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Key Features

  • Canker sore or ulcerative stomatitis

  • Large or persistent areas of ulcerative stomatitis may be secondary to

    • Erythema multiforme or drug allergies

    • Acute herpes simplex

    • Pemphigus

    • Pemphigoid

    • Epidermolysis bullosa acquisita

    • Bullous lichen planus

    • Behçet disease

    • Inflammatory bowel disease

  • Cause remains uncertain, although an association with human herpesvirus 6 has been suggested

  • Stress seems to be a major predisposing factor

  • Frequency of viral rhinitis and bedtime after 11 PM were independent predictors of aphthous ulcer frequency and severity in college students

Clinical Findings

  • Very common and easy to recognize

  • Found on freely moving, nonkeratinized mucosa (eg, buccal and labial mucosa and not attached gingiva or palate)

  • May be single or multiple, are usually recurrent, and appear as small, round painful ulcerations with yellow-gray fibrinoid centers surrounded by red halos

  • Minor ulcers are < 1 cm and generally heal in 10–14 days

  • Major ulcers are > 1 cm and can be disabling in their degree of oral pain

Diagnosis

  • Based on clinical appearance

  • Squamous cell carcinoma may occasionally present in this fashion. When the diagnosis is not clear, incisional biopsy is indicated

Treatment

  • Topical corticosteroids (triamcinolone acetonide, 0.1%, or fluocinonide ointment, 0.05%) in an adhesive base (Orabase-Plain) provide symptomatic relief

  • Other topical therapies are diclofenac 3% in hyaluronan 2.5%, doxymycine-cyanoacrylate, mouthwashes containing the enzymes amyloglucosidase and glucose oxidase, and amlexanox 5% oral paste

  • A 1-week tapering course of prednisone (40–60 mg daily orally) can be used

  • For recurrent ulcers

    • Cimetidine maintenance therapy

    • Thalidomide has been used selectively in those who are also HIV-positive

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