Aphthous Ulcer Treatment Guide: Causes, Symptoms, and Relief Strategies
- Mayta
- 3 days ago
- 2 min read
🧠 Definition & Terminology
Aphthous ulcers, commonly known as canker sores, are benign, non-infectious, ulcerative lesions of the oral mucosa, predominantly affecting non-keratinized epithelium. They are among the most common oral mucosal lesions, affecting up to 20–25% of the general population.
Recurrent Aphthous Stomatitis (RAS): When lesions recur periodically without an identifiable systemic cause.
Canker Sore: Layman’s term.
Aphthae: Singular “aphtha,” used in clinical literature.
🔬 Epidemiology
Prevalence: Affects up to 66% of individuals at least once in their lifetime.
Peak incidence: Adolescents and young adults.
Sex: Slight female predominance.
Ethnicity: Higher prevalence in developed countries, possibly due to dietary/environmental factors.
🔬 Pathophysiology
The precise mechanism remains incompletely understood, but immunologically mediated destruction of the mucosal epithelium is central to pathogenesis.
Pathogenic Sequence:
Triggering event (trauma, stress, antigen exposure).
Dysregulated immune response — involving T-cell mediated cytotoxicity.
Cytokine release — especially TNF-α, IL-2, and IFN-γ.
Epithelial ulceration due to inflammatory cell infiltration.
Healing by re-epithelialization, generally without scarring.
🎯 Etiology (Mnemonic: STING-FH)
Cause | Detail |
Stress | Academic, emotional |
Trauma | Braces, aggressive brushing, dental procedures |
Immunologic | Autoimmune diseases (e.g., Behçet's, SLE, IBD) |
Nutritional deficiencies | Iron, folate, vitamin B12, zinc |
Gastrointestinal disorders | Celiac disease, Crohn’s disease |
Food sensitivities | Chocolate, coffee, gluten, citrus, spicy food |
Hormonal changes | Menstruation, pregnancy |
🔍 Clinical Subtypes of Aphthous Ulcers
Type | Description | Features |
Minor Aphthous Ulcers | Most common (80%) | <1 cm, shallow, heal in 7–10 days, no scar |
Major Aphthous Ulcers (Sutton’s Disease) | 10–15% | >1 cm, deeper, heal in 2–6 weeks, may scar |
Herpetiform Ulcers | Least common | Multiple small (1–2 mm), coalesce into large ulcers, painful, heal in 7–10 days |
🧑⚕️ Clinical Presentation
History:
Recurrent painful oral ulcers
Interference with eating, speech, and oral hygiene
No systemic symptoms (if isolated RAS)
Locations:
Non-keratinized mucosa:
Buccal mucosa
Labial mucosa
Floor of mouth
Ventral tongue
Soft palate
Keratinized mucosa (e.g., gingiva, hard palate) is typically spared — useful in differentiating from HSV.
🩺 Physical Examination Findings
Positive Findings:
Round/oval ulcer with well-defined erythematous halo
Central yellow or grey base (fibrinopurulent pseudomembrane)
Painful on palpation
No crusting (vs herpes)
Negative Findings:
No vesicles or preceding blisters
No fever, malaise, lymphadenopathy
No systemic rash or genital ulceration (helps rule out Behçet)
⚖️ Differential Diagnosis
Condition | Key Differentiator |
Herpetic gingivostomatitis (HSV) | Preceding vesicles, keratinized mucosa, systemic symptoms |
Hand-foot-mouth disease (Coxsackie virus) | Accompanied by skin rash on hands/feet, fever |
Behçet’s Disease | Oral + genital ulcers + uveitis |
Crohn’s Disease | GI symptoms, perianal disease, iron deficiency anemia |
Pemphigus vulgaris | Bullae, positive Nikolsky sign |
SLE | Systemic signs, ANA+, butterfly rash |
Celiac Disease | Malabsorption symptoms, positive anti-TTG antibodies |
HIV/AIDS | Severe, persistent, often resistant to treatment |
🧪 Laboratory Workup (Only in Recurrent, Atypical, or Refractory Cases)
Test | Purpose |
CBC | Look for anemia (iron deficiency, macrocytic anemia from B12/folate deficiency) |
Iron studies, B12, Folate | Nutritional deficiencies |
ESR/CRP | Chronic inflammation (Crohn’s, SLE) |
Anti-tTG IgA / EMA IgA | Celiac disease |
ANA, RF, HLA-B51 | Autoimmune screen (SLE, Behçet) |
HIV ELISA & Western Blot | Immunocompromised state |
💊 Management
🟢 Mild/First Episode (Self-limited):
Topical corticosteroids:
Triamcinolone acetonide 0.1% dental paste – apply 2–4x/day
Topical anesthetics:
Benzocaine 10% gel or Lidocaine 2% gel
Barrier protection:
Orabase paste, sucralfate suspension
🟡 Moderate (Multiple or Painful Lesions):
Antiseptic mouthwashes:
Chlorhexidine gluconate 0.12% BID
Anti-inflammatory rinses:
Dexamethasone elixir (0.5 mg/5 mL) swish and spit
Oral analgesics:
NSAIDs or acetaminophen PRN
🔴 Severe (Major Aphthae or Refractory RAS):
Systemic corticosteroids:
Prednisolone 0.5 mg/kg/day x 5–7 days (with taper)
Colchicine or Dapsone for Behçet-related ulcers
Thalidomide or Azathioprine (Specialist-level, refractory only)
🧃 Adjunctive Therapy:
Nutritional replacement: Iron, folate, B12
Avoid triggers: SLS toothpaste, acidic/spicy food
Counseling: Stress management
👨⚕️ USMLE Step 1 & 2 Key Concepts
Aphthous ulcers = non-keratinized oral ulcer + no systemic symptoms.
Recurrent ulcers + genital ulcers + uveitis = Behçet’s disease.
HSV: keratinized mucosa, painful vesicles, grouped ulcers.
Initial therapy = topical corticosteroids; reserve systemic therapy for major/refractory cases.
🧾 Clinical Pearls
Aphthous ulcers in a patient with chronic diarrhea? 👉 Screen for celiac or Crohn’s disease.
Oral ulcers unresponsive to topical steroids? 👉 Rule out SLE, HIV, or immunodeficiency.
Aphthous ulcer + genital + eye involvement? 👉 Think Behçet syndrome and order HLA-B51.
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