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mouth ulcers

see also:

differential diagnoses

apthous ulcers

  • also known as aphthous stomatitis
  • oval or round ulcers usually on the inside of lips, cheeks or under the tongue where the mucosa is not tightly bound to underlying bone.
  • may also appear on genitals if associated with Behcet disease or HIV.
  • 40% have a FH
  • often triggered by stress, menses or mechanical trauma (eg. accidental self bite of mucosa)
  • perhaps one of the few conditions LESS prevalent in smokers!
  • 80% are of the minor recurrent type
  • higher incidence in those with coeliac disease

herpes simplex

  • primary herpetic gingivostomatitis
    • first exposure to Herpes simplex virus (HSV) may result in a widespread very painful ulcerated inflammation of oral mucosa, gums and tongue which usually lasts 10-14 days
    • often occurs in pre-school children
  • secondary recurrent HSV “cold sores”:
    • the common “cold sore”


  • Coxsackie virus A infection resulting in ulceration of the posterior pharynx - usually on the soft palate.
  • mainly children in Summer

hand, foot and mouth disease

  • Coxsackie A virus infection - mainly an infection of pre-school children; may also be caused by Enterovirus 71.
  • helpful diagnostic findings include:
    • purple blistering of medial borders of feet/great toe and hands
    • maculopapular rash over buttocks in infants

periodic fever with aphthous stomatitis, pharyngitis and adenitis (PFAPA syndrome)

  • recurrent febrile illness with aphthous stomatitis and adenitis starting in children aged 2-5yrs and becoming rare after age 10yrs
  • sporadic and familial cases are rare
  • periodicity of 3-6wks resembles cyclic neutropenia suggesting some common biologic clock mechanism
  • fevers up to 41degC for 3-6 days, then suddenly fall to normal
  • 40-70% develop aphthous ulcers
  • most have tender cervical adenopathy and pharyngitis
  • most have moderate neutrophilia and raised ESR
  • striking response to single dose of corticosteroids

hyperimmunoglobulin D syndrome (HIDS)

  • autosomal recessive periodic fever syndrome
  • episodic attacks of fever lasting 3-7 days, usually accompanied by chills, cervical lymphadenopathy, abdominal pain, and vomiting or diarrhoea
  • some experience headache, arthralgias or arthritis, aphthous ulceration, a pleomorphic rash, and, occasionally, splenomegaly
  • 2/3rds begin in 1st year of life
  • most have IgD >100 international units/mL
  • 80% have elevated IgA
  • raised ESR, CRP occur during attacks and may remain high between attacks

cyclic neutropenia

  • characterised by a 14-35 day periodic cycle of neutropenia which may cause aphthous ulcers and gingivitis during attacks

lingual zoster

  • vesicles present on only the left or the right side of the tongue with minimal crossing of the midline
  • may be associated with features of Ramsay Hunt Syndrome:
    • facial palsy, often mild
    • otalgia
    • vesicles in ear canal
    • occasionally, hearing loss

Steven's Johnson syndrome

neutropenic states


  • chronic ulcerated lesions in the elderly should raise the suspicion of carcinoma of the oropharynx, or chronic irritation from poorly fitting dentures


Behcet's disease

  • painful mouth ulcers are usually the first outward sign of Behcet disease and occur in about 70% of patients.
  • ulcers can occur anywhere in the mouth including on the tongue and inside the lips and cheeks.
  • usually last for 1-2 weeks but can remain for as long as 3 weeks.
  • onset is usually between 30 and 40 years of age
  • 1 in 10,000 from “Silk Road” ethnicities, 1 in 20,000 in Western ethnicities
  • may be associated with genital ulcers, uveitis, erythema nodosum, tonsillitis, general constitutional symptoms

oral lichen planus

  • mouth is involved in half of patients with lichen planus
  • painless white streaks or fern-like pattern on buccal mucosa
  • painful and persistent mouth ulcers (erosive lichen planus)
  • desquamative gingivitis
  • some cases are due to contact allergy to mercury amalgam dental fillings

discoid lupus erythematosis

  • usually mainly affects cheeks, nose, ears and sometimes light exposed areas (upper back, V neck, back of hands)
  • it can cause mouth and lip ulcers, and these lesions may predispose to SCC


oral candidiasis

  • white plaques rather than ulcers, but in the acute pseudomembranous form, these white patches can be peeled off to leave a raw area.

geographic tongue

angular cheilitis

  • red, painful fissuring of the angle of the mouth
  • may be due to:
    • candida - eg. dentures, diabetes, steroids, antibiotic use
    • Staph aureus
    • HSV cold sores
    • contact dermatitis from saliva due to constant dribbling or licking
    • dry chapped lips from sun/wind/cold exposure
    • poor nutrition - coeliac disease, iron deficiency, riboflavin deficiency
    • inflammatory bowel disease
    • sensitive skin - eg. atopic skin
    • retinoid use - eg. isotretoin for acne, acitretin for psoriasis
mouth_ulcers.txt · Last modified: 2022/05/07 23:07 by gary1

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