These painful ulcers affect around 20% of the population and may occur in association
with systemic disease, but most patients are healthy. Aphthous ulcers may be precipitated
by stress, trauma, menstruation, or stopping smoking. Genetic factors may also be
important.
Aphthous ulceration is divided into minor, major, and herpetiform subtypes. The
diagnosis is clinical, and management symptomatic.
Minor aphthous ulcers (80% of cases)
Ulcers start in childhood or adolescence, are <10mm in diameter, and heal in 7–14 days.
Crops of ulcers recur every 1–4 months. Ulcers become less frequent with age.
What should I look for?
• One to five shallow round or oval ulcers (<10mm in diameter) on non-keratinized
mucosa—floor of the mouth, buccal or labial mucosa (vesicles in herpes simplex rupture
to form ulcers, most often on the dorsum of the tongue and hard palate).
• Erythematous haloes.
• Grey-white slough on the base of the ulcer.
• Exclude other mucosal involvement, e.g. genital ulcers, ocular inflammation.
Major aphthous ulcers (10% of cases)
Ulcers usually start in childhood or adolescence, may be as much as 3cm in diameter, and
heal over months, often with scarring. Ulcers recur at shorter intervals than minor
aphthae. Major aphthae may be a sign of Behçet disease.
What should I look for?
• Crops of 1–6 large ulcers (>10mm in diameter) with a firm raised margin in any part of
the mouth.
• Considerable pain.
• Scarring and fibrosis (60%).
• Other mucosal involvement, e.g. genital ulcers, ocular inflammation.
• Palpate solitary long-standing non-healing ulcers to check for induration, and, if
indurated, consider biopsy to exclude oral cancer.
Herpetiform ulcers (10% of cases)
These tend to occur in patients in their third decade. The ulcers, which resemble ulcers
caused by Herpes virus, usually heal within 2 weeks and do not recur more frequently
than monthly.
What should I look for?
• Many (up to 100) tiny ulcers (1–2mm in diameter) anywhere in the mouth.
• Scarring and fibrosis (30%).