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Aphthous Ulcers, Emergency Medicine

Basics

Description

- Minor aphthous ulcers: - 70-90% of all aphthae - <5 mm in diameter; up to 5 appear at a time - Painful, shallow ulcers with necrotic centers - Raised, circumscribed margins and erythematous halos - Gray-white pseudomembrane - Affect nonkeratinized mucosa of anterior oral cavity - Labial and buccal mucosa - Floor of mouth - Ventral surface of tongue

- Rarely found on dorsum of tongue, hard palate, or gingiva - Last for 10-14 days; do not scar - Fever/constitutional symptoms rarely associated

- Major aphthous ulcers or Sutton disease: - 10-15% of all aphthae - Similar in appearance but more painful than minor form - >5 mm in diameter; 1-10 ulcers at a time - Deeper than minor form - Involve all areas of oropharynx including pharynx, soft/hard palate, lips - Last for weeks to months, may scar - Onset after puberty - Often associated with underlying disease - Fever is rarely associated

- Herpetiform aphthous ulcers: - 7-10% of all aphthae - Multiple small clusters - <5 mm in diameter, 10-100 at any time, may coalesce into plaques - Herpetiform in nature, but herpes simplex virus cannot be cultured from lesions. - Predisposition for women - Last for 7-30 days; scarring can occur

- Prodrome of burning or pricking sensation of oral mucosa 1-2 days prior to appearance of ulcers - Inquire about patient or family history of: - Systemic lupus erythematosus (SLE) - Inflammatory bowel disease (IBD) - Beh žet disease - Reiter disease - Gluten sensitivity - Cancer - HIV

- Needed only when systemic etiologies causing ulcers are suspected - Biopsy should be considered for ulcers lasting more than 3 wk - Should be guided by history and physical exam: - CBC series - Rapid plasma reagin (RPR) (syphilis) - Fluorescent treponemal antibody-absorption test - Antinuclear antibody test - Tzanck stain: Inclusion giant cells (herpes virus) - Biopsy: Multinucleated giant cells (cytomegalovirus) - Fungal cultures

- Trauma: - Drug exposure: - NSAIDs - Nicorandil - β-blockers

- Coxsackievirus: - Ulcers preceded by vesicles - Hand, foot, and buttock lesions

- Erythema multiforme: - Lip crusting - Lesions on attached and unattached mucosa skin lesions

- Cryptosporidium infection, mucormycosis, histoplasmosis - Necrotizing gingivitis

- Underlying disease: - Beh žet syndrome: - Genital ulceration - Uveitis - Retinitis

- Reactive arthritis (Reiter syndrome): - Uveitis - Urethritis - HLA-B27-associated arthritis

- Sweet syndrome: - Fever - Erythematous skin plaques/nodules - In conjunction with malignancy

- IBD: - Bloody or mucous diarrhea - GI ulcerations - Weight loss

- Gluten-sensitive enteropathy: - SLE: - Bullous pemphigoid/pemphigus vulgaris: - Vesiculobullous lesions on attached and unattached mucosa - Diffuse skin involvement

- Cyclic neutropenia: - Squamous cell carcinoma: - Chronic - Head/neck adenopathy

- Mild to moderate disease: - Avoid oral trauma/acidic foods - Topical anesthetic - Magnesium hydroxide/diphenhydramine hydrochloride 5 mg/5 mL in 1/1 mix swish and spit - Viscous lidocaine 2-5%: Applied to ulcer QID after meals until healed

- Protective bioadhesives - Topical OTC preparations (Orabase, Anbesol): Applied to ulcer QID after meals until healed

- Antimicrobial mouthwash - Chlorhexidine gluconate aqueous mouthwash 0.12% (Peridex): Mouth rinse QID after meals until healed

Painful ovoid or round ulcerations on the mucous membranes of the mouth, tongue or genitals: á

