Ulcer, Aphthous
Basics
Aphthous ulcers are the most common ulcerative disease of the oral mucosa.
Description
- Self-limited, painful ulcerations of the nonkeratinized oral mucosa, which are often recurrent
- Affects chewing, eating, and speaking
- Synonyms: canker sores; aphthae; aphthous stomatitis
- Comes from aphthi meaning “to set on fire” or “to inflame” in Greek; first used by Hippocrates to categorize oral disease
- Classification based on severity
- Simple aphthosis
- Common, episodic, infrequent (<7 episodes annually)
- Prompt healing (resolution in 1 to 2 weeks), few ulcers
- Minimal pain, little disability, limited to oral cavity
- Self-limiting, responds well to local treatments
- Complex aphthous ulcers
- Uncommon, episodic or continuous, slow healing
- Few to many ulcers, frequent or continuous ulceration
- Short or nonexistent disease-free intervals
- Marked pain, major disability
- Often need systemic treatments
- May have genital aphthae
- Simple aphthosis
- Classification based on ulcer morphology
- Minor aphthous ulcers (Mikulicz aphthae)
- Age of onset 5 to 19 years
- Usually <10 mm in diameter
- Number of ulcers: 1 to 5
- Self-limited, healing within 4 to 14 days
- Distribution: lips, cheeks, tongue, floor of mouth
- Rarely affects the roof of the mouth
- Nonscarring
- Affects males and females equally
- Major aphthous ulcers (Sutton disease), 10% of all aphthae
- Age of onset 10 to 19 years
- Usually >10 mm in diameter
- Number of ulcers: 1 to 10
- Distribution: lips, soft palate, pharynx
- May take weeks to months to heal
- Generally more painful than minor aphthous ulcers
- May cause scarring and be accompanied by fever and malaise
- Affects males and females equally
- Herpetiform ulcers, 5% of all aphthae
- Age of onset 20 to 29 years
- Usually 1 to 2 mm in diameter, form larger lesions when coalesced
- No association with herpes simplex virus
- Occur in small clusters numbering 10s to 100s, lasting 1 to 4 weeks
- Generally more painful than minor aphthous ulcers
- Scarring unusual
- May also affect the palate, gingiva, and pharynx
- Affects more females than males
- Minor aphthous ulcers (Mikulicz aphthae)
Epidemiology
- Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease of the oral mucosa and accounts for 25% of recurrent ulcers in adults and 40% in children.
- More common in patients <40 years of age, Caucasians, nonsmokers, and those of higher socioeconomic status
Incidence
5–60% depending on ethnic and socioeconomic groups
Prevalence
Lifetime prevalence of 5–85%
Etiology and Pathophysiology
Associated with stress-induced rise in salivary cortisol, multiple HLA antigens, cell-mediated immunity and inflammation
Genetics
Associations with specific HLA subtypes
Risk Factors
- Local trauma: sharp teeth, dental treatments, or mucosal injury secondary to toothbrushing
- Sodium lauryl sulfate–containing toothpaste
- Increased stress and anxiety
- Nutritional deficiencies: iron, zinc, vitamin B complex, and folate
- Immunodeficiency: HIV
- Recent cessation of tobacco use
- Medications (numerous)
- Endocrine alterations (i.e., menstrual cycle)
- Helicobacter pylori infection
- Underlying medical disorders (e.g., celiac disease, inflammatory bowel disease [IBD], Behçet syndrome)
General Prevention
- Avoid sodium lauryl sulfate–containing toothpaste
- Vitamin supplementation: vitamins B12, D, zinc
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Citation
Domino, Frank J., et al., editors. "Ulcer, Aphthous." 5-Minute Clinical Consult, 33rd ed., Wolters Kluwer, 2025. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688806/all/Ulcer__Aphthous.
Ulcer, Aphthous. In: Domino FJF, Baldor RAR, Golding JJ, et al, eds. 5-Minute Clinical Consult. Wolters Kluwer; 2025. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688806/all/Ulcer__Aphthous. Accessed November 6, 2024.
Ulcer, Aphthous. (2025). In Domino, F. J., Baldor, R. A., Golding, J., & Stephens, M. B. (Eds.), 5-Minute Clinical Consult (33rd ed.). Wolters Kluwer. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688806/all/Ulcer__Aphthous
Ulcer, Aphthous [Internet]. In: Domino FJF, Baldor RAR, Golding JJ, Stephens MBM, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2025. [cited 2024 November 06]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/1688806/all/Ulcer__Aphthous.
* Article titles in AMA citation format should be in sentence-case
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