated inposterior oropharynx. (See Herpangina.)
  • Consider hand-foot-and-mouth disease if there is an accompanying rash on hands or feet, especially in children < 10 years old with fever. (See Hand-foot-and-mouth disease.)
• Consider alternative diagnoses of non-infectious origin
  • Consider systemic lupus erythematosus (SLE) which can present with painful oropharyngeal ulcers either as an initial manifestation of this systemic auto-immune disease or as a finding in a patient with an established prior diagnosis of SLE.
  • Consider Behcet syndrome, especially in patients with a known prior history or anal or genitourinary ulcers.
  • Consider mucositis in patients receiving chemotherapy agents.
  • Consider various forms of auto-immune diseases with components of vasculitisthat can present with oropharyngeal ulcers on occasion such as
    • Kawasaki disease
    • sarcoidosis
    • inflammatory bowel disease.

Management

• When using topical medications instruct patients to apply topical products to a dry ulcer and to avoid food and drink for 30 minutes after application.
• Consider topical anesthetics (such as lidocaine or benzocaine) for immediate pain relief.
• Consider one of the following treatments to reduce pain and hasten ulcer healing:
  • a topical corticosteroid compounded for oral use, such as dexamethasone 5% oral paste 3 times daily or clobetasol propionate 0.05% oral paste 4 times daily
  • amlexanox applied 4 times daily (not available in United States)
• Consider systemic medications for severe recurrent ulcers. There is very little data to guide effective use of systemic medications. Treatments with limited evidence of benefit include montelukast (10 mg/day for 1 month then 10 mg every other day for 1 month), prednisone (25 mg/day for 15 days then tapered over 2 months), and beta-glucans (10 mg twice daily). Thalidomide is effective but has a high rate of adverse effects.
• For prevention of recurrent aphthous ulcers consider:
  • avoiding predisposing factors, such as oral trauma, toothpaste containing sodium lauryl sulfate, or food and drinks that may trigger ulcer eruption
  • amlexanox started at onset of prodromal symptoms (not available in United States)
  • vitamin B12 1,000 mcg sublingually once daily