  • Commonly referred to as "canker sores"Ł

Etiology

  • Unknown
  • Etiology likely multifactorial with some correlation with:Immunologic dysfunction; alteration of cell-mediated immune systemInfectionFood hypersensitivities (i.e., gluten)Vitamin deficiencyPregnancyMenstruationTraumaStressEthnicityImmunodeficiencyMedications: β-blockers, anti-inflammatory
  • Epidemiology: Usually occurs in children and young adults (Peak age of onset: Between 10 to 19 yr old)Most common inflammatory ulcerative condition of the oral cavity (20-40% of general population)More common in womenMay be familial

Diagnosis

Signs and Symptoms

  • Minor aphthous ulcers:70-90% of all aphthae<5 mm in diameter; up to 5 appear at a timePainful, shallow ulcers with necrotic centersRaised, circumscribed margins and erythematous halosGray-white pseudomembraneAffect nonkeratinized mucosa of anterior oral cavityLabial and buccal mucosaFloor of mouthVentral surface of tongueRarely found on dorsum of tongue, hard palate, or gingivaLast for 10-14 days; do not scarFever/constitutional symptoms rarely associated
  • Major aphthous ulcers or Sutton disease:10-15% of all aphthaeSimilar in appearance but more painful than minor form>5 mm in diameter; 1-10 ulcers at a timeDeeper than minor formInvolve all areas of oropharynx including pharynx, soft/hard palate, lipsLast for weeks to months, may scarOnset after pubertyOften associated with underlying diseaseFever is rarely associated
  • Herpetiform aphthous ulcers:7-10% of all aphthaeMultiple small clusters<5 mm in diameter, 10-100 at any time, may coalesce into plaquesHerpetiform in nature, but herpes simplex virus cannot be cultured from lesions.Predisposition for womenLast for 7-30 days; scarring can occur

History

  • Prodrome of burning or pricking sensation of oral mucosa 1-2 days prior to appearance of ulcers
  • Inquire about patient or family history of:Systemic lupus erythematosus (SLE)Inflammatory bowel disease (IBD)Beh žet diseaseReiter diseaseGluten sensitivityCancerHIV
  • Inquire about patient sexual history of syphilis or herpes virus
  • Inquire about current medications:

Physical Exam

  • See "Signs and Symptoms."Ł
  • Look for signs of dehydration:Vital signs should be within normal limits.Evaluate mucus membranes.
  • Evaluate for signs of secondary infection.
  • Evaluate for signs of systemic causes of ulcers (see "History"Ł).

Essential Workup

  • Diagnosis is made by history and clinical presentation.
  • Rule out oral manifestation of systemic disease:More likely if persists >3 wk or associated with constitutional symptoms
  • Focus on symptoms of eyes, mouth, genitalia, skin, GI tract, allergy, diet history and physical exam

Diagnosis Tests & Interpretation

Lab

Routine lab testing not indicated: á

  • Needed only when systemic etiologies causing ulcers are suspected
  • Biopsy should be considered for ulcers lasting more than 3 wk
  • Should be guided by history and physical exam:CBC seriesRapid plasma reagin (RPR) (syphilis)Fluorescent treponemal antibody-absorption testAntinuclear antibody testTzanck stain: Inclusion giant cells (herpes virus)Biopsy: Multinucleated giant cells (cytomegalovirus)Fungal cultures

Diagnostic Procedures/Surgery

An outpatient biopsy should be considered for any ulcer >3 wk á

Differential Diagnosis

  • Trauma:
  • Drug exposure:NSAIDsNicorandilβ-blockers
  • Infection:Herpes virus:Vesicular lesionsUlcers on attached mucosaCytomegalovirus:Immunocompromised patientVaricella virus:Characteristic skin lesionsCoxsackievirus:Ulcers preceded by vesiclesHand, foot, and buttock lesionsSyphilis:Other skin or genital lesionsErythema multiforme:Lip crustingLesions on attached and unattached mucosa skin lesionsCryptosporidium infection, mucormycosis, histoplasmosisNecrotizing gingivitis
  • Underlying disease:Beh žet syndrome:Genital ulcerationUveitisRetinitisReactive arthritis (Reiter syndrome):UveitisUrethritisHLA-B27-associated arthritisSweet syndrome:FeverErythematous skin plaques/nodulesIn conjunction with malignancyIBD:Bloody or mucous diarrheaGI ulcerationsWeight lossGluten-sensitive enteropathy:SLE:Bullous pemphigoid/pemphigus vulgaris:Vesiculobullous lesions on attached and unattached mucosaDiffuse skin involvementCyclic neutropenia:Squamous cell carcinoma:ChronicHead/neck adenopathy
  • Immunocompromised patient:HIVAgranulocytosisMalignancy

