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Case Note

Case Note: Painful Ulcers in the Mouth

History

A 20-year-old healthy-appearing male, with no significant past medical history, presents for management of 7-year history of intermittent painful ulcers in the mouth

Initial evaluation

  • No significant past medical history
  • Review of systems is non-contributory
    • Notably negative for fever, joint pains, diarrhea, and weight changes
  • Social history is notable for monogamous relationship with one partner; no history of sexually transmitted diseases
  • Does not drink alcohol or smoke
  • Presents for management of four small (4 mm) ulcers on the buccal mucosa with a rounded appearance and red border
    • Consistent with 7-year history of painful intermittent mouth ulcers
  • No genital ulcerations or other skin lesions
  • Image 1
    Image 1

Enter your diagnosis

Diagnosis

  • A diagnosis of aphthous ulceration is rendered

Initial Treatment

  • Topical analgesia with 2% lidocaine gel and 1% triamcinolone paste used four times daily is recommended
  • Gentle oral care recommended: avoiding hygiene products containing sodium lauryl sulfate, sharp/traumatic foods, and acidic foods
  • Follow-up if patient fails to respond

Follow-up evaluation strategy

Follow-up evaluation:

  • Patient notes symptomatic relief and feels that the ulcers resolved more quickly than in the past
  • Antimicrobial mouthwash rinses with 0.2% chlorhexidine gluconate mouthwash three times daily is recommended
  • Follow-up as need; patient to report any non-healing ulcers

Further recommendations:

  • Protective films, such as carmellose, may be applied to the ulcers to diminish discomfort
  • Topical corticosteroids (1% triamcinolone dental paste, 0.05% fluocinonide in Orabase, 2.5 mg hydrocortizone lozenge, betamethasone aerosol) may be used up to four or five times daily for 2 weeks or until ulcers resolve to speed healing and decrease pain from ulcers
  • 5% amlexanox paste may be applied four times daily for 2 weeks or until ulcers heal
  • 0.15% triclosan mouthwash twice daily for 6 weeks can reduce duration of lesions and pain, and lead to fewer outbreaks and fewer total ulcerations
  • Listerine mouthwash may reduce lesion duration and pain as well

Subsequent treatment steps:

  • Patients may be counseled to avoid foods that may trigger or worsen eruptions, such as nuts, acidic foods or drinks, salty meals, and alcohol
    • Oral hygiene products containing sodium lauryl sulfate may trigger oral ulcers in some patients as well
  • Systemic therapy is rarely indicated for minor aphthae of recurrent aphthous stomatitis
    • If local methods fail, physicians should revisit the differential diagnosis and consider extended workup for mimics of aphthous ulcers
  • In certain cases, physicians may opt to order lab tests to evaluate for nutritional deficiencies or rarer underlying causes of oral ulcerations
    • This may include evaluation of vitamins including iron, ferritin, total iron-binding capacity, folate, vitamin B levels, zinc, and magnesium, and evaluation of a complete blood count
    • Depending on the patient's history and review of systems, further testing for systemic diseases may be indicated, which could include antinuclear antibody and antineutrophilic cytoplasmic antibody levels, tissue transglutaminase antibodies, local or serological viral testing, gastroenterological evaluation, and more

General discussion

Aphthous ulcers are one of the most common diseases of the oral mucosa. They occur as shallow, rounded ulcers, with an inflammatory rim, often with a pseudomembrane, which can fade from yellow/green to gray over time. The ulcers preferentially affect non-keratinized mucosal surfaces, such as the labial or buccal mucosa, the sublingual mouth, or the tongue. Many patients suffer from recurrent lesions, termed recurrent aphthous stomatitis. The first lesions generally begin in childhood, and recurrent aphthous ulcers are more common in women, people under 40, Caucasian patients, non-smokers, and people of high socioeconomic status. The disease usually remits in adulthood, after age 30.

