Which physical findings are characteristic of pediatric aphthous ulcers?

Updated: Feb 25, 2019
  • Author: Michael C Plewa, MD; Chief Editor: Russell W Steele, MD  more...
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Aphthous ulcers (canker sores) occur on areas of the mouth in which the mucosa is nonkeratinized and loosely attached, particularly the buccal mucosa, the labial mucosa, the floor of the mouth, the ventral surface of the tongue, and the soft palate. Ulcers may appear as single or multiple lesions, and they are easily distinguished from primary or secondary viral infections, bacterial infections (eg, necrotizing ulcerative gingivitis), dermatologic conditions (lichen planus, cicatricial pemphigoid, pemphigus), and traumatic injuries (contusions, lacerations, burns) by the healthy appearance of adjacent tissues and the lack of distinguishing systemic features.

  • Minor ulcers are seldom larger than 5 mm but can be as large as 1 cm. They may be single or multiple. The ulcers are round-to-oval, they are covered by a gray or yellowish and fibrinous surface, and they are surrounded by an erythematous border.

  • Major recurrent aphthous ulcers (canker sores) can be 1-3 cm in diameter. They are deeper than minor ulcers and often have a raised, irregular, erythematous border. Patients with a history of major recurrent aphthous ulcers (canker sores) often have residual scarring in the oral mucosa from previous lesions.

  • Herpetiform aphthous ulcers appear as small (seldom >3 mm in diameter), tightly clustered lesions. They typically number 2-10 but may number as many as 100. They are not related to herpes simplex infections and do not present as or develop into vesicular lesions. The ulcers appear identical to minor aphthous ulcers with the exception of their small size, proximity to other lesions, and increased numbers. Confusion may arise if the lesions coalesce into a large lesion resembling major aphthous stomatitis.

  • The rest of the mouth should appear normal. However, halitosis and necrotic, exudative, or bleeding gums may be present with the following: (1) necrotizing ulcerative gingivostomatitis; (2) erythematous tonsils with periodic fever, aphthous pharyngitis, and adenopathy (PFAPA) syndrome; [17, 18] and (3) vesicular-ulcerative palatal lesions with coxsackieviral infection.

  • Vital signs should be normal. Secondary bacterial infection, PFAPA syndrome, primary viral infection, or rheumatologic disorder may cause fever.

  • Clinical evidence of dehydration may include decreased weight, tachycardia, hypotension, cool extremities, delayed capillary refill, depressed fontanelle, dry mucus membranes, decreased skin turgor, or decreased axillary moisture. Plotting the weight and height may reveal a trend toward the low percentiles for age; this finding suggests nutritional deficiency or malabsorption syndrome.

  • Skin findings should be normal, but rash may be present with Behçet syndrome, erythema multiforme, hand-foot-and-mouth disease, herpes simplex infection, lichen planus, MAGIC syndrome, pemphigus, pemphigoid, Sweet syndrome, syphilis, systemic lupus erythematosus, varicella (chickenpox), or varicella zoster.

  • The joints should be normal, but joints may be tender with effusion, erythema, or decreased range of motion in Reiter syndrome, systemic lupus erythematosus, or MAGIC syndrome.

  • The eyes should be normal, but examination may reveal conjunctival lesions in patients with Behçet syndrome or cicatricial pemphigoid. Uveitis or iritis may be present with Reiter syndrome or Behçet syndrome.

  • Cervical adenopathy should be minimal. Tender or markedly enlarged lymph nodes suggest PFAPA syndrome.

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