eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Aphthous Ulcers: Follow-up

Author: Michael C Plewa, MD, Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Saint Vincent Mercy Medical Center
Contributor Information and Disclosures

Updated: May 12, 2009

Follow-up

Deterrence/Prevention

  • Dietary supplementation with vitamins, zinc,56 or iron may prevent recurrence of aphthous ulcers (canker sores) in some individuals. Studies of lysine supplementation are preliminary and equivocal.49
  • Vitamin B12 supplementation may prevent ulcer recurrence even when B12 values are normal.47,48
  • A gluten-free diet is unlikely to improve recurrent aphthous ulcers (RAUs), or canker sores,57 unless the patient has celiac disease (gluten-sensitive enteropathy), which may be present in as many as 5% of patients in whom recurrent aphthous ulcers (canker sores) are initially diagnosed.
  • Susceptible patients may benefit from avoiding toothpaste or mouthwash products containing sodium lauryl sulfate (SLS).12,13
  • Use of a low-intensity ultrasound toothbrush may decrease recurrent aphthous ulcers (canker sores) activity.58
  • Use of mouthwash or toothpaste with triclosan59 or amyloglucosidase and glucose oxidase (Zendium) may decrease recurrent aphthous ulcers (canker sores).60
  • Stress reduction may be useful, although evidence for this intervention is lacking.
  • Although numerous reasons abound for convincing a pediatric patient to quit smoking or chewing tobacco, cessation does not have a beneficial effect on recurrent aphthous ulcers (canker sores), which nicotine appears to prevent.

Complications

  • Secondary bacterial infection is rare.
  • Patients with major recurrent aphthous ulcers (canker sores) can have clinically significant oral scarring.
  • Painful lesions can cause interruption in eating and drinking, leading to dehydration and perhaps nutritional deficiencies.
  • Patients with acquired immunodeficiency syndrome (AIDS) may have ulcerations that are resistant to topical steroid therapy. However, systemic steroids must be administered only with caution because of the possibility of adverse effects, especially the development of opportunistic infections.

Prognosis

  • Herpetiform and minor recurrent aphthous ulcers (canker sores) have a self-limited course and tend to have few or no sequelae.
  • Major recurrent aphthous ulcers (canker sores) can cause scarring, dehydration, and malnutrition; however, if recognized early and treated effectively, major recurrent aphthous ulcers (canker sores) can be well controlled, with minimal sequelae.

Patient Education

  • General therapeutic measures for active ulcers include good oral hygiene, nonirritating gargles, and increased fluid intake.
  • Cool bland beverages, such as milkshakes, are well tolerated. Patients should be advised to avoid salty or spicy foods.
  • Although efficacy for recurrent aphthous ulcers (canker sores) is unproven, stress control may benefit some patients.
  • For excellent patient education resources, visit eMedicine's Teeth and Mouth Center. Also, see eMedicine's patient education article Canker Sores.

Miscellaneous

Medicolegal Pitfalls

  • Close follow-up care is important for all patients treated with oral corticosteroids, especially those with human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS), to monitor for opportunistic infections.
  • Late diagnosis of easily treatable nutritional deficiencies (eg, deficiency of hematinics) may be problematic.
  • Death from dehydration or nutritional deficiency from aphthous ulceration is rare but preventable.
  • Late diagnosis of neutrophil abnormalities (cyclic neutropenia, Sweet syndrome), Reiter syndrome, inflammatory bowel disease, gluten-sensitive enteropathy, HIV infection, or Behçet disease can be problematic.
  • Late diagnosis of squamous cell carcinoma of the mouth can be problematic but is extremely rare in pediatric patients.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors Brett J Earl, MD, and Joseph Dobson to the writing and development of this article.



More on Aphthous Ulcers

Overview: Aphthous Ulcers
Differential Diagnoses & Workup: Aphthous Ulcers
Treatment & Medication: Aphthous Ulcers
Follow-up: Aphthous Ulcers
Multimedia: Aphthous Ulcers
References
Further Reading
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References

  1. Bachtiar EW, Cornain S, Siregar B, Raharjo TW. Decreased CD4+/CD8+ ratio in major type of recurrent aphthous ulcers: comparing major to minor types of ulcers. Asian Pac J Allergy Immunol. Jun-Sep 1998;16(2-3):75-9. [Medline].

