What should be the focus of history in the evaluation of aphthous stomatitis (canker sore)?

Updated: Sep 25, 2020
  • Author: Ginat W Mirowski, MD, DMD; Chief Editor: William D James, MD  more...
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Recurrent aphthous ulcers consist of one or multiple round-to-ovoid, shallow, punched-out–appearing, painful oral ulcers that recur at intervals of a few days to a few months. To evaluate oral ulcers as recurrent aphthous ulcers, ascertain the following information:

  • Nature of the lesions (number, size, duration, recurrence): The prodromal stage (when present) may begin with a pricking or burning sensation on the mucosa. The ulcers develop within 24-48 hours. Pain lasts 3-4 days or until a thicker fibrinous cover develops or early epithelialization occurs. Healing is complete in 7-14 days.

  • Age of the patient at onset

  • Cutaneous or mucosal changes

  • Symptoms of other organ system involvement

  • Current medications, including herbal medications and vitamins

  • Host factors associated with recurrent aphthous ulcer (see Causes): With regard to genetic factors, a family history is evident in some cases. Hematinic deficiency may play a role. Iron, folic acid, or vitamin B-6 and B-12 deficiencies are possible. [15, 16] Immune dysregulation may play possibly play a role. Physical or emotional stress is often reported by patients as associated with recurrent outbreaks. [17] This stress appears to affect onset but not duration or severity of episodes. [18]

  • Environmental factors associated with recurrent aphthous ulcer: Local, chemical, or physical trauma may initiate ulcer development in patients who are susceptible (pathergy). Allergy or sensitivity to chemicals or food additives may stimulate an outbreak. The role of microbial infection is debated.

  • HIV infection (associated with lesions) [19] : Aphthouslike oral ulcerations involving all 3 types of recurrent aphthous ulcers are observed. Approximately 66% of patients who are HIV positive have herpetiform and major recurrent aphthous ulcers. Unlike in healthy individuals, these ulcerations may be present on both keratinized and nonkeratinized surfaces, making it even more critical to rule out opportunistic infections. Ulcerations must be distinguished from those caused by HIV medications and fungal, viral, or bacterial infections. Tissue biopsy for pathologic evaluation and for culture is indicated.

  • Behçet syndrome (associated with lesions) [20, 21, 22, 23, 24, 25] : This complex, multisystemic inflammatory disorder of unknown cause is characterized by recurrent oral aphthae and at least 2 of the following findings: genital aphthae, synovitis, cutaneous pustular vasculitis, posterior uveitis, or meningoencephalitis. Oral aphthae of Behçet syndrome are clinically similar to those in recurrent aphthous ulcers but are accompanied by ocular and genital lesions. The incidence is highest in Japan, Southeast Asia, the Middle East, and southern Europe and in persons aged 30-40 years. Behçet syndrome is strongly associated with HLA-B51. Studies also demonstrate an association between IL-18 gene polymorphisms and Behçet syndrome, which was not observed in patients with aphthous stomatitis. [26]

  • Gluten-sensitive enteropathy (also known as celiac sprue) [27, 28, 29] : Oral lesions occur in most cases of gluten-sensitive enteropathy (GSE) and can often precede abdominal symptoms. Less than 5% of patients with recurrent aphthous ulcers have GSE, also known as celiac disease, or other minor mucosal abnormalities of the small intestine. However, celiac disease is not universally agreed to be causative; thus, the need for patients with aphthosis to be screened for celiac disease is unclear. [30, 31] Bowel symptoms may not be present, but patients may have folate deficiency, and they sometimes have reticulin antibodies.

  • Xerostomia or dry mouth: This may be a precipitating or aggravating factor in many patients since saliva is a lubricating agent with antimicrobial properties. [32]

No specific laboratory tests are available. It is important to exclude other disorders by medical history and a comprehensive laboratory evaluation when indicated.

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