What are the key characteristics to note when describing the appearance of aphthous ulcers in the mouth?

Correct Description of Aphthous Ulcers in the Mouth

Aphthous ulcers should be described using standardized terminology noting their well-demarcated, oval/round appearance with white/yellow pseudomembrane and erythematous halo, documenting their size, number, location, and depth. 1

Key Characteristics to Document

• Morphology: Well-demarcated, oval or round ulcers with white or yellow pseudomembrane surrounded by an erythematous halo (non-indurated red border) 1, 2

• Size classification:

  • Minor aphthous ulcers (80-90% of cases): <1 cm in diameter 3
  • Major aphthous ulcers: >1 cm in diameter 2, 4
  • Herpetiform aphthous ulcers: Multiple small ulcers (1-3 mm) 2, 4

• Location: Document specific site within the oral cavity, typically on non-keratinized mucosa (buccal mucosa, labial mucosa, floor of mouth, soft palate) 2

• Number: Single or multiple lesions 2

• Pain level: Usually extremely painful, often preceded by a burning sensation 2, 3

• Duration: Typically heal in 8-10 days for minor aphthae; major aphthae may persist longer 2, 4

Additional Important Features to Note

• Recurrence pattern: Document frequency of episodes if recurrent (defined as ≥4 episodes per year for recurrent aphthous stomatitis) 2

• Bipolar distribution: Note if ulcers appear in both oral and genital regions (may suggest Behçet's disease) 4

• Associated symptoms: Document any systemic symptoms like fever, weight loss, or joint pain that might indicate underlying conditions 1

• Healing pattern: Note if ulcers heal with or without scarring (major aphthae may heal with scarring) 2

Clinical Documentation Best Practices

• Use standardized terminology for consistency in documentation 5

• Include photo documentation whenever possible 5

• For patients with inflammatory bowel disease, document aphthous ulcers using validated endoscopic scores like CDEIS or SES-CD 5

• When describing aphthous ulcers in Crohn's disease patients, specify number, size, and presence of passable or non-passable strictures 5

Common Pitfalls to Avoid

• Failing to distinguish aphthous ulcers from herpes simplex lesions (primary differential diagnosis) 3

• Overlooking potential systemic causes of aphthous-like ulcers (e.g., inflammatory bowel disease, celiac disease, nutritional deficiencies) 2, 6

• Inadequate documentation of size, number, and distribution, which can lead to misdiagnosis or inappropriate management 1

• Relying solely on clinical appearance without appropriate testing for persistent ulcers (>2 weeks) 1

• Not documenting potential triggering factors such as trauma, stress, or dietary components (citrus fruits, tomatoes, walnuts) 4

When to Consider Specialist Referral

• For ulcers persisting >2 weeks or not responding to 1-2 weeks of treatment 7, 1

• When ulcers are associated with systemic symptoms suggesting underlying disease 1

• For recurrent, severe, or atypical presentations requiring biopsy or advanced diagnostic testing 7, 1