CC
A 19-year-old female is referred for evaluation of recurrent painful ulcerations inside her mouth. (Recurrent aphthous ulcerations, or synonymously, recurrent aphthous stomatitis [RAS], affects 20% of the population, with a slight female predilection.)
HPI
The patient reports that for the past 2 years (ulcerations often begin in adolescence and early adulthood), she has had episodes of one or more painful oral ulcers that develop spontaneously and last for up to 2 weeks, with ulcer-free intervals ranging from 1 to 3 months. She does not have any history of trauma or known infectious diseases. The ulcers occasionally occur at multiple sites simultaneously. The patient denies ocular irritation, hoarseness, and dysphagia. She further denies a history of lip swelling, cutaneous ulcerations, and anogenital ulcerations (extraoral mucosal ulcerations are atypical for simple RAS).
PMHX/PDHX/medications/allergies/SH/FH
The patient is a nonsmoker; takes no medications; and has no known history of immunosuppression, HIV, malnutrition, cancer, or previous infections of the head and neck region (potential risk factors for oral ulceration). She reports that her mother had “canker sores” as a teenager (family history often reported in RAS). Careful documentation of the patient’s HPI in conjunction with past medical history, medications, and family history is paramount in triaging RAS. Aphthous ulceration can be categorized on the basis of ulcer morphology into minor, major, and herpetiform ( Box 42.1 ). RAS can also be classified as simple or complex. Simple RAS is the most common form of disease and is characterized by one or more ulcers (of any morphology) occurring several times each year, limited to the oral mucosa and resolving within 2 weeks. Patients with complex aphthosis tend to experience larger and numerous ulcerations involving oral or orogenital locations. Lesions may take up to 4 weeks to resolve. Patients with unusual clinical findings or extraoral findings and those suspected to have complex aphthosis may warrant additional or multidisciplinary evaluation to exclude Behçet syndrome, MAGIC (mouth and genital ulcers with inflamed cartilage) syndrome, underlying gastrointestinal disease (gluten-sensitive enteropathy, ulcerative colitis, Crohn disease), cyclic neutropenia, and PFAPA (periodic fever with aphthous stomatitis, pharyngitis, adenitis) syndrome.
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Minor aphthous ulcer (Mikulicz aphthae). Less than 10 mm in size, requiring no treatment and resolving within 7–10 days without scarring. If the ulcer remains after 2 weeks, topical corticosteroid therapy is indicated. Palliative therapy in the form of a topical local anesthetic, such as 2% viscous lidocaine, diphenhydramine elixir (12.5 mg/mL), or topical benzocaine, may be indicated in cases of severe pain associated with minor aphthous ulcers.
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Major ulcers (periadenitis, mucosa necrotica recurrens, Sutton disease). Major aphthous ulcers, by definition, are >10 mm in diameter with deeper penetration than minor ulcers and therefore heal with scarring. Resolution of major aphthous ulcers may take longer than several weeks. Treatment of more severe forms of major aphthous ulcers includes the use of topical or systemic corticosteroid therapy. A protocol has been established by Kerr and Ship in the management of aphthous ulcers, especially with reference to those seen in HIV-infected patients.
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Herpetiform ulcers. Herpetiform ulcers occur as many (10–100) small ulcerations coalescing within a large area of nonkeratinized mucosa that can extend to keratinized mucosa. In name and clinical characteristics, these ulcers resemble ulcerations resulting from primary herpes simplex infection. Herpetiform ulcers are distinct from herpetic ulcers in that they lack viral particles and are not preceded by the formation of vesicles. Healing occurs within 7–10 days.
Examination
General. The patient is a well-developed and well-nourished female in no apparent distress.
Vital signs. Her blood pressure is 115/70 mm Hg, heart rate is 92 bpm, respirations are 18 breaths per minute, and temperature is 36.1°C (afebrile; fever is unexpected with simple aphthous ulcers).
Maxillofacial. There is no extraoral or asymmetric lip or facial swelling (lip swelling and RAS may occur in underlying gastrointestinal disorders) and no cervical lymphadenopathy or cutaneous lip or facial skin ulceration. There is no evidence of conjunctivitis.
Intraoral. There are several superficial ulcerations at various stages of development in the oral mucosa, measuring 3 to 7 mm. A 7-mm ulcer is located on the left buccal mucosa, with a 3-mm erythematous focus (developing ulceration) anterior to it. A 5-mm ulceration is present on the right ventral tongue ( Fig. 42.1 ). The well-developed ulcerations appear round to oval with a central yellow ulceration surrounded by an erythematous margin of mucosa (characteristic clinical appearance for RAS). There does not appear to be any source of trauma in association with the ulcers, such as sharp dental restorations or fractured dental cusps. Gentle palpation of the ulcerations reveals they are superficial in nature, without induration or fixation to deeper structures. There is no evidence of vestibular mucosal fissuring, mucosal “tags” or mucosal redundancy, or diffuse gingival erythema (nonspecific yet suggestive extraintestinal clinical findings that may occur in the oral cavity in the setting of underlying inflammatory bowel disease). Fig. 42.2 is example of vestibular fissuring in a pediatric patient with RAS later shown to have underlying inflammatory bowel disease.
