Aphthous Stomatitis: Background, Pathophysiology, Epidemiology

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Aphthous Stomatitis
Author: Ginat W Mirowski, MD, DMD; Chief Editor: William D James, MD more...
Updated: Feb 09, 2016

Background
Aphthous stomatitis, also known as recurrent aphthous ulcers or canker sores, is
among the most common oral mucosal lesion physicians and dentists observe.
Aphthous stomatitis is a disorder of unknown etiology that may cause significant
morbidity. One or several discrete, shallow, painful ulcers are visible on the
unattached oral mucous membranes. Individual ulcers typically last 7-10 days and
heal without scarring. Larger ulcers may last several weeks to months and can scar
when healing.

Pathophysiology
Although the process in idiopathic recurrent aphthous ulcers is usually self-limiting,
in some individuals, ulcer activity can be almost continuous. Similar ulcers can be
noted in the genital region. Behet syndrome, systemic lupus erythematosus, and
inflammatory bowel disease are systemic diseases associated with oral recurrent
aphthous ulcers.
Recurrent aphthous ulcers occur on nonkeratinized or poorly keratinized surfaces of
the mucosa such as following:
Labial and buccal mucosa
Maxillary and mandibular sulci
Unattached gingiva
Soft palate
Tonsillar fauces
Floor of the mouth
Ventral surface of the tongue
Inferior lateral surface of the tongue
The clinical presentation of aphthous ulcers is defined by the number of recurrences
and severity of disease. Clinically, the number and size of the ulcers are the two
main criteria used to divide ulcers into three forms: minor, major, and herpetiform.
Simple aphthae are common and considered mild, with 1-4 episodes per year. In
general, there are few lesions of the minor or herpetiform form. In contrast, complex
aphthosis has a severe clinical course, with an almost continuous presence of minor
or major ulcers. These may be debilitating and may also involve the genitalia of both
men and women. It is imperative that these patients be evaluated to rule out Behet
disease as well as inflammatory bowel disease.

Recurrent aphthous ulcer minor (Mikulicz ulcer)

This is the most common form, accounting for 80-85% of cases. Discrete, painful,
shallow, recurrent ulcers smaller than 1 cm in diameter characterize this form,
shown in the image below. At any time, one or multiple ulcers can be manifest.
These ulcers heal within 7-14 days without scarring. The periodicity varies among
individuals, with some having long ulcer-free episodes and some never being free
from ulcers.

Minor aphthous ulcer: Small superficial oval erosions with yellow pseudomembrane and an
erythematous border are evident on the labial aspect of the left lower lip.

Recurrent aphthous ulcer major (Sutton ulcer, periadenitis mucosa

necrotica recurrens)
This form accounts for about 5-10% of cases and present as round or oval ulcers
that range in size from 2-3 cm in diameter, as shown in the image below. Major
aphthae typically present as a single ulcer, but multiple ulcers may occur. The ulcers
present on the soft palate, lips, or oropharynx. They may be deep with smooth or
irregular borders. The ulcers may coalesce. Healing, which may take 6 weeks or
even months, results in scarring; severe distortion of oral and pharyngeal mucosa
may occur. These are more common in patients with HIV disease.

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Major aphthous ulcer: Large oval ulcer with white pseudomembrane and raised red border
located on the right upper labial mucosa adjacent to the buccal commissure. Note the
irregular margin so typical in major aphthae.

Herpetiform recurrent aphthous ulcer

In this rare form (<5% of cases), ulcers are typically about 1-2 mm in diameter. The
aphthae tend to occur in clusters or crops consisting of 10-100 ulcers. Clusters may
be small and localized, or they may be distributed throughout the soft mucosa of the
oral cavity. These too occur predominantly on unkeratinized mucosa, as shown in
the image below. It is important to differentiate these ulcers from herpes simplex
virus (HSV), which also may appear as recurrent crops. HSV is an infectious
disease that often presents with vesicles that quickly ulcerate and involve the
keratinized mucosa of the hard palate, dorsal tongue and attached gingiva.

Herpetiform aphthous ulcer: Grouped and single tiny white to yellow ulcers scattered on the
labial mucosa and on the ventral aspect of the tongue.

