4.04 Aphthous Ulcer (Canker Sore)
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agk's Library of Common Simple Emergencies

Presentation
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The patient complains of a painful lesion in 
the mouth, and may be worried about having 
herpes. A pale yellow, flat, even-bordered 
ulcer surrounded by a red halo may be seen on 
the buccal or labial mucosa, lingual sulci, 
soft palate, pharynx, tongue, or gingiva. 
Lesions are usually solitary, but can be 
multiple and recurrent. The pain is usually 
greater than the size of the lesions would 
suggest. Major aphthae (larger than 1 cm) 
indicate a severe form of the disease which may 
last for weeks of months.

What to do:
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- Attempt to differentiate from lesions of 
   herpes simplex and reassure the patient of 
   the benign nature of most canker sores.
- Inform the patient that these lesions usually 
   last 1-2 weeks, and that they should avoid 
   hot, acidic or irritating food and drink.
- For transient pain relief, try a tablet of 
   sucralfate crushed in a small amount of warm 
   water, swirled in the mouth or gargled. 
   Tetracycline elixir (or a capsule dissolved 
   in water) not swallowed, but applied to 
   cauterize lesions or used as a mouth wash 
   can relieve pain after single or repeated 
   application. Benadryl elixir mixed one-to- 
   one with Kaopectate, Xylocaine 2% Viscous 
   Solution, and Orabase HC applied topically 
   can also provide symptomatic relief.
- For more severe cases, prescribe triamcino- 
   lone acetonide 0.1% suspension (add inject- 
   able Kenolog to sterile water without 
   preservatives) in a 5ml oral rinse and 
   spit out four times a day after meals and 
   before bed, taking nothing by mouth for an 
   hour afterward. An alternative regimen is 
   dexamathasone elixir 1.5mg in 15ml qid rinse 
   and swallow, tapering to three days of 0.5ml 
   in 5ml, then three days swallowing every 
   other dose, but discontinuing the regimen as 
   soon as the mouth becomes comfortable.
- In very severe cases, try a burst dose of 
   prednisone 40-60mg qd x5 (no tapering).

Discussion
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Aphthous stomatitis has been studied for many 
years by numerous investigators. Although many 
exacerbating factors have been identified, the 
cause as yet remains unknown. Lesions can be 
precipitated by minor trauma, food allergy, 
stress, and systemic illness. Recurrent 
aphthous ulcers may accompany malignancy or 
autoimmune disease. At present, the treatment 
is only palliative, and may not alter the 
course of the syndrome. Apthous ulcers may be 
an immune reaction to damaged mucosa or altered 
oral bacteria. Herpangina and hand-foot-and- 
mouth disease can produce ulcers resembling 
aphthous ulcers, but which are instead part of 
coxsackie viral exanthems, usually with fever 
and occurring in clusters among children. 
Behcet's syndrome is an idiopathic condition 
characterized by oral ulcers clinically 
indistinguishable from aphthae but accompanied 
by genital ulcers, conjunctivitis, retinitis, 
iritis, leukocytosis, eosinophilia and 
increased erythrocyte sedimentation rate.

References:
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- Vincent SD, Lilly GE: Clinical, historic and 
   therapeutic features of aphthous stomatitis. 
   *Oral Surg Oral Med Oral Pathol* 1992; 
   74:79-86.

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