Treatment

Ed Treatment/Procedures

  • Treatment guided by severity and duration of symptoms
  • Goal is for symptomatic pain relief and reduction of inflammation.

Medication

  • Mild to moderate disease:Avoid oral trauma/acidic foodsTopical anestheticMagnesium hydroxide/diphenhydramine hydrochloride 5 mg/5 mL in 1/1 mix swish and spitViscous lidocaine 2-5%: Applied to ulcer QID after meals until healedProtective bioadhesivesTopical OTC preparations (Orabase, Anbesol): Applied to ulcer QID after meals until healedTopical anti-inflammatoryAmlexanox 5% paste (Aphthasol): applied to ulcer QID after meals until healedAntimicrobial mouthwashChlorhexidine gluconate aqueous mouthwash 0.12% (Peridex): Mouth rinse QID after meals until healed
  • Severe disease:Prednisone tablets: 30-60 mg PO per day Ś 7 dThalidomide: 50-200 mg PO per day Ś 4 wk

Follow-Up

Disposition

Admission Criteria

  • Unable to eat or drink after appropriate analgesia
  • Abnormal vital signs or evidence of dehydration

Discharge Criteria

  • Tolerating fluids
  • Adequate analgesia
  • Normal vital signs

Issues for Referral

Follow up with primary care physician if lesions have not resolved within 2 wk. á

Follow-Up Recommendations

  • Avoid oral trauma (hard foods) or acidic foods.
  • Referral to a specialist if underlying disease suspected

Pearls and Pitfalls

  • The vast majority of aphthous ulcers are benign, self-limited, and treated symptomatically
  • ED physicians must consider underlying systemic cause of ulcers.

Additional Reading

  • Akintoye áSO, Greenberg áMS. Recurrent aphthous stomatitis. Dent Clin North Am. 2005;49:31-47.
  • Brocklehurst áP, Tickle áM, Glenny áAM, et al. Systemic interventions for recurrent aphthous stomatitis (mouth ulcers). Cochrane Database Syst Rev. 2012;(9). Art No.: CD005411. doi:10.1002/14651858.CD005411.pub2.
  • Chattopadhyay áA, Shetty áKV. Recurrent aphthous stomatitis. Otolaryngol Clin North Am. 2011;44:79-81.
  • Chavan áM, Jain áH, Diwan áN, et al. Recurrent aphthous stomatitis: A review. J Oral Pathol Med. 2012;41:557-583.
  • Scully áC. Aphthous ulceration. Clinical practice. N Engl J Med. 2006;355:165-172.
  • Wanda áC, Chi áAC, Neville áBW. Common oral lesion: Part I. Superficial mucosal lesions. Am Fam Physician. 2007;75:501-507.

Codes

ICD9

  • 528.2 Oral aphthae
  • 608.89 Other specified disorders of male genital organs
  • 616.50 Ulceration of vulva, unspecified

ICD10

  • K12.0 Recurrent oral aphthae
  • N50.8 Other specified disorders of male genital organs
  • N76.6 Ulceration of vulva

SNOMED

  • 427617000 aphthous ulceration of skin and/or mucous membrane (disorder)
  • 426965005 aphthous ulcer of mouth (disorder)
  • 403479008 Suttons ulcer (vulval aphthosis) (disorder)
  • 426567008 Aphthous ulcer of male genital organ (disorder)