PANCE Blueprint EENT (7%)

Aphthous ulcers (ReelDx + Lecture)


Aphthous ulcers

6-year-old with painless lesions on the 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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Aphthous ulcers are discrete, painful, ovoid, or round ulcerations on the mucous membranes of the mouth, tongue, or genitals, commonly referred to as “canker sores

  • The lesions are typically 3 to 5 mm, round to oval ulcers with a peripheral rim of erythema and a yellowish, adherent exudate centrally
  • The vast majority of aphthous ulcers are benign, self-limited, and usually heal within 7 to 14 days
  • Providers must consider the 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 it persists >3 wks or is associated with constitutional symptoms.  Focus on symptoms of eyes, mouth, genitalia, skin, GI tract, allergy, diet history, and physical exam

The severity and duration of symptoms guide treatment. 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
  • High-potency topical corticosteroids (e.g., dexamethasone elixir 0.5 mg/5 mL to swish and spit three to four times per day) are the first-line treatment for patients with recurrent aphthous stomatitis
  • Monitor PO status (especially in small children)
  • Referral to a specialist if an underlying disease is suspected

osmosis Osmosis
Question 1
A 32-year-old woman presents to her primary care PA with recurrent mouth ulcers for the past six months. She describes the ulcers as painful, round, and with a yellowish center surrounded by a red halo. She denies any skin rashes, genital ulcers, or ocular symptoms. She has tried over-the-counter topical anesthetics with minimal relief. She has no significant past medical history and takes no medications. Physical examination reveals multiple small ulcers on the buccal mucosa and the floor of the mouth. Which of the following is the most appropriate next step in the management of this patient?
Prescribe topical corticosteroids
Initiate oral acyclovir therapy
Oral acyclovir is used for treating herpes simplex virus (HSV) infections, which can cause oral ulcers. However, the description of the ulcers and the absence of systemic symptoms do not suggest HSV, making acyclovir an inappropriate choice.
Order a biopsy of the ulcer
While biopsy can be helpful in diagnosing uncertain cases or when malignancy is suspected, it is not typically necessary for the initial management of classic recurrent aphthous stomatitis, especially in the absence of alarming features.
Start systemic corticosteroids
Systemic corticosteroids are reserved for severe cases of RAS or when topical therapy is ineffective. Given the lack of systemic involvement and the patient's description of localized ulcers, systemic corticosteroids would not be the most appropriate next step.
Recommend avoidance of spicy and acidic foods
While avoiding spicy and acidic foods may help reduce irritation and discomfort associated with oral ulcers, this recommendation alone does not constitute adequate management for recurrent aphthous stomatitis. Topical treatment aimed at reducing inflammation and promoting healing is necessary.
Question 1 Explanation: 
This patient's presentation is consistent with recurrent aphthous stomatitis (RAS), characterized by painful, round ulcers with a yellowish center and red halo, occurring in the absence of systemic symptoms like skin rashes, genital ulcers, or ocular symptoms. Topical corticosteroids are the mainstay of treatment for RAS, as they can reduce inflammation and pain, and promote faster healing of the ulcers. A topical corticosteroid, such as triamcinolone in dental paste or another appropriate formulation, applied directly to the ulcers can provide significant symptomatic relief and is an appropriate next step in management.
Question 2
A 25-year-old man presents with a 3-day history of painful oral ulcerations. On exam, you note several small, round ulcers on the buccal mucosa surrounded by erythematous haloes. The lesions are painful but there is no induration. He has no other systemic symptoms. Which of the following is the most appropriate next step in management?
Biopsy of the lesions
Not necessary given the classic appearance. Aphthous ulcers are a clinical diagnosis.
Blood cultures
There are no systemic symptoms to indicate an underlying infection.
HIV screening
May be considered in high-risk patients, but is not routinely warranted.
Oral antiviral therapy
Antivirals are not used to treat aphthous ulcers.
Reassurance and symptomatic treatment
Question 2 Explanation: 
The patient's presentation is classic for recurrent minor aphthous ulcers. In an otherwise healthy patient with no systemic symptoms, the most appropriate next step is reassurance about the benign nature of the condition along with symptomatic treatment such as topical anesthetics. Biopsy and blood cultures are not needed given the classic appearance. HIV screening and antiviral therapy are not routinely indicated.
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References: Merck Manual · UpToDate

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