Epidemiology
US frequency
Recurrent aphthous ulcers are the most common oral mucosal disease in North
America. They affect 20% of the population, with the incidence rising to more than
50% in certain groups of students in professional schools. Children from high
socioeconomic groups may be affected more than those from low socioeconomic
groups.[1] Note the following point prevalence and lifetime prevalence rates[2] :
Point prevalence in the pediatric population in the United States: 1.2-1.5%
Lifetime prevalence in the pediatric population in the United States: 40.18%

International frequency
Recurrent aphthous ulcers occur worldwide and are reported on every populated
continent. Recurrent aphthous ulcers affect 2-66% of the international population.[3] .
Epidemiologic studies have been conducted in various subpopulations and report
data on both point prevalence and lifetime prevalence, as follows:
Lifetime prevalence in the adult population in the United States and Canada:
46.4-69.4% [4]
Europe lifetime prevalence: 36-37% [4]
Sweden point prevalence: 0.5-2% [5, 6]
Turkey point prevalence: 1.2-2.3% [7, 8]
Jordan lifetime prevalence: 78% [9]
Iran lifetime prevalence: 25.2% [10]
Sulaimani City, Iraq lifetime prevalence: 28.2% [11]
India point prevalence: 1.5% in Northern India [12]
India lifetime prevalence: 50.3% [13]

Sex
In children and in some adult communities who are affected, the incidence of
recurrent aphthous ulcer is higher in women and girls than in men or boys.[4]

Age
Recurrent aphthous ulcer minor is the most common form of childhood recurrent
aphthous ulcer. Approximately 1% of American children may have recurrent

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aphthous ulcers, with onset before age 5 years. The percentage of patients who are
affected decreases after the third decade.[14]
Recurrent aphthous ulcer major has a typical onset after puberty and can persist for
the remainder of an individual's life, although after late adulthood episodes become
much less common.[14]
Herpetiform recurrent aphthous ulcer first occurs in the second decade of life; the
majority of persons have onset when younger than 30 years. The frequency and the
severity of episodes may increase during the third and fourth decades and then
decrease with advancing age.[14]
Clinical Presentation

Contributor Information and Disclosures

Author
Ginat W Mirowski, MD, DMD Adjunct Associate Professor, Departments of Oral Pathology, Medicine, and
Radiology, Indiana University School Medicine
Ginat W Mirowski, MD, DMD is a member of the following medical societies: American Academy of Dermatology,
American Medical Womens Association
Disclosure: Nothing to disclose.
Coauthor(s)
Diana V Messadi, DDS, MMSc, DMSc Professor of Dentistry, Associate Dean for Education and Faculty
Development, Chair, Section of Oral Medicine and Orofacial Pain, University of California, Los Angeles, School of
Dentistry
Diana V Messadi, DDS, MMSc, DMSc is a member of the following medical societies: American Academy of Oral
and Maxillofacial Pathology, American Academy of Oral Medicine, American Association for Cancer Research,
American Association for Cancer Research, Women in Cancer Research, American Association for Dental
Research, American Association of University Women, American Dental Association, American Dental Education
Association, Arab American Dental Society, Association of Egyptian-American Scholars, California Dental
Association, Egyptian Dental Association, International Association for Dental Research, Southern California
Academy of Oral Pathology, West Los Angeles Dental Society
Disclosure: Nothing to disclose.
Heather C Rosengard, MPH Johns Hopkins University School of Medicine
Disclosure: Nothing to disclose.
Specialty Editor Board
Richard P Vinson, MD Assistant Clinical Professor, Department of Dermatology, Texas Tech University Health
Sciences Center, Paul L Foster School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Texas
Medical Association, Association of Military Dermatologists, Texas Dermatological Society
Disclosure: Nothing to disclose.
Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, Rutgers
New Jersey Medical School
Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology,
American Society of Dermatopathology, Society for Investigative Dermatology
Disclosure: Nothing to disclose.
Chief Editor
William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director,
Department of Dermatology, University of Pennsylvania School of Medicine
William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society
for Investigative Dermatology
Disclosure: Nothing to disclose.
Additional Contributors
David P Fivenson, MD Associate Director, St Joseph Mercy Hospital Dermatology Program, Ann Arbor, Michigan
David P Fivenson, MD is a member of the following medical societies: American Academy of Dermatology,
Michigan State Medical Society, Society for Investigative Dermatology, Photomedicine Society, Wound Healing
Society, Michigan Dermatological Society, Medical Dermatology Society
Disclosure: Nothing to disclose.
Christy L Nebesio, MD Dermatologist
Christy L Nebesio, MD is a member of the following medical societies: Alpha Omega Alpha
Disclosure: Nothing to disclose.
Jeffrey M Casiglia, DMD, DMSc Lecturer, Harvard School of Dental Medicine; Private Practice, Salem,
Massachusetts

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Jeffrey M Casiglia, DMD, DMSc is a member of the following medical societies: American Academy of Oral
Medicine, American Dental Association
Disclosure: Nothing to disclose.

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