Canker Sore

Aka: Canker Sore, Aphthous Ulcer, Aphthous Stomatitis, Minor Aphthae, Herpetiform Aphthous Stomatitis, Sutton's Aphthae, Major Aphthae

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II. Epidemiology

  1. Prevalence: 5-21% in United States
  2. Most common ulcerative condition of the oropharynx
  3. Family History in 40% of patients
  4. Age
    1. Peaks ages 10 to 20 years old
    2. Prevalence decreases after age 50 years

III. Pathophysiology

  1. Benign Autoimmune Condition
  2. Inflammatory Bowel Disease and Celiac Sprue may predispose to Aphthous Ulcers
  3. May be due to local injury
  4. Not infectious
  5. Nutritional deficiency may contribute in some cases
    1. Iron Deficiency Anemia
    2. Vitamin B12 Deficiency or Folic Acid Deficiency

IV. Types

  1. Minor Aphthae (75 to 85% of cases)
    1. Painful ulcers <1 cm in size
    2. Persist 7-14 days
    3. Resolve spontaneously without scarring
  2. Herpetiform Aphthae (5 to 10% of cases)
    1. Patches of up to 100 small (1-3 mm) ulcers occurring throughout the oral cavity
    2. Persist 7-14 days (similar to Minor Aphthae)
    3. Resolve spontaneously without scarring (similar to Minor Aphthae)
  3. Major Aphthae or Sutton Disease (5 to 10% of cases)
    1. Painful ulcers >1 cm
    2. Persist up to 6 weeks
    3. Associated with HIV Infection
    4. Resolve spontaneously WITH mucosal scarring risk

V. Symptoms

  1. Multiple painful Oral Ulcers

VI. Signs: Minor Aphthae

  1. Small round or oval white ulcer 1-5 mm in size
    1. White or yellow pseudomembrane covers center
    2. Surrounded by halo of reddened mucosa
    3. Typically less than 1 cm in size (except in cases of Major Aphthae)
  2. Distribution
    1. Single or multiple ulcers may coalesce
    2. Forms on nonkeratinizing oral mucus membranes
      1. Labial mucosa
      2. Buccal mucosa
      3. Ventral Tongue

VII. Differential Diagnosis

  1. See Oral Ulcer
  2. See Oral Lesion
  3. Primary Herpetic Gingivostomatitis
  4. Herpangina
  5. Hand Foot and Mouth Disease
  6. Behcet's Syndrome
  7. Reiter's Syndrome
  8. Inflammatory Bowel Disease
  9. Celiac Sprue
  10. PFAPA Syndrome
    1. Periodic Fever
    2. Aphthous Stomatitis
    3. Pharyngitis
    4. Cervical Adenitis

VIII. Management: General

  1. Good Oral Hygiene
  2. Avoid Toothpaste containing Sodium Lauryl Sulfate (SLS)
    1. Aphthous Ulcer recurrence associated with use
    2. Reference
      1. Herlofson (1994) Acta Odontol Scand 52:257-9 [PubMed]
  3. Chlorhexidine gluconate (Peridex) mouthwash
    1. Reduces severity of episode
    2. Prolonged use may stain teeth

IX. Management: Controlling Pain

  1. Topical Anesthetic
    1. Precautions
      1. Avoid extensive use over too wide an area
        1. May cause cotton-mouth feeling or taste loss
        2. May be worse than original problem
      2. Avoid in young children (age <2 years)
        1. Risk of Seizures with Lidocaine (LAST Reaction)
        2. Risk of Methemoglobinemia with benzocaine
    2. Dyclonine HCl Solution rinse provides numbing for 1 hour
    3. Lidocaine (Xylocaine, ointment 5% or viscous) rinses
    4. Diphenhydramine HCl (Benadryl elixir) rinse
      1. Alone or with Kaopectate
    5. Anesthetic (Benzocaine) in Denture-like adhesive:
      1. Benzodent
      2. Orajel Denture
    6. Other rinses
      1. Milk of Magnesia rinse
  2. Silver Nitrate Stick
    1. Destroys local nerve endings
    2. Provides pain relief for duration of eruption
    3. Ulcers may enlarge and heal more slowly
  3. Coat lesions
    1. Carafate (Sucralfate)
    2. Canker Cover
  4. Clean region after meals (may prevent irritation)
    1. Peroxide rinses (Peroxyl, Gly-Oxide or Hydrogen Peroxide 3% diluted 1:1 with water)
    2. Salt water gargles
  5. Magic Mouthwash
    1. Example: Mix of viscous Lidocaine, Benadryl, maalox with or without a Corticosteroid

