What is the diagnosis and recommended treatment for a patient with multiple minor aphthous ulcers and mild gingival inflammation?

Diagnosis and Treatment of Multiple Canker Sores with Mild Gingival Inflammation

Diagnosis

The clinical presentation of multiple canker sores (aphthous ulcers) with mildly inflamed gums is consistent with recurrent aphthous stomatitis (RAS), which presents as well-demarcated, oval or round ulcers with a white or yellow pseudomembrane surrounded by an erythematous halo. 1

Key Diagnostic Features

• Typical RAS morphology includes multiple, small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors. 2
• The ulcers are characteristically well-demarcated with a white/yellow pseudomembrane and surrounding erythema. 1
• Mild gingival inflammation often accompanies the ulcerative lesions in RAS. 2

Critical Timing for Further Evaluation

• If ulcers persist beyond 2 weeks or fail to respond after 1–2 weeks of treatment, biopsy is mandatory to exclude malignancy, systemic disease, or other serious conditions. 3, 1
• For acute presentations lasting less than 2 weeks with typical morphology, empiric treatment can be initiated without extensive workup. 1

When to Perform Laboratory Testing

Before proceeding to biopsy or if ulcers are recurrent (≥4 episodes per year), obtain the following baseline studies: 3, 1

• Complete blood count to detect anemia, leukemia, or neutropenia 3, 1
• Fasting blood glucose to exclude diabetes 3, 1
• HIV antibody testing in persistent cases 3, 1
• Syphilis serology 3, 1
• Coagulation studies if biopsy is planned 3
• Consider serum antibodies (Dsg1, Dsg3, BP180, BP230) if autoimmune bullous disease is suspected 3

Treatment Approach

First-Line Topical Therapy

Topical corticosteroids are the cornerstone of treatment for symptomatic relief and should be initiated immediately for typical RAS presentations. 4, 5

• For multiple ulcers or difficult-to-reach locations: Use dexamethasone mouth rinse (0.1 mg/ml) to cover several areas of the oral cavity. 4
• For limited, easily accessible ulcers: Apply clobetasol gel or ointment (0.05%) directly to lesions. 4
• Topical antiseptic/anti-inflammatory agents such as triclosan and diclofenac should be tried first before escalating to corticosteroids in mild cases. 5
• Local anesthetics such as lidocaine can provide symptomatic pain relief. 5

Adjunctive Measures

• Eliminate sources of trauma and avoid painful stimuli. 4
• Maintain effective oral hygiene despite discomfort. 4
• Avoid hard, acidic, salty foods, toothpastes containing sodium lauryl sulfate, alcohol, and carbonated drinks. 5
• Barrier preparations such as Gengigel mouth rinse/gel or Gelclair may provide additional pain control. 1

Escalation for Refractory Cases

If topical therapy fails after 1–2 weeks or ulcers are highly symptomatic and recurrent, consider systemic corticosteroids: 4

• High-dose pulse oral prednisone/prednisolone 30–60 mg (or 1 mg/kg) for 1 week, followed by dose tapering over the second week. 4
• For recurrent aphthous stomatitis with frequent episodes, colchicine combined with topical treatments is suitable for most cases. 6
• Pentoxifylline or other systemic agents may be considered in severe refractory cases. 5

Intralesional Therapy for Persistent Ulcers

• If ulcers do not resolve with topical treatment, intralesional triamcinolone injection (weekly; total dose 28 mg) in conjunction with topical clobetasol gel or ointment (0.05%) should be considered. 4

Critical Pitfalls to Avoid

• Never delay biopsy beyond 2 weeks for persistent ulcers, as this risks missing malignancy (squamous cell carcinoma, lymphoma) or serious systemic diseases such as tuberculosis, autoimmune conditions, or hematologic malignancies. 3, 1
• Do not rely solely on topical treatments without establishing a definitive diagnosis if ulcers persist or recur frequently, as multiple oral ulcers may indicate Crohn's disease, blood disorders, or autoimmune conditions. 3, 1
• Avoid performing oral biopsies before confirming normal coagulation status and adequate platelet count to prevent severe bleeding complications. 3
• Consider systemic associations: RAS can be linked to gastrointestinal diseases (celiac disease, inflammatory bowel disease), nutritional deficiencies (iron, folate, vitamin B12), immune disorders (HIV, neutropenia), or Behçet's disease. 6, 1

Specialist Referral Indications

Refer to an oral medicine specialist for: 7, 1

• Ulcers lasting more than 2 weeks 7, 1
• Ulcers not responding to 1–2 weeks of appropriate treatment 7, 1
• Recurrent episodes (≥4 per year) that are severe or significantly impact quality of life 1
• Atypical morphology or clinical features 1