Ulcer, Aphthous


Aphthous ulcers are the most common ulcerative disease of the oral mucosa.


  • 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


  • 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

5–60% depending on ethnic and socioeconomic groups

Lifetime prevalence of 5–85%

Etiology and Pathophysiology

Associated with stress-induced rise in salivary cortisol, multiple HLA antigens, cell-mediated immunity and inflammation

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

There's more to see -- the rest of this topic is available only to subscribers.