pediatria polska 90 (2015) 256–259

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Case report/Kazuistyka

Major recurrent aphthous stomatitis in mother and

son with HIV/AIDS infection – Case report

Mario Augusto Gori Gomes, Fabio Marzullo Zaroni, Marilia Compagnoni

Martins, Antonio Adilson Soares de Lima *
Department of Stomatology, Universidade Federal do Paraná, UFPR, Brazil

article info abstract

Article history: Recurrent aphthous stomatitis is a condition characterized by painful ulcers of variable
Received: 27.01.2015 size and duration that typically affect non-keratinized oral mucosa. They are classified
Accepted: 05.02.2015 clinically into minor, major and herpetiformis. Ulcers may result in impairment of
Available online: 16.02.2015 speech, oral hygiene and feeding, leading to nutritional deficit and poor quality of life.
Individuals with AIDS usually manifest this type of ulceration more severely and fre-
Keywords: quently. The objective of this paper is to report a case of two patients (mother and son)
 Aphthous stomatitis with HIV infection and simultaneously presenting major recurrent aphthous stomatitis.
 HIV infections © 2015 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
 Immunocompromised patients
 Oral ulcer

impairment in feeding and speech, leading to a nutritional

Introduction
Recurrent aphthous stomatitis is a condition characterized
by single or multiple painful ulcers of variable size and
duration that typically affect non-keratinized oral mucosa [1].
Ulcers are classified clinically into minor, major and herpeti-
formis. Minor aphthous stomatitis measures less than 10 mm
and heals on average from 10 to 14 days and is more
common than the others. The major type aphthous stomati-
tis (ulcers' size ranging from 10 to 30 mm) is less common but
more severe. These ulcers' healing time is longer (weeks or
months) and usually results in scars. Herpetiformis recurrent
aphthous stomatitis (1–3 mm size) are less frequent and the
number of ulcers can be highly increased up to 100 ulcers per
episode [1]. Recurrent aphthous stomatitis may result in
deficit and poor quality of life [1].
Studies show that recurrent aphthous stomatitis has
a higher prevalence in young adults, with decreased inci-
dence and severity with increasing age [2]. The etiology
remains unknown although there is evidence for immuno-
genic factors [2]. Other possible causes are trauma, drug use,
lack of B12 vitamin, folic acid, iron and other dietary factors,
stress, hormonal changes, metabolic diseases and infection
by microorganisms [3].
Treatment of recurrent aphthous stomatitis has not yet
reached a consensus. Systemic interventions are used as
a palliative but there is not enough evidence to support or
refute any treatment [4]. There are not well-designed studies
that can attest the effectiveness of topical treatments,
specially, in patients with HIV/AIDS [5]. Some authors

* Corresponding author at: School of Dentistry, Department of Stomatology, Av. Prefeito Lothário Meissner, 632, Jardim Botånico,
80210-170 Curitiba, PR, Brazil. Tel.: +55 41 3360 4134; fax: +55 41 3360 4134.
E-mail address: antollima@gmail.com (A.A. Soares de Lima).
http://dx.doi.org/10.1016/j.pepo.2015.02.001
0031-3939/© 2015 Polish Pediatric Society. Published by Elsevier Sp. z o.o. All rights reserved.
 pediatria polska 90 (2015) 256–259 257

Fig. 1 – Oral ulcers in labial mucosa (child) Fig. 2 – Oral ulcer in tongue (child)

believe that individuals with AIDS usually manifest more

severe and frequent ulcers [1, 6].
Fast and effective treatment is important to decrease the
painful discomfort, and difficulty in speaking. Furthermore,
it facilitates feeding and oral hygiene, which contributes to
the overall health condition of the patient.
The objective of this paper is to report a case of two
patients (mother and son), both immunosuppressed by HIV
infection and simultaneously presenting major recurrent
aphthous stomatitis.

