Self-limited painful ulcerations of the oral mucosa that are typically recurrent; they occur on nonkeratinized mucosa inside the mouth: the inner side of the lips and cheeks, the back and floor of the mouth, and under the tongue.
- The 1st episode of aphthous stomatitis usually occurs during the 1st or 2nd decade of life. The incidence then begins to decrease after the 3rd decade. It affects 20% of the US population.
- Aphthous ulcers may be categorized into 3 types:
- Minor aphthous ulcers:
- 70–90% of all aphthae
- <10 mm in diameter
- Up to 5 appear at a time.
- Heal in 7–10 days
- Major aphthous ulcers (also called Sutton disease):
- 10–15% of all aphthae
- >10 mm in diameter
- 1–10 ulcers at a time
- Take weeks to months to heal
- Scarring may occur.
- Herpetiform aphthous ulcers:
- Minor aphthous ulcers:
- Vitamin, iron, or folic acid deficiency
- Smoking (1)[A]
- Toothpastes containing sodium lauryl sulfate (2)
- Celiac disease (3)
Possible familial correlation
Unknown etiology; likely multifactorial with some correlation with
- Immunologic dysfunction
- Activation of cell-mediated immunes system:
- Food hypersensitivities
- Vitamin deficiency
- Psychological and genetic factors
Diagnosis is made by history and clinical presentation.
- Prodrome of burning or pricking sensation of oral mucosa 1–2 days prior to appearance of ulcers
- Inquire about family history of systemic lupus erythematosus (SLE), inflammatory bowel disease (IBD), or Behçet disease.
- Inquire about patient medical history of SLE, HIV, IBD, Behçet disease, or cancer.
- Look for signs of dehydration.
- Vital signs should be within normal limits.
- Evaluate for signs of secondary infection.
Diagnostic Tests & Interpretation
- Complete blood count (CBC)
- Rapid plasma reagin test
- Antinuclear antibody (ANA) test
- Tzanck stain (herpesvirus)
- Celiac disease serology
- Vitamins B6 and B12
- Serum iron and folate
- Biopsy: Multinucleated giant cells (cytomegalovirus)
- Fungal cultures: Cryptosporidium
- Rule out oral manifestation of systemic disease.
- Drug exposure:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Vesicular lesions
- Ulcers on attached mucosa
- Cytomegalovirus: Immunocompromised patient
- Varicella virus: Characteristic skin lesions
- Ulcers preceded by vesicles
- Hand, foot, 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
- Reiter syndrome:
- HLA–B27-associated arthritis
- Behçet syndrome:
- Sweet syndrome:
- Erythematous skin plaques/nodules
- In conjunction with malignancy
- Bloody or mucous diarrhea
- GI ulcerations
- SLE: Malar rash
- Bullous pemphigoid/pemphigoid vulgaris:
- Vesiculobullous lesions on attached and unattached mucosa
- Diffuse skin involvement
- Cyclic neutropenia: Periodic fever
- Squamous cell carcinoma:
- Head/neck adenopathy
- Immunocompromised patient:
- Debacterol (available over the counter [OTC]), a topical treatment, chemically cauterizes the oral lesion, eliminating pain associated with the lesion.
- 5-Aminosalicylic acid 5% cream: 3× daily × 2 weeks
- Dyclonine HCl 1% solution: 5-mL rinse q.i.d.
- Magnesium hydroxide/diphenhydramine hydrochloride: 5 mg/5 mL in 1:1 mix; swish and swallow q.i.d.
- Sucralfate: 10 mL; swish and swallow or swish and spit q.i.d.
- Viscous lidocaine 2%: Apply to ulcer as needed q.i.d.
- Topical OTC preparations (e.g., Orabase, Anbesol)
- Promote ulcer healing/prevent recurrence (1st-line agents):
- Triamcinolone 0.1% in Orabase: Apply to ulcer 2–4× daily until healed.
- Amlexanox 5% paste: 0.5 cm applied to ulcer q.i.d. after meals
- Clobetasol 0.05%: 0.5 cm applied to ulcer 2× daily
- Fluocinonide 0.05% gel: 0.5 cm applied to ulcer up to 5× daily
- 2nd-line agents:
- Prednisone tablets: 40 mg/d P0 × 7 days
- Thalidomide: 200 mg/d P0 × 4 weeks
Issues for Referral
Follow up with otolaryngologist if lesions have not resolved within 2 weeks.
Vitamin and iron supplementation
- Unable to eat or drink after appropriate analgesia
- Abnormal vital signs or evidence of dehydration
- Tolerating fluids
- Adequate analgesia
- Normal vital signs
1. Porter SR, Scully Cbe C. Aphthous ulcers (recurrent). Clin Evid (Online). 2007.
2. Herlofson BB, Barkvoll P. Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study. Acta Odontol Scand. 1994;52:257–9.
3. Pastore L, Carroccio A, Compilato D, et al. Oral Manifestations of Celiac Disease. J Clin Gastroenterol. 2008.
McBride DR. Management of aphthous ulcers. Am Fam Physician. 2000;62:149–54, 160.
Scully C, Gorsky M, Lozada-Nur F. The diagnosis and management of recurrent aphthous stomatitis: a consensus approach. J Am Dent Assoc. 2003;134:200–7.
Shashy RG, Ridley MB. Aphthous ulcers: a difficult clinical entity. Am J Otolaryngol. 2000;21:389–93.
Ship JA, Chavez EM, Doerr PA, et al. Recurrent aphthous stomatitis. Quintessence Int. 2000;31:95–112.
Woo SB, Sonis ST. Recurrent aphthous ulcers: a review of diagnosis and treatment. J Am Dent Assoc. 1996;127:1202–13.
- 528.00 Stomatitis and mucositis, unspecified
- 528.2 Stomatitis and mucositis
- 426965005 aphthous ulcer of mouth (disorder)
- 61170000 stomatitis (disorder)
- Risk of recurrence decreases with quitting smoking 1[A].
- Use of toothpastes without the ingredient sodium lauryl sulfate may reduce or even prevent recurrences (2).
- Avoid oral trauma from aggressive toothbrushing or foods with sharp edges.
- Self-limited painful ulcerations of the oral mucosa that are typically recurrent; they occur on nonkeratinized mucosa inside the mouth: the inner side of the lips and cheeks, the back and floor of the mouth, and under the tongue
- Risk factors include: Trauma; stress; vitamin, iron, or folic acid deficiency; immunodeficiency, smoking; toothpastes containing sodium lauryl sulfate; celiac disease
- Most are self limiting; treat symptoms with topical agents like: Debacterol, Triamcinolone 0.1% in Orabase, others