  2. Buno IJ, Huff JC, Weston WL, et al. Elevated levels of interferon gamma, tumor necrosis factor alpha, interleukins 2, 4, and 5, but not interleukin 10, are present in recurrent aphthous stomatitis. Arch Dermatol. Jul 1998;134(7):827-31. [Medline].

  3. Healy CM, Thornhill MH. Induction of adhesion molecule expression on blood vessels and keratinocytes in recurrent oral ulceration. J Oral Pathol Med. Jan 1999;28(1):5-11. [Medline].

  4. Birek C, Grandhi R, McNeill K, et al. Detection of Helicobacter pylori in oral aphthous ulcers. J Oral Pathol Med. May 1999;28(5):197-203. [Medline].

  5. Maleki Z, Sayyari AA, Alavi K, Sayyari L, Baharvand M. A study of the relationship between Helicobacter pylori and recurrent aphthous stomatitis using a urea breath test. J Contemp Dent Pract. Jan 1 2009;10(1):9-16. [Medline].

  6. Haisraeli-Shalish M, Livneh A, Katz J, et al. Recurrent aphthous stomatitis and thiamine deficiency. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Dec 1996;82(6):634-6. [Medline].

  7. Thomas KT, Feder HM Jr, Lawton AR, Edwards KM. Periodic fever syndrome in children. J Pediatr. Jul 1999;135(1):15-21. [Medline].

  8. Padeh S, Brezniak N, Zemer D, et al. Periodic fever, aphthous stomatitis, pharyngitis, and adenopathy syndrome: clinical characteristics and outcome. J Pediatr. Jul 1999;135(1):98-101. [Medline].

  9. Ghodratnama F, Wray D, Bagg J. Detection of serum antibodies against cytomegalovirus, varicella zoster virus and human herpesvirus 6 in patients with recurrent aphthous stomatitis. J Oral Pathol Med. Jan 1999;28(1):12-5. [Medline].

  10. Lin SS, Chou MY, Ho CC, et al. Study of the viral infections and cytokines associated with recurrent aphthous ulceration. Microbes Infect. Apr 2005;7(4):635-44. [Medline].

  11. Gupta SK, Gupta RC, Seth AK, et al. Epidemiological evaluation of recurrent stomatitis, nitrates in drinking water, and cytochrome b5 reductase activity. Am J Gastroenterol. Jul 1999;94(7):1808-12. [Medline].

  12. Herlofson BB, Barkvoll P. Sodium lauryl sulfate and recurrent aphthous ulcers. A preliminary study. Acta Odontol Scand. Oct 1994;52(5):257-9. [Medline].

  13. Herlofson BB, Barkvoll P. The effect of two toothpaste detergents on the frequency of recurrent aphthous ulcers. Acta Odontol Scand. Jun 1996;54(3):150-3. [Medline].

  14. Koridze Kh. Definition of risk of the aphthous stomatitis by hygienic indices [in Russian]. Georgian Med News. Apr 2005;25-8. [Medline].

  15. Ficarra G. Oral ulcers in HIV-infected patients: an update on epidemiology and diagnosis. Oral Dis. May 1997;3 Suppl 1:S183-9. [Medline].

  16. Holbrook WP, Kristmundsdottir T, Loftsson T. Aqueous hydrocortisone mouthwash solution: clinical evaluation. Acta Odontol Scand. Jun 1998;56(3):157-60. [Medline].

  17. Bell J. Amlexanox for the treatment of recurrent aphthous ulcers. Clin Drug Investig. 2005;25(9):555-66. [Medline].

  18. Binnie WH, Curro FA, Khandwala A, Van Inwegan RG. Amlexanox oral paste: a novel treatment that accelerates the healing of aphthous ulcers. Compend Contin Educ Dent. Nov 1997;18(11):1116-8, 1120-2, 1124 passim. [Medline].

  19. Greer RO Jr, Lindenmuth JE, Juarez T, Khandwala A. A double-blind study of topically applied 5% amlexanox in the treatment of aphthous ulcers. J Oral Maxillofac Surg. Mar 1993;51(3):243-8; discussion 248-9. [Medline].

  20. Khandwala A, Van Inwegen RG, Alfano MC. 5% amlexanox oral paste, a new treatment for recurrent minor aphthous ulcers: I. Clinical demonstration of acceleration of healing and resolution of pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Feb 1997;83(2):222-30. [Medline].