Case report

A 10-year-old, white, male boy was brought by his mother Fig. 3 – Oral ulcers in mouth floor (child)
to the clinic of Oral Medicine of the School of Dentistry
(Universidade Federal do Paraná, Brazil) complaining of
ulcers throughout the mouth. The patient was diagnosed
HIV positive with vertical transmission at 6 months of age.
He was receiving treatment for HIV infection with antiretro-
viral drugs.
During anamnesis the mother reported that her son had
many ear infections that led to a perforation of the eardrum
and progressive loss of hearing. Intraoral examination
revealed the presence of ulcerated lesions on labial mucosa
(Fig. 1), buccal mucosa, tongue (Fig. 2) and mouth floor
(Fig. 3). Ulcers had yellowish necrotic background, raised
borders and an erythematous halo. The patient reported
severe pain, difficulty feeding and brushing teeth. According
to the mother, these ulcerated lesions used to occur
frequently. Furthermore, bilateral submandibular lymphade-
nopathy was observed on the extraoral examination. The Fig. 4 – Oral ulcer in labial mucosa (mother)
lesions were diagnosed as major recurrent aphthous stoma-
titis due to size, appearance and history of recurrence.
Family history revealed that the mother was ex-alcoholic, diagnosis of major recurrent aphthous stomatitis was estab-
ex-smoker, hypertensive and HIV positive for 16 years. The lished according to the signs and symptoms.
mother was being treated with antiretroviral and antihyper- Both patients were treated with mouthwash of 0.5 mg
tensive drugs. Intraoral examination of the mother revealed dexamethasone elixir in intervals of 8 h for 7 days. They
the presence of ulcerated lesions on labial mucosa (Fig. 4), were instructed not to swallow the medicine. At the end of
buccal mucosa (Fig. 5), and tongue. Submandibular lympha- treatment, both patients still presented some residual
denopathy was noted on the right side of her neck. The lesions. However, there were no complaints of pain or
258 pediatria polska 90 (2015) 256–259
Fig. 5 – Oral ulcer in buccal mucosa (mother)
discomfort to feed and ulcers already showed signs of
remission. Two weeks later, they had no more aphthous
ulcerations in the mouth and were referred for dental
treatment.
Discussion
Recurrent aphthous stomatitis is a condition that affects
oral cavity and oropharynx. Clinically, this condition can be
classified into three types: minor, major and herpetiformis
[6]. According to the ‘‘Classification and Diagnostic Criteria
for Oral Lesions in HIV Infection’’ (proposed by Ec-Clearing-
house on Oral Problems Related to HIV Infection and WHO
Centre on Oral Manifestations Collaborating on the Immu-
nodeficiency Virus in 1993), recurrent aphthous stomatitis is
part of the group 3 (lesions observed in HIV infection). This
classification considers that the incidence of major and
herpetiformis types are increased in patients with HIV
infection [7]. For pediatric patients with HIV infection this
classification is modified and recurrent aphthous stomatitis
is in the group 1 (lesions commonly associated with
pediatric HIV infection) [8].
Patients in this case report presented several oral ulcera-
tions over 1 cm in size with recurrence pattern and scars
from previous injuries. Ulcers were located in the labial
mucosa, buccal mucosa, tongue and mouth floor. This
condition is compatible with major recurrent aphthous
stomatitis because ulcers are deeper, painful, repair slowly
and may leave a scar. Besides, these lesions generally are
more than 1 cm in diameter [9].
Literature shows that recurrent aphthous stomatitis is
most prevalent in adolescents and young adults [10]. The
incidence may vary depending on the population, diagnostic
criteria and environmental factors [11]. Prevalence of recur-
rent aphthous ulceration in children is 39% and seems to be
related to the presence of this entity in one or both parents
[12]. In this case report, mother and son manifested simul-
taneously several lesions. This fact possibly is due to
immunosuppression associated with HIV infection that is
considered an etiological factor. Moreover, the influence of
genetic factor cannot be ruled out because one of the
parents presented recurrent aphthous stomatitis too.
Patients with AIDS may manifest various clinical condi-
tions in the form of mouth ulcers. Ulcers caused by herpes
simplex virus and cytomegalovirus infections are considered
the most prevalent during the course of acquired immuno-
deficiency syndrome [13]. Thus, the diagnosis should consi-
der the history and clinical presentation [14]. In the present
case, the diagnosis of major recurrent aphthous ulceration
was established. The following data were fundamental to
define the diagnosis: (a) multiple ulcers greater than 1 cm,
(b) lesions in areas of non-keratinized mucosa, (c) presence
of scars, and (d) lesions with history of recurrence.
Treatment of recurrent aphthous ulcerations, regardless
of type, remains a challenge. Actually, despite numerous
types of treatment, there is no effective therapy or medica-
tion. Drugs usually relieve pain, discomfort and reduce
healing time. The use of protective and/or topical anesthetic
agents is recommended for patients with less frequent
minor recurrent aphthous ulcers or herpetiformis types. In
cases of more frequent minor and herpetiformis types or
major ulcers, there are a number of topical treatment
options, such as anesthetics, sucralphate and corticosteroids
(0.05% fluocinonide, clobetasol propionate 0.05% and dexa-
methasone elixir 0.5 mg/5 mL) [14]. Systemic treatment
options may include firstly corticosteroids like prednisone
0.5–1.0 mg/kg or intralesional injection of triamcinolone
40 mg/mL. Second option of systemic treatment includes
immunomodulators, like thalidomide (200 mg/day) [14].
The established treatment for the patients was mouth-
wash with 0.5 mg dexamethasone elixir in intervals of 8 h for
7 days. They were instructed not to swallow the medicine.
Furthermore, the patients were monitored clinically to control
opportunistic infections such as oral candidiasis.
Systemic corticosteroids can be occasionally used in the
short term to treat severe episodes of recurrent aphthous
ulcerations. On the other hand, the use of this therapeutic
modality for long periods is not recommended due to the
side effects, especially in immunosuppressed patients [15].
Recurrent aphthous stomatitis observed during the
course of HIV infection may be severe and can result in
significant morbidity in these patients. Ulcers may interfere
with oral functions and alter patient's quality of life.
Attention should be given to clinical aspects of the lesions
to establish correct diagnosis and treatment. Currently, the
main goals of treatment are to promote early repair of
injuries, relieve pain while maintaining nutritional intake
and reduce recurrence.
Authors' contributions/Wkład autorów
AASdeL – study design, FMZ – data collection, MCM –
acceptance of final manuscript version. MAGG – literature
search.
Conflict of interest/Konflikt interesu
None declared.
 pediatria polska 90 (2015) 256–259
Financial support/Finansowanie
None declared.
Ethics/Etyka
The work described in this article has been carried out in
accordance with The Code of Ethics of the World Medical
Association (Declaration of Helsinki) for experiments invol-
ving humans; EU Directive 2010/63/EU for animal experi-
ments; Uniform Requirements for manuscripts submitted to
Biomedical journals.
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