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
• 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

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