Aphthous Ulcers, Emergency Medicine

Basics

Description

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 system
- Infection
- Food hypersensitivities (i.e., gluten)
- Vitamin deficiency
- Pregnancy
- Menstruation
- Trauma
- Stress
- Ethnicity
- Immunodeficiency
- Medications: 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 women
- May be familial

Diagnosis

Signs and Symptoms

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

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 disease
- Reiter disease
- Gluten sensitivity
- Cancer
- HIV
Inquire about patient sexual history of syphilis or herpes virus
Inquire about current medications:
- NSAIDs
- β-blockers

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 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

Diagnostic Procedures/Surgery
An outpatient biopsy should be considered for any ulcer >3 wk á

Differential Diagnosis

Trauma:
- Biting
- Dentures
- Braces
Drug exposure:
- NSAIDs
- Nicorandil
- β-blockers
Infection:
- Herpes virus:
  - Vesicular lesions
  - Ulcers on attached mucosa
- Cytomegalovirus:
  - Immunocompromised patient
- Varicella virus:
  - Characteristic skin lesions
- Coxsackievirus:
  - Ulcers preceded by vesicles
  - Hand, foot, and buttock lesions
- Syphilis:
  - Other skin or genital 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:
  - Weight loss
- SLE:
  - Malar rash
  - ANA positive
- Bullous pemphigoid/pemphigus vulgaris:
  - Vesiculobullous lesions on attached and unattached mucosa
  - Diffuse skin involvement
- Cyclic neutropenia:
  - Periodic fever
- Squamous cell carcinoma:
  - Chronic
  - Head/neck adenopathy
Immunocompromised patient:
- HIV
- Agranulocytosis
- Malignancy

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 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
- Topical anti-inflammatory
  - Amlexanox 5% paste (Aphthasol): applied to ulcer QID after meals until healed
- Antimicrobial mouthwash
  - Chlorhexidine 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 d
- Thalidomide: 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)

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