Aphthous stomatitis in ChildSee also in: Anogenital,Oral Mucosal Lesion
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SynopsisAphthous ulcers, or aphthae (canker sores), are the most common cause of recurring ulcers of the mucous membranes. They affect approximately 25% of the general population (estimates range from 20% up to 50%). The mouth is the most common site. The precise cause of aphthous ulceration is unknown, but studies point to a defect in regulation of cellular immunity that results in increased T-cell reactivity to either mucous membrane keratinocytes or microorganisms on the mucosal surface.
Aphthous ulcers are divided into 3 main subtypes: minor, major, and herpetiform. Minor and major aphthae are the predominant subtypes seen in pediatric patients.
Minor aphthae (Mikulicz ulcers) represent about 87% of pediatric cases and are single or multiple lesions that are 1.0 cm or less in diameter, mildly painful, and which generally heal within 1-2 weeks without scarring. They favor the buccal mucosa, labial mucosa, and the floor of the mouth. They usually develop in childhood or adolescence and continue to occur sporadically throughout life.
Major aphthae (Sutton disease) represent approximately 13% of pediatric cases. They are greater than 1 cm in diameter and are usually first seen at the onset of puberty. These lesions are extremely painful, last from 2-6 weeks, and generally heal with scarring. They favor the labial mucosa, soft palate, tongue, or pharynx. Systemic symptoms, such as fever and odynophagia, may be seen.
Herpetiform aphthae typically do not appear until adulthood. They are characterized by multiple ulcerations that are 1-3 mm in diameter and occur in clusters. Their clinical course is similar to that of minor aphthous ulcers in that they usually heal in less than one month without scarring. They can be seen anywhere on the oral mucosa. They are more common in females.
Most patients with aphthous ulcers suffer recurrences and this is termed recurrent aphthous stomatitis (RAS). RAS is more common in women, in patients younger than 40, in nonsmokers, and in people of higher socioeconomic status. Prevalence seems to be higher in patients of Northern European descent.
There are 2 well-recognized patterns for recurring oral ulcerations:
- Simple aphthosis is primarily marked by minor aphthae that recur intermittently with disease-free intervals of weeks to months. Patients are generally young and healthy, with lesions limited to the mouth and no underlying systemic disease. Patients frequently report a family history of oral ulceration. In addition to presumed genetic risk, epidemiologic studies (and patient reports) support an association between new lesions and oral trauma, chemical irritation, emotional stress, and smoking cessation. Pregnancy and hormonal changes in menses appear to increase risk. Some studies suggest that those who were breast-fed as infants may be at decreased risk. Most affected individuals experience less severe and fewer episodes after 50 years of age.
- Complex aphthosis is marked by the near-constant presence of 3 or more oral and/or genital aphthae. When genital ulcers are involved, complex aphthosis is sometimes called Lipschütz disease. Complex aphthosis usually occurs in the presence of an underlying disease such as human immunodeficiency virus (HIV), gluten-sensitive enteropathy, inflammatory bowel disease, or Behçet disease. By definition, Behçet disease is accompanied by other findings, including genital ulcers, uveitis, and other skin and systemic inflammatory processes. Complex aphthosis is also seen in rarer conditions such as MAGIC syndrome (mouth and genital ulcers, inflamed cartilage), PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and lymphadenopathy), and cyclical neutropenia (fever approximately every 3 weeks, oral ulcers, neutropenia).
K12.0 – Recurrent oral aphthae
426965005 – Aphthous ulcer of mouth
Differential Diagnosis & PitfallsDiseases with oral ulcerations clinically distinguishable from aphthae:
- Hand-foot-and-mouth disease – Usually has skin lesions.
- Herpangina – Localized to the soft palate and tonsillar region.
- Chemotherapy-induced mucositis
- Erosive lichen planus – White striae radiating from the periphery of the ulcer.
- Pemphigus vulgaris – Ragged ulcers and erosions that are chronic.
- Herpes zoster – Unilateral distribution; cutaneous vesicles.
- Varicella – Cutaneous lesions predominate.
- Herpes simplex virus, including primary herpes gingivostomatitis – Involvement of keratinized mucosa.
- HIV infection – Recurrent painful oral ulcers.
- Chemical burn (eg, from holding aspirin against the mucosa)
- Oral candidiasis – Typically painless or mild burning sensation; no actual ulceration.
Drug Reaction DataBelow is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.
Patient Information for Aphthous stomatitis in Child
OverviewCanker sores (aphthous ulcers), or aphthae, are the most common cause of periodic (recurring) ulcers of the oral and genital linings (mucous membrane surfaces). Their cause is unknown, but stress, lack of sleep, mechanical injury (trauma), and perhaps some vitamin deficiencies, toothpastes, and foods can make the condition worse. Some people with anemia and other medical conditions that weaken the immune system may be more likely to develop canker sores.
There are 3 types of canker sore:
- Minor aphthae (80% of cases)
- Major aphthae (Sutton disease, approximately 10% of cases)
- Herpetiform aphthae (10% of cases)
Major aphthae are extremely painful, last from 2-4 weeks, and generally cause scars after they heal.
Herpetiform aphthae progress in a way that is similar to minor aphthous ulcers.
Who’s At RiskCanker sores affect approximately 25% of the general population. They are more common in women, and they usually start to appear in children or teens.
People infected with HIV/AIDS are often severely affected.
Signs & SymptomsThe most common locations of canker sores are inside the mouth or lips or on the tongue. The genitals may also be affected. Ulcers can have a white, gray, or yellow base.
- Minor aphthae are single or multiple lesions, 1.0 cm or less in diameter.
- Major aphthae are deep ulcers greater than 2.0 cm in diameter.
- Herpetiform aphthae appear as multiple ulcerations.
Self-Care GuidelinesNone usually necessary except gentle oral care. There is no cure for canker sores, but the following measures may help relieve the pain associated with them:
- Apply protective pastes to form a barrier over the ulcer.
- Apply local anesthetics (benzocaine, lidocaine) to help numb the area.
- Use antibacterial mouthwashes.
- Avoid products or foods that seem to trigger episodes.
- Maintain a good diet or take vitamins.
- Get enough sleep and reduce stress.
When to Seek Medical CareSee your child's doctor for evaluation if canker sores do not heal, occur frequently, or are extremely uncomfortable or painful.
TreatmentsMost people are treated with topical steroids or other medications applied to the affected area, to speed up healing of the lesions. These include:
- Topical calcineurin inhibitors (tacrolimus or pimecrolimus).
- Prednisone may be used in severe situations.
- Other oral medications, dapsone and colchicine, may be used in more severe cases, when repeated outbreaks (recurrences) continue for years.
Bolognia, Jean L., ed. Dermatology, pp.419, 1087. New York: Mosby, 2003.
Freedberg, Irwin M., ed. Fitzpatrick's Dermatology in General Medicine. 6th ed. pp.1115-1116, 1098-1099, 2360, 2467. New York: McGraw-Hill, 2003.
Aphthous stomatitis in ChildSee also in: Anogenital,Oral Mucosal Lesion