X. Management: Aborting Lesions and shortening course

  1. Topical Corticosteroids
    1. Kenalog 0.1% in Orabase applied four times daily
    2. Clobetasol gel
    3. Allow Corticosteroid tablet to dissolve at lesion qid
      1. HydrocortisoneSodium Succinate 2.5 mg
      2. Betamethasone 17-valeraet 0.1 mg
    4. Aphthasol (Amlexanox 5% oral paste)
      1. Applied to lesions after meals and at bedtime
    5. Oral Steroid rinse
      1. Dexamethasone elixir mouth rinses (swish and spit)
    6. Debacterol
      1. Cotton swab with hollow handle containing sulfuric acid and phenol.
      2. Applied for 5-10 seconds (stings)
      3. Rinse vigorously afterward
      4. (2018) David Johnson, MD, per correspondence received 6/10/2018
      5. Rhodus (1998) Quintessence Int 29(12):769-73 +PMID: 10196853 [PubMed]
  2. Suppress oral streptococci
    1. Not recommended typically (listed for historical reasons)
    2. Saturate gauze pledget with antibiotic
    3. Dissolve in 30 cc water or elixir of Benadryl
      1. Tetracycline 250 to 100 mg or
      2. Keflex 250 mg
    4. Apply for 10-20 minutes 4-6 times/day for 5-7 days

XI. Management: Severe, recurrent Aphthous Ulcers (medications used historically)

  1. Systemic Corticosteroids
    1. Precaution: May exacerbate conditions in differential diagnosis (HSV, Thrush)
    2. Taken for 4 days during prodromal period OR
    3. Prednisone 60 mg orally daily tapered off over 2-3 weeks
  2. Colchicine 0.6-1.8 mg orally daily
    1. Response in 4-6 weeks
    2. Significant toxicity
  3. Phenelzine (MAO inhibitor)
    1. Strict dietary and concurrent medication limits
  4. Dapsone
  5. Thalidomide
    1. High risk medication (highly Teratogenic, category X in pregnancy)
    2. May be useful in severe cases in HIV patients

XII. Prevention

  1. Vitamin B12 1000 mcg sublingual daily
    1. May reduce recurrence in frequent Aphthous Ulcers regardless of Vitamin B12 level

XIII. Course

  1. See types above
  2. Typical Aphthous Ulcers (Canker Sores), aside from Major Aphthae, resolve spontaneously without treatment in 14 days

XIV. References

  1. (2022) Presc Lett 29(8): 47
  2. (2013) Presc Lett 20(1): 4
  3. Porter (2005) Clin Evid 13:1687-94 [PubMed]
  4. Gonsalves (2007) Am Fam Physician 75:501-7 [PubMed]
  5. Randall (2022) Am Fam Physician 105(4): 369-76 [PubMed]

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Related Studies

Ontology: Aphthous Stomatitis (C0038363)

Definition (MEDLINEPLUS)

Canker sores are small, round sores on the inside of the cheek, under the tongue, or in the back of the throat. They usually have a red edge and a gray center. They can be quite painful. They are not the same as cold sores, which are caused by herpes simplex.

Canker sores aren't contagious. They may happen if you have a viral infection. They may also be triggered by stress, food allergies, lack of vitamins and minerals, hormonal changes or menstrual periods. In some cases the cause is unknown.

