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Referral and warning signs
When to refer
Refer to Dentist/Oral Medicine Specialist/Physician if: Ulcers are severe, large (major aphthae), or very frequent. Ulcers persist > 3 weeks. Suspicion of underlying systemic disease (associated fever, weight loss, rash, joint pain, genital ulcers, GI symptoms). Diagnosis is uncertain.
Red flags
- Ulcer persisting > 3 weeks.
- Indurated (hard) base or rolled borders.
- Associated systemic symptoms suggesting underlying disease (fever, weight loss, etc.).
- Ulcers also present on genitals or eyes (suggests Behçet's).
Signs and symptoms
- Recurrent episodes of painful oral ulcers.
- Ulcers are typically round/oval, shallow, with a yellowish-grey base and surrounding red halo.
- Usually affect non-keratinized mucosa (inside lips, cheeks, under tongue, floor of mouth). Seldom on gums or hard palate.
- Three clinical forms:
- - Minor Aphthae (Most common): 1-6 small ulcers (<1 cm, usually 2-4 mm), heal without scarring in 7-14 days.
- - Major Aphthae (Sutton's disease): Larger (>1 cm), deeper ulcers, often persist for weeks to months, heal with scarring. Can be very painful and debilitating.
- - Herpetiform Aphthae: Multiple (10-100), very small (1-2 mm) pinpoint ulcers that coalesce. Heal in 7-14 days. (Clinically resemble herpes but are NOT caused by HSV).
Risk factors
- Often idiopathic (unknown cause).
- Genetic predisposition / Family history.
- Local trauma (e.g., accidental bite, dental work, sharp food).
- Stress.
- Hormonal changes (menstrual cycle).
- Food sensitivities (less common).
- Sodium Lauryl Sulphate (SLS) in toothpaste (in susceptible individuals).
- Association with systemic conditions (less common, consider if severe/atypical):
- - Nutritional deficiencies (Iron, B12, Folate, Zinc).
- - Gastrointestinal diseases (Celiac disease, Crohn's disease).
- - Immunodeficiencies (HIV).
- - Behçet's disease (oral + genital ulcers + eye inflammation).
- - PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) in children.
Diagnosis
Clinical assessment
Diagnosis based on characteristic history of recurrent oral ulcers and typical clinical appearance (location on non-keratinized mucosa, morphology) in the absence of signs of other specific causes (e.g., herpes vesicles, systemic illness).
Differential diagnosis
- Herpes Simplex Virus (HSV) stomatitis (usually preceded by vesicles, involves keratinized mucosa like gums/palate).
- Traumatic ulcers (relate to specific trauma).
- Oral manifestations of systemic disease (Behçet's, Crohn's, Celiac, HIV, nutritional deficiency).
- Lichen planus (erosive form).
- Pemphigus/Pemphigoid.
- Drug reactions.
- Squamous cell carcinoma (persistent, indurated ulcer).
Investigations
- Usually clinical diagnosis for typical minor aphthae.
- Consider investigations if ulcers are severe, persistent, atypical, or associated with systemic symptoms:
- - FBC, Iron/Ferritin, Vitamin B12, Folate levels.
- - Celiac serology.
- - HIV test.
- - Biopsy (if atypical or malignancy suspected).
Diagnostic criteria
Recurrent oral ulcers with characteristic morphology and location, after excluding other specific causes.
Management
Non-pharmacological management
- Avoid known triggers (specific foods, trauma).
- Manage stress.
- Maintain good oral hygiene.
- Consider switching to SLS-free toothpaste.
Pharmacological treatment
- Goal is symptomatic relief (reduce pain, shorten duration), no cure.
- Topical Treatments:
- - Antiseptic Mouthwashes: Chlorhexidine 0.12%/0.2% rinse BID (may reduce secondary infection and severity). Warm salt water rinses. (LOC: HC2)
- - Topical Anaesthetics: Lidocaine gel/solution applied before meals for pain relief. (LOC: HC2)
- - Topical Corticosteroids: Most effective for reducing pain/inflammation. Triamcinolone acetonide in orabase (Kenalog in Orabase) applied to ulcer BID-TID. Topical Beclomethasone or Betamethasone mouthwash/spray. (LOC: HC4)
- Systemic Medications (For severe, frequent, or major aphthae - Specialist use):
- - Systemic Corticosteroids: Short course of Prednisolone (e.g., UCG recommends 20mg Q8H tapering over 7 days). Requires careful consideration of risks/benefits. (LOC: HC4)
- - Other systemic agents (Colchicine, Dapsone, Thalidomide, Immunosuppressants) - reserved for very severe/refractory cases under specialist care (RR).
Monitoring
Monitor frequency and severity of recurrences. Monitor response to treatment.
Complications
- Pain and discomfort impacting eating, drinking, speaking.
- Weight loss / Nutritional deficiency (if severe/prolonged).
- Scarring (major aphthae).
Prevention
- Identify and avoid individual triggers if possible.
- Manage stress.
- Maintain good oral hygiene.
- Address underlying systemic conditions or deficiencies if identified.
Patient education
- Explanation of aphthous ulcers as common, recurrent, non-infectious sores.
- Reassurance (not herpes, not cancer usually).
- Trigger avoidance.
- How to use topical treatments for relief.
- When to seek further evaluation for persistent or severe ulcers.
Uganda-specific notes
Common condition. Differentiate from infectious ulcers (Herpes, Candida). Management focuses on symptomatic relief with rinses/topical steroids. Consider underlying HIV or nutritional deficiency in severe/atypical cases.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 23, Section 23.2.10