Approach to the Patient with Aphthous Stomatitis

Aphthous stomatitis (canker sores) is a common self-limited ulcerative condition of the oral mucosa. About 20% of the population is affected at one time or another. The lesions can be disturbing in appearance and very painful. The primary physician should be able to differentiate them from more serious pathology and provide symptomatic relief.

PATHOPHYSIOLOGY, CLINICAL PRESENTATION, AND COURSE (1, 2, 3 and 4)

Pathogenesis

The underlying pathophysiology is incompletely understood, but a heightened immunologic response to oral mucosal antigens appears to play an important role. There is a genetic predisposition and an increased prevalence among patients with such autoimmune diseases as Crohn disease, chronic ulcerative colitis, Behçet syndrome, and Reiter syndrome; a link with gluten-sensitive enteropathy has been suggested. Contributing factors include deficiencies of iron, folate, and vitamin B₁₂; psychological stress; generalized physical debility; and trauma. Although vitamin and mineral deficiencies usually produce stomatitis, they have been increasingly linked to recurrent aphthous ulceration as well. In some women, flares occur premenstrually. Regardless of etiology, once mucosal breakdown has occurred, the lesions are invaded by mouth flora and become secondarily infected.

Clinical Presentation

Aphthous stomatitis develops in four clinical stages:

Premonitory: tingling, burning, or hyperesthetic sensation, lasting up to 24 hours
Preulcerative: lasting from 18 hours to 3 days, characterized by moderately painful erythematous macules or papules with erythematous halos
Ulcerative: lasting 1 to 16 days, characterized by painful discrete ulcers 2 to 10 mm in diameter, occurring singly or in groups and covered by a gray-yellow membrane with a dusky erythematous halo; pain ceases during this stage.
Healing: averaging 2 weeks (range from 4 to 5 weeks), usually without scarring unless lesions are very large

Aphthous ulcers are classified according to size. Most are minor (i.e., <1 cm in diameter) and appear in crops of four or five. Major lesions are greater than 1 cm, solitary, and indolent and, as noted, may scar as they heal. Lesions are painful and may occur anywhere within the oral cavity. In two thirds of patients, recurrent lesions do not develop, but in one third, recurrences continue for up to 40 years.

DIFFERENTIAL DIAGNOSIS (2,3,6,7)

A host of conditions can cause oral ulcers (Table 224-1). Many are characterized by involvement beyond the oral cavity. Pemphigus is suggested by the presence of bullous lesions elsewhere on the body (although oral lesions may precede others by years) and a Tzanck smear from the base of the lesion showing acantholytic cells; immunofluorescence studies may be necessary if there is recurrent disease. The ulcerated mucosal lesions of herpes simplex infection are limited to mucosal surfaces attached to bone (e.g., the hard palate and attached gingiva), whereas aphthous ulcers may occur anywhere in the oral cavity; the Tzanck preparation shows multinucleated giant cells as it does with herpes zoster, which is characterized by a dermatomal skin distribution (see Chapters 192 and 193). The ulcers of Behçet syndrome are identical to those of aphthous stomatitis; genital ulceration and eye involvement help to differentiate the condition from simple
aphthous disease. In hand-foot-and-mouth disease, papulovesicular lesions with an erythematous halo appear on the hands, feet, and lips in addition to the mouth; the lesions ulcerate and then heal over 7 to 10 days. Because the condition is due to an enterovirus, the mucosal findings may be preceded by viral gastrointestinal symptoms. In squamous cell carcinoma of the oral cavity, there is a single ulcerated lesion that fails to heal; a history of smoking and drinking is typically prominent (see Chapter 211).

Only gold members can continue reading. Log In or Register to continue