In most cases, the sores go away by themselves. Some ointments, creams or rinses may help with the pain. Avoiding hot, spicy food while you have a canker sore also helps.
Definition (NCI) A recurrent disease of the oral mucosa of unknown etiology. It is characterized by small white ulcerative lesions, single or multiple, round or oval, lasting for 7-14 days and healing without scarring.
Definition (MSH) A recurrent disease of the oral mucosa of unknown etiology. It is characterized by small white ulcerative lesions, single or multiple, round or oval. Two to eight crops of lesions occur per year, lasting for 7 to 14 days and then heal without scarring. (From Jablonski's Dictionary of Dentistry, 1992, p742)
Definition (CSP) recurrent disease of the oral mucosa of unknown etiology, characterized by small white ulcerative lesions lasting 7 to 14 days.
Concepts Disease or Syndrome (T047)
MSH D013281
ICD9 528.2
SnomedCT 426965005, 398870000, 303117009, 321258009, 83312008, 322224003, 196536003, 196534000, 155661008, 196529004, 367526005, 110426005
English Aphthae, Aphthous Stomatitides, Aphthous Ulcer, Canker Sore, Sore, Canker, Sores, Canker, Stomatitides, Aphthous, Stomatitis, Aphthous, Ulcer, Aphthous, Ulcers, Aphthous, Aphthous Stomatitis, CANKER SORES ORAL, STOMATITIS APHTHOUS, ULCERS APHTHOUS ORAL, aphthous stomatitis, Oral aphthae NOS, Ulcerative stomatitis NOS, Oral aphthous ulcer, Aphthous stomatitis, Canker sore, Aphthous ulceration, Aphthous ulcer, Aphthous ulcer of mouth, Aphthous ulcer of mouth (disorder), Oral aphthae, Aphthous ulcers, aphthous ulcer (diagnosis), aphthous ulcer, Stomatitis aphhnous, Ulcer aphthous oral, Ulcers aphthous oral, Stomatitis aphthous, Ulcer aphthous, Canker sores oral, Stomatitis, Aphthous [Disease/Finding], Ulcer;aphthous, aphthae, aphtha, aphthous oral ulcers, aphthous ulcerations, aphthous ulcers, canker sores, oral aphthous ulcers, aphthous ulceration, canker sore, cankers sores, oral aphthae, oral aphthous ulcer, oral canker sores, Aphthous Ulcers, Canker Sores, Oral aphthous ulcer (disorder), Aphthous ulceration (disorder), Oral aphthae NOS (disorder), (Oral aphthae) or (mouth ulcer) (disorder), (Oral aphthae) or (mouth ulcer), Oral aphthae (disorder), Ulcerative stomatitis, Canker sores, Aphtha (morphologic abnormality), Aphtha, oral; aphthae, stomatitis; aphthae, stomatitis; aphthous, ulcer; aphthae, ulcer; aphthous, aphthae; oral, aphthae; stomatitis, aphthae; ulcer, aphthous; stomatitis, aphthous; ulcer, Oral aphthae, NOS, Oral aphthae (disorder) [Ambiguous], Oral aphthous ulcer [Ambiguous]
French STOMATITE APHTEUSE, Aphtes buccaux, Ulcère buccal aphteux, Ulcère aphteux, Ulcération aphteuse orale, Aphthe, APHTES BUCCAUX, ULCERATIONS APHTEUSES BOUCHE, Aphte, Stomatite aphteuse
Portuguese ESTOMATITE AFTOSA, Úlcera aftosa, Ulcerações da boca, Úlcera aftosa da boca, Aftas da boca, Úlceras aftosas da boca, Afta, FERIDA CANCEROSA ORAL, ULCERAS AFTOSAS DA BOCA, Estomatite aftosa, Aftas, Estomatite Aftosa, Úlcera Aftosa, Úlcera Dolorosa
Spanish ESTOMATITIS AFTOSA, Úlcera aftosa, Úlcera aftosa oral, Úlceras bucales, Aftas orales, Úlceras aftosas orales, ulceración aftosa en boca, ulceración aftosa en boca (trastorno), ORALES, LESIONES ULCERADAS, ULCERAS AFTOSAS, úlcera aftosa, aftas bucales (trastorno), aftas orales, afta oral (trastorno), ulceración aftosa, aftas bucales, SAI (trastorno), ulceración aftosa (trastorno), estomatitis aftosa, úlcera aftosa oral, aftas bucales, aftas bucales, SAI, aftas orales (trastorno), afta oral, afta (anomalía morfológica), aftas orales (concepto no activo), afta, Estomatitis aftosa, Afta, Canker Sore, Estomatitis Aftosa, Úlcera Aftosa
German STOMATITIS APHTHOSA, orale Aphten, Ulkus aphthoes, Ulkus aphthoes oral, aphthoeses Ulkus, Mundulzerationen, Aphthen, APHTOESE MUNDGESCHWUERE, MUNDSCHLEIMHAUT LAESION, Stomatitis aphtosa, Aphthae, Aphthe, Aphthenerkrankung, Ulkus, aphthöses
Dutch kankerpijn oraal, orale aften, afte, orale aftoïde ulcus, zweren aftoïd oraal, stomatitis aftoïd, aftoïde stomatitis, aften; oraal, aften; stomatitis, aften; ulcus, aphthosa; stomatitis, aphthosum; ulcus, oraal; aften, stomatitis; aften, stomatitis; aphthosa, ulcus; aften, ulcus; aphthosum, afteuze stomatitis, Afte, Mondaften, recidiverende, Mondzweer, Recidiverende mondaften, Stomatitis, afteuze
Italian Aftosi orale, Ulcera aftosa della bocca, Ulcere aftose della bocca, Afta, Afte, UIcera dolorosa, Ulcera aftosa, Stomatite aftosa
Japanese 口腔アフタ, アフタ性口内潰瘍, 口腔口唇潰瘍, アフタ性口腔潰瘍, ｺｳｸｳｺｳｼﾝｶｲﾖｳ, ｱﾌﾀｾｲｺｳﾅｲｴﾝ, ｱﾌﾀｾｲｶｲﾖｳ, ｺｳｸｳｱﾌﾀ, ｱﾌﾀｾｲｺｳﾅｲｶｲﾖｳ, ｱﾌﾀｾｲｺｳｸｳｶｲﾖｳ, ｱﾌﾀ, 回帰壊死性粘液腺周囲炎, 濾胞性口内炎, 口唇潰瘍, アフタ性口内炎, 潰瘍-アフタ性, 急性ヘルペス性口内炎, 急性ヘルペス性歯肉口内炎, アフタ性潰瘍, アフタ, 口内炎-アフタ性
Swedish Stomatit, aftös
Finnish Aftainen suutulehdus
Russian AFTY, IAZVA AFTOZNAIA, STOMATIT AFTOZNYI, PERIADENIT, AFTOZNYI STOMATIT, АФТОЗНЫЙ СТОМАТИТ, АФТЫ, ПЕРИАДЕНИТ, СТОМАТИТ АФТОЗНЫЙ, ЯЗВА АФТОЗНАЯ
Czech Aftózní vřed, Aftózní vřed v ústech, Aftózní stomatitida, Aftózní vředy v ústech, Orální afty, Afta, aphtha, stomatitida aftózní, aftózní stomatitida, aft, afta, afty
Croatian STOMATITIS, AFTOZNI
Polish Zapalenie jamy ustnej pryszczykowe, Zapalenie jamy ustnej plamisto-włóknikowe, Zapalenie jamy ustnej aftowe, Aftowe zapalenie jamy ustnej
Hungarian Aftás stomatitis, Oralis aphthák, Fekély, aphthás, Oralis aphthás fekély, Fekélyek, oralis, aphthás, Stomatitis aphtosa, Aphthás fekély, Aphthák, orális aphtás stomatitis
Norwegian Aftøs stomatitt, Munnskold, Stomatitt, aftøs, After
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Periadenitis Mucosa Necrotica Recurrens (C0086789)

