What is an aphthous ulcer?

Aphthous Ulcers: Diagnosis and Management

Aphthous ulcers are well-demarcated, oval or round ulcers with a white or yellow pseudomembrane and an erythematous halo, representing the most common type of oral ulcerative disease affecting 10-20% of the population. 1, 2

Clinical Presentation

• Aphthous ulcers present as extremely painful, shallow ulcerations with an erythematous halo on unattached oral mucosa 2
• Three clinical subtypes exist: minor (most common, 80-90%), major, and herpetiform 2
• Minor aphthous ulcers typically heal within 8-10 days without scarring 3
• Major aphthous ulcers are larger (>1cm), deeper, more painful, and may take weeks to months to heal, often leaving scars 3
• Herpetiform aphthous ulcers appear as clusters of multiple small (1-3mm) painful ulcers 3

Diagnostic Features

• Typical aphthous ulcers have a yellow or white base with a well-defined erythematous border 1, 2
• They are usually located on non-keratinized, movable oral mucosa (buccal mucosa, labial mucosa, floor of mouth) 1
• Pain is a predominant feature, often preceded by a burning sensation 3
• Recurrent aphthous stomatitis (RAS) is defined by the recurrence of oral aphthous ulcers at least 4 times per year 4

Differential Diagnosis

• Oral herpes simplex is the primary differential diagnosis 2
• Other conditions to consider include:
  • Traumatic ulceration (related to sharp teeth edges or appliances) 1
  • Infectious causes (bacterial, fungal, viral) 1
  • Systemic diseases (inflammatory bowel disease, celiac disease) 4
  • Drug-induced ulcerations (NSAIDs, nicorandil, betablockers) 4, 3
  • Malignancy (particularly for solitary chronic ulcers) 4

Diagnostic Approach for Persistent Ulcers

• For ulcers persisting beyond 2 weeks or not responding to treatment, further investigation is warranted 5
• First-line testing should include:
  • Full blood count to screen for anemia, leukemia, and other blood disorders 5
  • Fasting blood glucose to identify hyperglycemia 5
  • HIV antibody testing to rule out HIV-associated ulceration 5, 6
  • Syphilis serology testing 5
• Second-line testing may include:
  • Nutritional deficiency screening (iron, folate, vitamin B12) 5, 4
  • Autoimmune markers if autoimmune conditions are suspected 5
  • Biopsy for persistent ulcers to rule out malignancy 1, 5

Management

• Avoidance of triggers such as hard, acidic, and salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks 7
• First-line treatment includes:
  • Topical antiseptic/anti-inflammatory agents like triclosan 7
  • Local anesthetics such as benzocaine or lidocaine for pain relief 8, 7
• Second-line treatment:
  • Topical corticosteroids for more severe cases 2, 7
• For severe or refractory cases:
  • Systemic medications may be considered, including colchicine, pentoxifylline, or prednisolone 7
  • Laser therapy has shown promising results in promoting analgesia and healing 6

Special Considerations

• Recurrent aphthous ulcers may be associated with systemic conditions requiring further evaluation:
  • Inflammatory bowel disease 4
  • Celiac disease 4, 3
  • Behçet's disease (characterized by bipolar aphthosis - oral and genital ulcers) 3
  • HIV infection (higher prevalence in patients with low CD4 counts) 6
• Any solitary chronic ulcer should be biopsied to rule out squamous cell carcinoma 4

Common Pitfalls

• Relying solely on clinical appearance without appropriate testing for persistent ulcers 5
• Overlooking systemic causes of recurrent oral ulcers 5, 4
• Treating symptoms without establishing a definitive diagnosis for persistent ulcers 5