Aphthous Ulcer, Acute

Presentation

Patients present with a painful lesion in their mouth, often worried about having herpes. Lesions may interfere with eating, speaking, or swallowing. Minor oral trauma from dental appliances, dentures, and orthodontic hardware may be causative, or patients may inadvertently produce traumatic ulcers through biting of their oral mucosa.

Simple aphthosis (apthous ulcers), episodic lesions that are few in number, healing within 1 to 2 weeks, and recurring infrequently, is the more common scenario. Conversely, complex aphthosis presents with numerous severe lesions, which are persistent and associated with marked pain or disability.

Aphthous ulcers, also known as canker sores , are the most common oral ulcer and are characterized by a painful prodrome lasting 2 to 48 hours followed by the appearance of shallow, erythematous ulcers with a gray base. They can present as one or more flat, even-bordered, round or oval ulcers with a central friable pseudomembranous base surrounded by a bright red halo. They may be seen on nonkeratinized unattached mucosa, such as the buccal or labial mucosa, lingual sulci, soft palate, pharynx, lateral and ventral tongue, or gingiva. Lesions are usually solitary but can be multiple and recurrent without antecedent vesicles or bulla. The pain is usually greater than the size of the lesions would suggest.

Minor aphthae (<10 mm in circumference) comprise 80% of all aphthae, are usually located on the buccal or labial mucosa, and heal spontaneously in 7 to 10 days without scarring ( Fig. 42.1 ). Ten percent of all lesions are major aphthae , which are larger than 10 mm in circumference and deeper. They may heal over weeks to months and often result in scarring. Major aphthae may also be located posteriorly on the soft palate, tonsils, and pharynx ( Fig. 42.2 ). Major aphthae that last for months and are slow to heal may be associated with human immunodeficiency virus (HIV) infection. The remaining 10% of aphthae are herpetiform aphthae , which are smaller (1–3 mm), grouped, or coalescent ulcers that may be present on keratinized mucosa of the dorsal tongue and palate and heal spontaneously over 1 to 4 weeks ( Fig. 42.3 ). Herpes simplex virus is not, by definition, found in these lesions.