Concepts Disease or Syndrome (T047)
MSH D013281
ICD10 K12.0
SnomedCT 80244009, 307774001, 398676009, 196535004, 196531008
English MJAU - major aphthous ulcer, Periadenitis mucosa necr. rec., Major oral aphthous ulceration, periadenitis mucosa necrotica recurrens, periadenitis mucosa necrotica recurrens (diagnosis), recurrent aphthous ulcer, sutton's disease, aphthous recurrent ulcers, Major oral aphthous ulceration (disorder), Sutton's disease, Periadenitis mucosa necrotica recurrens, Mikulicz's aphthae, Recurring scarring aphthae, MJAU - Major aphthous ulceration, Major aphthous ulceration, Sutton's aphthae, Major aphthous ulceration (disorder), Periadenitis mucosa necrotica recurrens (disorder), Aphthae major (disorder), Aphthae major, periadenitis; periadenitis mucosa necrotica recurrens, Periadenitis Mucosa Necrotica Recurrens
Portuguese Periadenite Mucosa Necrótica Recidivante
Spanish Periadenitis Mucosa Necrótica Recurrente, afta cicatrizal recidivante, enfermedad de Sutton, afta de Mikulicz, afta mayor (trastorno), afta mayor, aftas de Sutton, periadenitis mucosa necrótica recurrente (trastorno), periadenitis mucosa necrótica recurrente, úlcera aftosa mayor (trastorno), úlcera aftosa mayor
French Aphtes nécrosants et mutilants
German Periadenitis mucosa necrotica recurrens, Sutton Aphthe
Czech periadenitis mucosa necrotica recurrens, recidivující afty
Italian Periadenite mucosa necrotica ricorrente
Dutch periadenitis; periadenitis mucosa necrotica recurrens, Periadenitis mucosa necrotica recurrens
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Minor oral aphthous ulceration (C0585213)

