DESCRIPTION

Painful ovoid or round ulcerations on the mucous membranes of the mouth, tongue or genitals:

• Commonly referred to as "canker sores"

ETIOLOGY

• Unknown
• Etiology likely multifactorial with some correlation with:
  • Immunologic dysfunction; alteration of cell-mediated immune system
  • Infection
  • Food hypersensitivities (i.e., gluten)
  • Vitamin deficiency
  • Pregnancy
  • Menstruation
  • Trauma
  • Stress
  • Ethnicity
  • Immunodeficiency
  • Medications: β-blockers, anti-inflammatory
• Epidemiology: Usually occurs in children and young adults (Peak age of onset: Between 10 to 19 yr old)
  • Most common inflammatory ulcerative condition of the oral cavity (20-40% of general population)
  • More common in women
  • May be familial

[Outline]

• DESCRIPTION
• ETIOLOGY

SIGNS AND SYMPTOMS

• Minor aphthous ulcers:
  • 70–90% of all aphthae
  • < 5 mm in diameter; up to 5 appear at a time
  • Painful, shallow ulcers with necrotic centers
  • Raised, circumscribed margins and erythematous halos
  • Gray-white pseudomembrane
  • Affect nonkeratinized mucosa of anterior oral cavity
    • Labial and buccal mucosa
    • Floor of mouth
    • Ventral surface of tongue
  • Rarely found on dorsum of tongue, hard palate, or gingiva
  • Last for 10–14 days; do not scar
  • Fever/constitutional symptoms rarely associated
• Major aphthous ulcers or Sutton disease:
  • 10–15% of all aphthae
  • Similar in appearance but more painful than minor form
  • > 5 mm in diameter; 1–10 ulcers at a time
  • Deeper than minor form
  • Involve all areas of oropharynx including pharynx, soft/hard palate, lips
  • Last for weeks to months, may scar
  • Onset after puberty
  • Often associated with underlying disease
  • Fever is rarely associated
• Herpetiform aphthous ulcers:
  • 7–10% of all aphthae
  • Multiple small clusters
  • < 5 mm in diameter, 10–100 at any time, may coalesce into plaques
  • Herpetiform in nature, but herpes simplex virus cannot be cultured from lesions.
  • Predisposition for women
  • Last for 7–30 days; scarring can occur

History

• Prodrome of burning or pricking sensation of oral mucosa 1–2 days prior to appearance of ulcers
• Inquire about patient or family history of:
  • Systemic lupus erythematosus (SLE)
  • Inflammatory bowel disease (IBD)
  • Behçet disease
  • Reiter disease
  • Gluten sensitivity
  • Cancer
  • HIV
• Inquire about patient sexual history of syphilis or herpes virus
• Inquire about current medications:
  • NSAIDs
  • β-blockers

Physical Exam

• See "Signs and Symptoms."
• Look for signs of dehydration:
  • Vital signs should be within normal limits.
  • Evaluate mucus membranes.
• Evaluate for signs of secondary infection.
• Evaluate for signs of systemic causes of ulcers (see "History").

ESSENTIAL WORKUP

• Diagnosis is made by history and clinical presentation.
• Rule out oral manifestation of systemic disease:
  • More likely if persists > 3 wk or associated with constitutional symptoms
• Focus on symptoms of eyes, mouth, genitalia, skin, GI tract, allergy, diet history and physical exam

DIAGNOSIS TESTS & INTERPRETATION

Lab

Routine lab testing not indicated:

• Needed only when systemic etiologies causing ulcers are suspected
• Biopsy should be considered for ulcers lasting more than 3 wk
• Should be guided by history and physical exam:
  • CBC series
  • Rapid plasma reagin (RPR) (syphilis)
  • Fluorescent treponemal antibody-absorption test
  • Antinuclear antibody test
  • Tzanck stain: Inclusion giant cells (herpes virus)
  • Biopsy: Multinucleated giant cells (cytomegalovirus)
  • Fungal cultures

