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Canker Sore
Aka: Canker Sore, Aphthous Ulcer, Aphthous Stomatitis, Minor Aphthae, Herpetiform Aphthous Stomatitis, Sutton's Aphthae, Major Aphthae- See Also
- Epidemiology
- Prevalence: 5-21% in United States
- Most common ulcerative condition of the oropharynx
- Family History in 40% of patients
- Age
- Peaks ages 10 to 20 years old
- Prevalence decreases after age 50 years
- Pathophysiology
- Benign Autoimmune Condition
- Inflammatory Bowel Disease and Celiac Sprue may predispose to Aphthous Ulcers
- Nutritional deficiency may contribute in some cases
- Types
- Minor Aphthae (75 to 85% of cases)
- Painful ulcers <1 cm in size
- Persist 7-14 days
- Resolve spontaneously without scarring
- Herpetiform Aphthae (5 to 10% of cases)
- Patches of up to 100 small (1-3 mm) ulcers occurring throughout the oral cavity
- Persist 7-14 days (similar to Minor Aphthae)
- Resolve spontaneously without scarring (similar to Minor Aphthae)
- Major Aphthae or Sutton Disease (5 to 10% of cases)
- Painful ulcers >1 cm
- Persist up to 6 weeks
- Associated with HIV Infection
- Resolve spontaneously WITH mucosal scarring risk
- Minor Aphthae (75 to 85% of cases)
- Symptoms
- Multiple painful Oral Ulcers
- Signs: Minor Aphthae
- Small round or oval white ulcer 1-5 mm in size
- White or yellow pseudomembrane covers center
- Surrounded by halo of reddened mucosa
- Typically less than 1 cm in size (except in cases of Major Aphthae)
- Distribution
- Single or multiple ulcers may coalesce
- Forms on nonkeratinizing oral mucus membranes
- Labial mucosa
- Buccal mucosa
- Ventral Tongue
- Small round or oval white ulcer 1-5 mm in size
- Course
- See types above
- Differential Diagnosis
- Management: General
- Good Oral Hygiene
- Avoid Toothpaste containing Sodium Lauryl Sulfate (SLS)
- Aphthous Ulcer recurrence associated with use
- Reference
- Chlorhexidine gluconate (Peridex) mouthwash
- Reduces severity of episode
- Prolonged use may stain teeth
- Management: Controlling Pain
- Topical Anesthetic
- Precautions
- Avoid extensive use over too wide an area
- May cause cotton-mouth feeling or taste loss
- May be worse than original problem
- Avoid in young children
- Risk of Seizures with Lidocaine
- Risk of Methemoglobinemia with benzocaine
- Avoid extensive use over too wide an area
- Dyclonine HCl Solution provides numbing for 1 hour
- Lidocaine (Xylocaine, ointment 5% or viscous)
- Diphenhydramine HCl (Benadryl elixir)
- Alone or with Kaopectate
- Anesthetic (Benzocaine) in Denture-like adhesive:
- Benzodent
- Orajel Denture
- Precautions
- Silver Nitrate Stick
- Destroys local nerve endings
- Provides pain relief for duration of eruption
- Ulcers may enlarge and heal more slowly
- Coat lesions
- Carafate (Sucralfate)
- Canker Cover
- Clean region after meals (may prevent irritation)
- Peroxide rinses (Peroxyl or Hydrogen Peroxide 3% diluted 1:1 with water)
- Magic Mouthwash
- Example: Mix of viscous Lidocaine, Benadryl, maalox with or without a Corticosteroid
- Topical Anesthetic
- Management: Aborting Lesions and shortening course
- Topical Corticosteroids
- Kenalog 0.1% in Orabase applied qid
- Allow Corticosteroid tablet to dissolve at lesion qid
- HydrocortisoneSodium Succinate 2.5 mg
- Betamethasone 17-valeraet 0.1 mg
- Aphthasol (Amlexanox 5% oral paste)
- Applied to lesions after meals and at bedtime
- Oral Steroid rinse
- Dexamethasone elixir mouth rinses (swish and spit)
- Debacterol
- Cotton swab with hollow handle containing sulfuric acid and phenol.
- Applied for 5-10 seconds (stings)
- Rinse vigorously afterward
- (2018) David Johnson, MD, per correspondence received 6/10/2018
- Rhodus (1998) Quintessence Int 29(12):769-73 +PMID: 10196853 [PubMed]
- Suppress oral streptococci
- Not recommended typically (listed for historical reasons)
- Saturate gauze pledget with antibiotic
- Dissolve in 30 cc water or elixir of Benadryl
- Tetracycline 250 to 100 mg or
- Keflex 250 mg
- Apply for 10-20 minutes 4-6 times/day for 5-7 days
- Topical Corticosteroids
- Management: Severe, recurrent Aphthous Ulcers (medications used historically)
- Systemic Corticosteroids
- Precaution: May exacerbate conditions in differential diagnosis (HSV, Thrush)
- Taken for 4 days during prodromal period OR
- Prednisone 60 mg orally daily tapered off over 2-3 weeks
- Colchicine 0.6-1.8 mg orally daily
- Response in 4-6 weeks
- Significant toxicity
- Phenelzine (MAO inhibitor)
- Strict dietary and concurrent medication limits
- Dapsone
- Thalidomide
- High risk medication (highly Teratogenic, category X in pregnancy)
- May be useful in severe cases in HIV patients
- Systemic Corticosteroids
- References