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Ulcer, Aphthous

Ulcer, Aphthous is a topic covered in the 5-Minute Clinical Consult.

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  • Self-limited, painful ulcerations of the nonkeratinized oral mucosa, which are often recurrent (1)
  • Synonyms: canker sores; aphthae; aphthous stomatitis
  • Comes from aphth meaning “ulcer” in Greek; used by Hippocrates between 460 and 370 BC to categorize oral disease
  • Classification
    • Simple aphthosis (1)
      • Common
      • Episodic
      • Prompt healing, few ulcers
      • 3 to 6 episodes per year
      • Minimal pain, little disability, limited to oral cavity
    • Complex aphthous ulcers (1)
      • Uncommon
      • Episodic or continuous
      • Slow healing
      • Few to many ulcers
      • Frequent or continuous ulceration
      • Marked pain
      • Major disability
  • Ulcer morphology
    • Minor aphthous ulcers (2)
      • Usually <10 mm in diameter
      • Self-limited, healing within 4 to 14 days
      • Rarely affect the roof of the mouth
      • Nonscarring
    • Major aphthous ulcers (2)
      • Usually >10 mm in diameter
      • Can affect the roof of the mouth
      • May take weeks to months to heal
      • Generally, more painful than minor aphthous ulcers
      • May cause scarring
    • Herpetiform ulcers (2)
      • Usually 2 to 3 mm in diameter, may coalesce to form larger ulcerations
      • Unrelated to viral-caused herpetic stomatitis
      • Occur in small clusters numbering 10s to 100s, lasting 1 to 4 weeks
      • Generally, more painful than minor aphthous ulcers
      • May cause scarring


  • Most frequent chronic disease of the oral cavity, affecting 5–25% of the population (2)
  • More common in patients between 10 and 40 years of age, women, and those of higher socioeconomic status (2)
  • Less frequent with advancing age (1)
  • Minor aphthous ulcers
    • Most common: 70–85% of all aphthae
  • Major aphthous ulcers
    • 10–15% of all aphthae
  • Herpetiform
    • Least common: 5–10% of all aphthae

Etiology and Pathophysiology

Likely multifactorial; association with stress-induced rise in salivary cortisol, multiple HLA antigens, cell-mediated immunity; exact etiology unknown (1). However, tumor necrosis factor-α (TNF-α) is a proinflammatory cytokine and is implied in development of new aphthous ulcers (3).

Risk Factors

  • Genetic factors: 40% of patients with recurrent aphthous stomatitis (RAS) have a family history; most genetic associations with HLA antigen subtypes (1)
  • Local trauma: sharp teeth, dental treatments, or mucosal injury secondary to tooth brushing
  • Sodium lauryl sulfate–containing toothpaste
  • Increased stress and anxiety
  • Nutritional deficiencies: iron, vitamin B12, folic acid (3)
  • Gluten-sensitive enteropathy/celiac disease, inflammatory bowel disease (IBD) (3)
  • Immunodeficiency
  • Recent cessation of tobacco use
  • Food sensitivity: to benzoic acid/cinnamaldehyde
  • Medications
    • NSAIDs
    • β-Blockers
    • Alendronate
    • Methotrexate
    • ACE inhibitors (1)
  • Neutropenia
  • Anemia
  • Endocrine alterations (i.e., menstrual cycle) (2)
  • Oral streptococci (3)
  • Helicobacter pylori infection
  • Epstein-Barr virus (1)

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Stephens, Mark B., et al., editors. "Ulcer, Aphthous." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117080/all/Ulcer__Aphthous.
Ulcer, Aphthous. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117080/all/Ulcer__Aphthous. Accessed March 26, 2019.
Ulcer, Aphthous. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117080/all/Ulcer__Aphthous
Ulcer, Aphthous [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 26]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117080/all/Ulcer__Aphthous.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Ulcer, Aphthous ID - 117080 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/117080/all/Ulcer__Aphthous PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -