PANCE Blueprint EENT (7%)

Aphthous ulcers (ReelDx + Lecture)


Aphthous ulcers

6-year-old with painless lesions on gum line

Patient will present as → a 22-year-old complaining of a painful sore for 2 days.  He denies any alcohol or tobacco use and otherwise feels fine. The examination is significant for a 2-mm round ulceration with a yellow-gray center surrounded by a red halo on the left buccal mucosa

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Painful ovoid or round ulcerations on the mucous membranes of the mouth, tongue or genitals: Commonly referred to as “canker sores”

  • Prodrome of burning or prickling sensation of oral mucosa 1–2 days prior to the appearance of ulcers
  • The vast majority of aphthous ulcers are benign, self-limited, and treated symptomatically
  • Providers must consider underlying systemic causes of ulcers:
    • Inquire about patient or family history of:
      • Systemic lupus erythematosus (SLE)
      • Inflammatory bowel disease (IBD)
      • Behçet disease
      • Reiter disease
      • Gluten sensitivity
      • Cancer
      • HIV
      • Inquire about sexual history of syphilis or herpes virus
      • Inquire about current medications:
      • NSAIDs
      • β-blockers

Diagnosis is made by history and clinical presentation.

  • Biopsy should be considered for ulcers lasting more than 3 weeks
  • Rule out an oral manifestation of systemic disease: More likely if persists >3 wk or associated with constitutional symptoms.  Focus on symptoms of eyes, mouth, genitalia, skin, GI tract, allergy, diet history, and physical exam

Treatment guided by severity and duration of symptoms. The goal is for symptomatic pain relief and reduction of inflammation.

  • Mild to moderate disease:
    • Avoid oral trauma/acidic foods
  • Topical anesthetic
    • Magnesium hydroxide/diphenhydramine hydrochloride 5 mg/5 mL in 1/1 mix swish and spit
    • Viscous lidocaine 2–5%: Applied to ulcer QID after meals until healed
  • Monitor PO status (especially in small children)
  • Referral to a specialist if underlying disease suspected.

osmosis Osmosis
Question 1
An 18-year-old sexually active woman presents with a single ulcer that is located on the lower lip and is painful. She is a smoker and has noticed that the ulcers have been recurrent and correlate with the onset of menses. The most likely diagnosis is Aphthous stomatitis
Kawasaki disease
Aphthous stomatitis
Squamous cell carcinoma of the lip
Koplik’s spot
Question 1 Explanation: 
Aphthous stomatitis, also known as canker sores, are painful eruptions that affect the mucosal surface of the mouth. The cause is unknown. Lesions typically develop at the same time and resolve in 5 to 10 days. A viral cause has not been proved. A streptococcal bacterium has been implicated. The lesions recur at regular intervals and may correlate with the onset of menses in some women. Treatment consists of toothpaste swish therapy, triamcinolone acetonide (Kenalog in Orabase), or tetracycline solution swish and swallow. Severe cases may respond to systemic corticosteroids.
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References: Merck Manual · UpToDate

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