The most common form of recurrent aphthous stomatitis is characterized by minor aphthous ulcers, which comprise about 80% of cases of recurrent aphthous stomatitis. These lesions are between 2 and 8 mm in diameter and heal over a 10- to 14-day period. Major aphthous ulcers are less common, making up 10-15% of cases, but often are more symptomatic and may require more aggressive treatment. Major aphthae are often 1 cm or more in diameter. A third type of aphthous stomatitis is termed herpetiform ulceration (although it is unrelated to herpes virus infection) and is characterized by multiple, pinpoint ulcerations. Approximately 80% of patients suffer from minor aphthae; major and herpetiform ulcerations are more likely to prompt patients to seek treatment, as they may last for weeks with significant discomfort.

Pyoderma gangrenosum lesions may occur in isolation or in association with an underlying systemic disorder, such as a rheumatologic disease, inflammatory bowel disease, malignancy (especially hematologic), immunodeficiency, or infection. Lesions may also be induced by medications; for example, exogenous granulocyte-monocyte colony-stimulating factor, isotretinoin, and sunitinib may cause pyoderma gangrenosum-like lesions. In these cases, lesions may respond by stopping the inciting medication and topical treatment. Rare familial forms have also been described (the syndrome of pyoderma gangrenosum, acne, and pyogenic arthritis [PAPA syndrome]). The diagnostic evaluation of pyoderma gangrenosum thus requires formal exclusion of conditions that may mimic this disorder in addition to diagnostic work up for associated systemic diseases. Therapy for oral ulcerations is aimed at providing symptomatic relief and promoting ulcer healing. For major disease, systemic medications may diminish the duration or frequency of attacks.

There is an important differential diagnosis when evaluating patients with oral ulcers, even if the history and examination is strongly suggestive of aphthous ulcerations. Persistent diarrhea may suggest underlying inflammatory bowel disease. Weight loss and signs of malabsorption may be a clue to gluten sensitivity. Genital ulcerations or a history of ulcerations at the site of trauma may suggest Beh├žet's syndrome. Antecedent or concurrent urethritis and arthritis may be a clue to reactive arthritis. Herpes simplex virus can present with oral ulcers, often grouped and at the same location with each episode. Other infectious agents can also present with oral ulcers, including primary syphilis, gonorrhea, coxsackievirus infection (hand-foot-mouth disease), and other herpes viruses (CMV, EBV, and VZV). HIV infection, including acute seroconversion, can present with oral ulcers, either due to the virus itself or co-infection (candida, hairy leukoplakia, Kaposi sarcoma).

Chronic oral ulceration can also occur due to oral lichen planus or autoimmune blistering disorders. Medications which cause immunosuppression or neutropenia can lead to oral ulcerations. Certain drug eruptions, ranging from localized specific eruptions (fixed drug eruption, erythema multiforme) to systematized reactions (Stevens-Johnson Syndrome/toxic epidermal necrolysis) can present with localized oral erosions mimicking aphthous stomatitis as well. Cyclic neutropenia, Sweet syndrome, and periodic fever syndromes are rare causes of recurrent ulcerations. Any ulcer that lasts for more than 3 or 4 weeks requires evaluation to rule out other serious diseases, including local malignancies.

Further reading

Baccaglini L, et al. Urban legends series: recurrent aphthous stomatitis. Oral Dis 2011;17:755-70.

Chattopadhyay A. Recurrent aphthous stomatitis. Otolaryngol Clin N Am 2011;44:79-88.

Femiano F et al. Guidelines for diagnosis and management of aphthous stomatitis. Pediatr Infect Dis J 2011;26:728-32.

Messadi DV, Younai F. Aphthous ulcers. Dermatol Ther 2010;23:281-90.

Munoz-Corcuera M, et al. Oral ulcers: clinical aspects. A tool for dermatologists. Part I. Acute ulcers. Clin Exp Derm 2009;34:289-94.

Munoz-Corcuera M, et al. Oral ulcers: clinical aspects. A tool for dermatologists. Part II. Chronic ulcers. Clin Exp Derm 2009;34:456-61.

Scully C. Aphthous ulceration. N Engl J Med 2006;355:165-72.

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