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Oral & Dental Health

Aphthous Ulceration

Common condition characterized by recurrent episodes of painful, well-defined, round or oval ulcers on the non-keratinized oral mucosa (cheeks, lips, tongue, floor of mouth). Cause is often unknown.

Also known as: Canker Sores, Recurrent Aphthous Stomatitis (RAS)

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Referral and warning signs

When to refer

Refer to Dentist/Oral Medicine Specialist/Physician if: Ulcers are severe, large (major aphthae), or very frequent. Ulcers persist > 3 weeks. Suspicion of underlying systemic disease (associated fever, weight loss, rash, joint pain, genital ulcers, GI symptoms). Diagnosis is uncertain.

Red flags

  • Ulcer persisting > 3 weeks.
  • Indurated (hard) base or rolled borders.
  • Associated systemic symptoms suggesting underlying disease (fever, weight loss, etc.).
  • Ulcers also present on genitals or eyes (suggests Behçet's).

Signs and symptoms

  • Recurrent episodes of painful oral ulcers.
  • Ulcers are typically round/oval, shallow, with a yellowish-grey base and surrounding red halo.
  • Usually affect non-keratinized mucosa (inside lips, cheeks, under tongue, floor of mouth). Seldom on gums or hard palate.
  • Three clinical forms:
  • - Minor Aphthae (Most common): 1-6 small ulcers (<1 cm, usually 2-4 mm), heal without scarring in 7-14 days.
  • - Major Aphthae (Sutton's disease): Larger (>1 cm), deeper ulcers, often persist for weeks to months, heal with scarring. Can be very painful and debilitating.
  • - Herpetiform Aphthae: Multiple (10-100), very small (1-2 mm) pinpoint ulcers that coalesce. Heal in 7-14 days. (Clinically resemble herpes but are NOT caused by HSV).

Risk factors

  • Often idiopathic (unknown cause).
  • Genetic predisposition / Family history.
  • Local trauma (e.g., accidental bite, dental work, sharp food).
  • Stress.
  • Hormonal changes (menstrual cycle).
  • Food sensitivities (less common).
  • Sodium Lauryl Sulphate (SLS) in toothpaste (in susceptible individuals).
  • Association with systemic conditions (less common, consider if severe/atypical):
  • - Nutritional deficiencies (Iron, B12, Folate, Zinc).
  • - Gastrointestinal diseases (Celiac disease, Crohn's disease).
  • - Immunodeficiencies (HIV).
  • - Behçet's disease (oral + genital ulcers + eye inflammation).
  • - PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) in children.

Diagnosis

Clinical assessment

Diagnosis based on characteristic history of recurrent oral ulcers and typical clinical appearance (location on non-keratinized mucosa, morphology) in the absence of signs of other specific causes (e.g., herpes vesicles, systemic illness).

Differential diagnosis

  • Herpes Simplex Virus (HSV) stomatitis (usually preceded by vesicles, involves keratinized mucosa like gums/palate).
  • Traumatic ulcers (relate to specific trauma).
  • Oral manifestations of systemic disease (Behçet's, Crohn's, Celiac, HIV, nutritional deficiency).
  • Lichen planus (erosive form).
  • Pemphigus/Pemphigoid.
  • Drug reactions.
  • Squamous cell carcinoma (persistent, indurated ulcer).

Investigations

  • Usually clinical diagnosis for typical minor aphthae.
  • Consider investigations if ulcers are severe, persistent, atypical, or associated with systemic symptoms:
  • - FBC, Iron/Ferritin, Vitamin B12, Folate levels.
  • - Celiac serology.
  • - HIV test.
  • - Biopsy (if atypical or malignancy suspected).

Diagnostic criteria

Recurrent oral ulcers with characteristic morphology and location, after excluding other specific causes.

Management

Non-pharmacological management

  • Avoid known triggers (specific foods, trauma).
  • Manage stress.
  • Maintain good oral hygiene.
  • Consider switching to SLS-free toothpaste.

Pharmacological treatment

  • Goal is symptomatic relief (reduce pain, shorten duration), no cure.
  • Topical Treatments:
  • - Antiseptic Mouthwashes: Chlorhexidine 0.12%/0.2% rinse BID (may reduce secondary infection and severity). Warm salt water rinses. (LOC: HC2)
  • - Topical Anaesthetics: Lidocaine gel/solution applied before meals for pain relief. (LOC: HC2)
  • - Topical Corticosteroids: Most effective for reducing pain/inflammation. Triamcinolone acetonide in orabase (Kenalog in Orabase) applied to ulcer BID-TID. Topical Beclomethasone or Betamethasone mouthwash/spray. (LOC: HC4)
  • Systemic Medications (For severe, frequent, or major aphthae - Specialist use):
  • - Systemic Corticosteroids: Short course of Prednisolone (e.g., UCG recommends 20mg Q8H tapering over 7 days). Requires careful consideration of risks/benefits. (LOC: HC4)
  • - Other systemic agents (Colchicine, Dapsone, Thalidomide, Immunosuppressants) - reserved for very severe/refractory cases under specialist care (RR).

Monitoring

Monitor frequency and severity of recurrences. Monitor response to treatment.

Complications

  • Pain and discomfort impacting eating, drinking, speaking.
  • Weight loss / Nutritional deficiency (if severe/prolonged).
  • Scarring (major aphthae).

Prevention

  • Identify and avoid individual triggers if possible.
  • Manage stress.
  • Maintain good oral hygiene.
  • Address underlying systemic conditions or deficiencies if identified.

Patient education

  • Explanation of aphthous ulcers as common, recurrent, non-infectious sores.
  • Reassurance (not herpes, not cancer usually).
  • Trigger avoidance.
  • How to use topical treatments for relief.
  • When to seek further evaluation for persistent or severe ulcers.

Uganda-specific notes

Common condition. Differentiate from infectious ulcers (Herpes, Candida). Management focuses on symptomatic relief with rinses/topical steroids. Consider underlying HIV or nutritional deficiency in severe/atypical cases.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 23, Section 23.2.10

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