  21. Murray B, McGuinness N, Biagioni P, et al. A comparative study of the efficacy of Aphtheal in the management of recurrent minor aphthous ulceration. J Oral Pathol Med. Aug 2005;34(7):413-9. [Medline].

  22. Gorsky M, Epstein J, Raviv A, Yaniv R, Truelove E. Topical minocycline for managing symptoms of recurrent aphthous stomatitis. Spec Care Dentist. Jan-Feb 2008;28(1):27-31. [Medline].

  23. Skulason S, Holbrook WP, Kristmundsdottir T. Clinical assessment of the effect of a matrix metalloproteinase inhibitor on aphthous ulcers. Acta Odontol Scand. Feb 2009;67(1):25-9. [Medline].

  24. Gorsky M, Epstein J, Rabenstein S, Elishoov H, Yarom N. Topical minocycline and tetracycline rinses in treatment of recurrent aphthous stomatitis: a randomized cross-over study. Dermatol Online J. 2007;13(2):1. [Medline].

  25. Rattan J, Schneider M, Arber N, et al. Sucralfate suspension as a treatment of recurrent aphthous stomatitis. J Intern Med. Sep 1994;236(3):341-3. [Medline].

  26. Jasmin JR, Muller-Giamarchi M, Jonesco-Benaiche N. Local treatment of minor aphthous ulceration in children. ASDC J Dent Child. Jan-Feb 1993;60(1):26-8. [Medline].

  27. Kutcher M. Evaluating the efficacy of 2-octyl cyanoacrylate bioadhesive for treatment of oral ulcerations. Compend Contin Educ Dent Suppl. 2001;12-6; quiz 22. [Medline].

  28. Kutcher MJ, Ludlow JB, Samuelson AD, Campbell T, Pusek SN. Evaluation of a bioadhesive device for the management of aphthous ulcers. J Am Dent Assoc. Mar 2001;132(3):368-76. [Medline].

  29. Shemer A, Amichai B, Trau H, Nathansohn N, Mizrahi B, Domb AJ. Efficacy of a mucoadhesive patch compared with an oral solution for treatment of aphthous stomatitis. Drugs R D. 2008;9(1):29-35. [Medline].

  30. Mizrahi B, Golenser J, Wolnerman JS, Domb AJ. Adhesive tablet effective for treating canker sores in humans. J Pharm Sci. Dec 2004;93(12):2927-35. [Medline].

  31. Rhodus NL, Bereuter J. An evaluation of a chemical cautery agent and an anti-inflammatory ointment for the treatment of recurrent aphthous stomatitis: a pilot study. Quintessence Int. Dec 1998;29(12):769-73. [Medline].

  32. Porter SR, Al-Johani K, Fedele S, Moles DR. Randomised controlled trial of the efficacy of HybenX in the symptomatic treatment of recurrent aphthous stomatitis. Oral Dis. Mar 2009;15(2):155-61. [Medline].

  33. Moghadamnia AA, Motallebnejad M, Khanian M. The efficacy of the bioadhesive patches containing licorice extract in the management of recurrent aphthous stomatitis. Phytother Res. Feb 2009;23(2):246-50. [Medline].

  34. Burgess JA, van der Ven PF, Martin M, Sherman J, Haley J. Review of over-the-counter treatments for aphthous ulceration and results from use of a dissolving oral patch containing glycyrrhiza complex herbal extract. J Contemp Dent Pract. Mar 1 2008;9(3):88-98. [Medline].

  35. Martin MD, Sherman J, van der Ven P, Burgess J. A controlled trial of a dissolving oral patch concerning glycyrrhiza (licorice) herbal extract for the treatment of aphthous ulcers. Gen Dent. Mar-Apr 2008;56(2):206-10; quiz 211-2, 224. [Medline].

  36. Buchsel PC. Polyvinylpyrrolidone-sodium hyaluronate gel (Gelclair): a bioadherent oral gel for the treatment of oral mucositis and other painful oral lesions. Expert Opin Drug Metab Toxicol. Nov 2008;4(11):1449-54. [Medline].

  37. Katz J, Langevitz P, Shemer J, et al. Prevention of recurrent aphthous stomatitis with colchicine: an open trial. J Am Acad Dermatol. Sep 1994;31(3 Pt 1):459-61. [Medline].