Diagnostic Procedures/Surgery

An outpatient biopsy should be considered for any ulcer > 3 wk

DIFFERENTIAL DIAGNOSIS

• Trauma:
  • Biting
  • Dentures
  • Braces
• Drug exposure:
  • NSAIDs
  • Nicorandil
  • β-blockers
• Infection:
  • Herpes virus:
    • Vesicular lesions
    • Ulcers on attached mucosa
  • Cytomegalovirus:
    • Immunocompromised patient
  • Varicella virus:
    • Characteristic skin lesions
  • Coxsackievirus:
    • Ulcers preceded by vesicles
    • Hand, foot, and buttock lesions
  • Syphilis:
    • Other skin or genital lesions
  • Erythema multiforme:
    • Lip crusting
    • Lesions on attached and unattached mucosa skin lesions
  • Cryptosporidium infection, mucormycosis, histoplasmosis
  • Necrotizing gingivitis
• Underlying disease:
  • Behçet syndrome:
    • Genital ulceration
    • Uveitis
    • Retinitis
  • Reactive arthritis (Reiter syndrome):
    • Uveitis
    • Urethritis
    • HLA-B27-associated arthritis
  • Sweet syndrome:
    • Fever
    • Erythematous skin plaques/nodules
    • In conjunction with malignancy
  • IBD:
    • Bloody or mucous diarrhea
    • GI ulcerations
    • Weight loss
  • Gluten-sensitive enteropathy:
    • Weight loss
  • SLE:
    • Malar rash
    • ANA positive
  • Bullous pemphigoid/pemphigus vulgaris:
    • Vesiculobullous lesions on attached and unattached mucosa
    • Diffuse skin involvement
  • Cyclic neutropenia:
    • Periodic fever
  • Squamous cell carcinoma:
    • Chronic
    • Head/neck adenopathy
• Immunocompromised patient:
  • HIV
  • Agranulocytosis
  • Malignancy

[Outline]

• SIGNS AND SYMPTOMS
• ESSENTIAL WORKUP
• DIAGNOSIS TESTS & INTERPRETATION
• DIFFERENTIAL DIAGNOSIS

ED TREATMENT/PROCEDURES

• Treatment guided by severity and duration of symptoms
• Goal is for symptomatic pain relief and reduction of inflammation.

MEDICATION

• Mild to moderate disease:
  • Avoid oral trauma/acidic foods
  • Topical anesthetic
    • Magnesium hydroxide/diphenhydramine hydrochloride 5 mg/5 mL in 1/1 mix swish and spit
    • Viscous lidocaine 2–5%: Applied to ulcer QID after meals until healed
  • Protective bioadhesives
    • Topical OTC preparations (Orabase, Anbesol): Applied to ulcer QID after meals until healed
  • Topical anti-inflammatory
    • Amlexanox 5% paste (Aphthasol): applied to ulcer QID after meals until healed
  • Antimicrobial mouthwash
    • Chlorhexidine gluconate aqueous mouthwash 0.12% (Peridex): Mouth rinse QID after meals until healed
• Severe disease:
  • Prednisone tablets: 30–60 mg PO per day × 7 d
  • Thalidomide: 50–200 mg PO per day × 4 wk

[Outline]

• ED TREATMENT/PROCEDURES
• MEDICATION

DISPOSITION

Admission Criteria

• Unable to eat or drink after appropriate analgesia
• Abnormal vital signs or evidence of dehydration

Discharge Criteria

• Tolerating fluids
• Adequate analgesia
• Normal vital signs

Issues for Referral

Follow up with primary care physician if lesions have not resolved within 2 wk.

FOLLOW-UP RECOMMENDATIONS

• Avoid oral trauma (hard foods) or acidic foods.
• Referral to a specialist if underlying disease suspected

[Outline]

• DISPOSITION
• FOLLOW-UP RECOMMENDATIONS

• The vast majority of aphthous ulcers are benign, self-limited, and treated symptomatically
• ED physicians must consider underlying systemic cause of ulcers.

ICD9

• 528.2 Oral aphthae
• 608.89 Other specified disorders of male genital organs
• 616.50 Ulceration of vulva, unspecified

ICD10

• K12.0 Recurrent oral aphthae
• N50.8 Other specified disorders of male genital organs
• N76.6 Ulceration of vulva

[Outline]

• ICD9
• ICD10

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• Brocklehurst P, Tickle M, Glenny AM, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012;(9). Art No.: CD005411. doi:10.1002/14651858.CD005411.pub2.
• Chattopadhyay A, Shetty KV. Recurrent aphthous stomatitis. Otolaryngol Clin North Am. 2011;44:79–81.
• Chavan M, Jain H, Diwan N, et al. Recurrent aphthous stomatitis: A review. J Oral Pathol Med. 2012;41:557–583.
• Scully C. Aphthous ulceration. Clinical practice. N Engl J Med. 2006;355:165–172.
• Wanda C, Chi AC, Neville BW. Common oral lesion: Part I. Superficial mucosal lesions. Am Fam Physician. 2007;75:501–507.

Matthew R. Berkman