Concepts Disease or Syndrome (T047)
SnomedCT 307772002, 196530009, 398870000, 83312008
English MIAU - minor aphthous ulcer, Minor aphthous ulceration, MIAU - Minor aphthous ulceration, aphthous stomatitis, recurrent aphthous stomatitis, recurrent canker sore, canker sore, ulcerative stomatitis, canker sores, Minor oral aphthous ulceration, Minor aphthous ulceration (disorder), Minor oral aphthous ulceration (disorder), Aphthae minor
Spanish úlcera aftosa menor (trastorno), úlcera aftosa menor, afta menor, úlcera aftosa oral menor (trastorno), úlcera aftosa oral menor
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Herpetiform aphthous stomatitis (C0585635)

Concepts Disease or Syndrome (T047)
ICD10 K12.0
SnomedCT 319297003, 196533006, 307775000, 320278005, 83312008
English Herpetiform aphth stomatitis, Herpetiform aphthous ulcer, Herpetiform aphthous ulceration, Oral herpetifrm aphthous ulcer, Herpetiform aphthae, Oral herpetiform aphthous ulceration, Stomatitis herpetiformis, stomatitis herpetiformis (diagnosis), stomatitis herpetiformis, Herpetiform aphthous stomatitis, Herpetiform aphthous ulceration (disorder), Oral herpetiform aphthous ulceration (disorder), Herpetiform aphthous stomatitis (disorder), herpetiformis; stomatitis, stomatitis; herpetiformis, Herpetiform aphthous ulceration [Ambiguous]
Spanish úlcera aftosa oral herpetiforme (trastorno), ulceración aftosa oral herpetiforme, afta herpetiforme, estomatitis herpetiforme, ulceración aftosa herpetiforme (trastorno), ulceración aftosa herpetiforme, úlcera aftosa oral herpetiforme, estomatitis aftosa herpetiforme (trastorno), estomatitis aftosa herpetiforme
Dutch herpetiformis; stomatitis, stomatitis; herpetiformis
Derived from the NIH UMLS (Unified Medical Language System)

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