  38. Revuz J, Guillaume JC, Janier M, et al. Crossover study of thalidomide vs placebo in severe recurrent aphthous stomatitis. Arch Dermatol. Jul 1990;126(7):923-7. [Medline].

  39. Jacobson JM, Greenspan JS, Spritzler J, et al. Thalidomide for the treatment of oral aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Diseases AIDS Clinical Trials Group. N Engl J Med. May 22 1997;336(21):1487-93. [Medline].

  40. Wu JJ, Huang DB, Pang KR, et al. Thalidomide: dermatological indications, mechanisms of action and side-effects. Br J Dermatol. Aug 2005;153(2):254-73. [Medline].

  41. Altenburg A, Zouboulis CC. Current concepts in the treatment of recurrent aphthous stomatitis. Skin Therapy Lett. Sep 2008;13(7):1-4. [Medline].

  42. O'Neill ID. Off-label use of biologicals in the management of inflammatory oral mucosal disease. J Oral Pathol Med. Nov 2008;37(10):575-81. [Medline].

  43. Tezel A, Kara C, Balkaya V, Orbak R. An Evaluation of Different Treatments for Recurrent Aphthous Stomatitis and Patient Perceptions: Nd:YAG Laser versus Medication. Photomed Laser Surg. Feb 2009;27(1):101-6. [Medline].

  44. Zand N, Ataie-Fashtami L, Djavid GE, Fateh M, Alinaghizadeh MR, Fatemi SM, et al. Relieving pain in minor aphthous stomatitis by a single session of non-thermal carbon dioxide laser irradiation. Lasers Med Sci. Apr 12 2008;[Medline].

  45. Sharon-Buller A, Sela M. CO2-laser treatment of ulcerative lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 2004;97(3):332-4. [Medline].

  46. Alidaee MR, Taheri A, Mansoori P, Ghodsi SZ. Silver nitrate cautery in aphthous stomatitis: a randomized controlled trial. Br J Dermatol. Sep 2005;153(3):521-5. [Medline].

  47. Volkov I, Rudoy I, Freud T, et al. Effectiveness of vitamin B12 in treating recurrent aphthous stomatitis: a randomized, double-blind, placebo-controlled trial. J Am Board Fam Med. Jan-Feb 2009;22(1):9-16. [Medline].

  48. Gulcan E, Toker S, Hatipoglu H, Gulcan A, Toker A. Cyanocobalamin may be beneficial in the treatment of recurrent aphthous ulcers even when vitamin B12 levels are normal. Am J Med Sci. Nov 2008;336(5):379-82. [Medline].

  49. Wright EF. Clinical effectiveness of lysine in treating recurrent aphthous ulcers and herpes labialis. Gen Dent. Jan-Feb 1994;42(1):40-2; quiz 51-2. [Medline].

  50. Kerr AR, Drexel CA, Spielman AI. The efficacy and safety of 50 mg penicillin G potassium troches for recurrent aphthous ulcers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Dec 2003;96(6):685-94. [Medline].

  51. Samet N, Laurent C, Susarla SM, Samet-Rubinsteen N. The effect of bee propolis on recurrent aphthous stomatitis: a pilot study. Clin Oral Investig. Jun 2007;11(2):143-7. [Medline].

  52. Shrivastava R, John GW. Treatment of Aphthous Stomatitis with topical Alchemilla vulgaris in glycerine. Clin Drug Investig. 2006;26(10):567-73.

  53. Thornhill MH, Baccaglini L, Theaker E, Pemberton MN. A randomized, double-blind, placebo-controlled trial of pentoxifylline for the treatment of recurrent aphthous stomatitis. Arch Dermatol. Apr 2007;143(4):463-70. [Medline].

  54. Yang TY, Jang TY. The value of local botulinum toxin A injection in the treatment of the pain of aphthous ulcer. Eur Arch Otorhinolaryngol. Mar 2009;266(3):445-8. [Medline].

  55. Collier PM, Neill SM, Copeman PW. Topical 5-aminosalicylic acid: a treatment for aphthous ulcers. Br J Dermatol. Feb 1992;126(2):185-8. [Medline].

  56. Sharquie KE, Najim RA, Al-Hayani RK, Al-Nuaimy AA, Maroof DM. The therapeutic and prophylactic role of oral zinc sulfate in management of recurrent aphthous stomatitis (ras) in comparison with dapsone. Saudi Med J. May 2008;29(5):734-8. [Medline].

  57. Hunter IP, Ferguson MM, Scully C, et al. Effects of dietary gluten elimination in patients with recurrent minor aphthous stomatitis and no detectable gluten enteropathy. Oral Surg Oral Med Oral Pathol. May 1993;75(5):595-8. [Medline].

  58. Brice SL. Clinical evaluation of the use of low-intensity ultrasound in the treatment of recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jan 1997;83(1):14-20. [Medline].

  59. Skaare AB, Herlofson BB, Barkvoll P. Mouthrinses containing triclosan reduce the incidence of recurrent aphthous ulcers (RAU). J Clin Periodontol. Aug 1996;23(8):778-81. [Medline].

  60. Fridh G, Koch G. Effect of a mouth rinse containing amyloglucosidase and glucose oxidase on recurrent aphthous ulcers in children and adolescents. Swed Dent J. 1999;23(2-3):49-57. [Medline].

  61. Field EA, Brookes V, Tyldesley WR. Recurrent aphthous ulceration in children--a review. Int J Paediatr Dent. Apr 1992;2(1):1-10. [Medline].

  62. Hodosh M, Hodosh SH, Hodosh AJ. Treatment of aphthous stomatitis with saturated potassium nitrate/dimethyl isosorbide. Quintessence Int. Feb 2004;35(2):137-41. [Medline].

  63. Mahdi AB, Coulter WA, Woolfson AD, Lamey PJ. Efficacy of bioadhesive patches in the treatment of recurrent aphthous stomatitis. J Oral Pathol Med. Sep 1996;25(8):416-9. [Medline].

  64. Rogers RS. Recurrent aphthous stomatitis: clinical characteristics and associated systemic disorders. Semin Cutan Med Surg. Dec 1997;16(4):278-83. [Medline].

  65. Saxen MA, Ambrosius WT, Rehemtula al-KF AL, et al. Sustained relief of oral aphthous ulcer pain from topical diclofenac in hyaluronan: a randomized, double-blind clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Oct 1997;84(4):356-61. [Medline].

  66. Scully C. Clinical practice. Aphthous ulceration. N Engl J Med. Jul 13 2006;355(2):165-72. [Medline].

  67. Ueta E, Osaki T, Yoneda K, et al. A clinical trial of Azelastine in recurrent aphthous ulceration, with an analysis of its actions on leukocytes. J Oral Pathol Med. Mar 1994;23(3):123-9. [Medline].

  68. Victoria JM, Correia-Silva Jde F, Pimenta FJ, et al. Serotonin transporter gene polymorphism (5-HTTLPR) in patients with recurrent aphthous stomatitis. J Oral Pathol Med. Sep 2005;34(8):494-7. [Medline].

  69. Vincent SD, Lilly GE. Clinical, historic, and therapeutic features of aphthous stomatitis. Literature review and open clinical trial employing steroids. Oral Surg Oral Med Oral Pathol. Jul 1992;74(1):79-86. [Medline].

  70. Wormser GP, Mack L, Lenox T, et al. Lack of effect of oral acyclovir on prevention of aphthous stomatitis. Otolaryngol Head Neck Surg. Jan 1988;98(1):14-7. [Medline].

  71. Ylikontiola L, Sorsa T, Hayrinen-Immonen R, Salo T. Doxymycine-cyanoacrylate treatment of recurrent aphthous ulcers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 1997;83(3):329-33. [Medline].

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Keywords

aphthous ulcers, aphthous stomatitis, canker sores, mouth sores, mouth ulcers, recurrent aphthous ulcers, RAU, recurrent aphthous stomatitis, RAS, aphthae minor, ulcerative stomatitis, Sutton disease, Sutton's disease, minor aphthous ulcers, major aphthous ulcers, herpetiform ulcers, Helicobacter pylori, malabsorption, celiac disease, regional enteropathy, myalgia, arthralgia, inflammatory bowel disease, gluten-sensitive enteropathy, Behçet disease, systemic lupus erythematosus, HIV, AIDS, Crohn disease, cyclic neutropenia, mouth and genital ulcers with inflamed cartilage, MAGIC syndrome, treatment, diagnosis

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Contributor Information and Disclosures

Author

Michael C Plewa, MD, Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Saint Vincent Mercy Medical Center
Michael C Plewa, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Halim Hennes, MD, MS, Pediatric Emergency Medicine Research Director, Professor, Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin
Halim Hennes, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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