Approach Considerations

In 2013, Tappuni et al introduced the Ulcer Severity Score (USS) because of the lack of standardized assessment methods for aphthous stomatitis.^[79]The USS incorporates six ulcer characteristics: number, size, duration, ulcer-free period, site, and pain. This scoring template may be of value to future studies assessing treatment efficacy, although at present it is not widely used. Challacombe et al suggest using the USS in combination with the Oral Health Related Quality of Life (OHR-QoL) score in order to better estimate the impact of clinically significant aphthous stomatitis on patients.^[80]

Laboratory Studies

The following laboratory studies may be helpful:

Complete blood cell count; to rule out cyclic neutropenia, 5 consecutive weekly evaluations should be obtained
Measurement of erythrocyte sedimentation rate^[81]
HIV status
Determination of iron, ferritin, total iron-binding capacity, folate, homocysteine, and vitamin B-6, B-12, B-1, and B-2 levels^{[16, 42, 82]}
Serum antiendomysium antibody and transglutaminase assay (positive in celiac disease).
Tzanck smears and viral cultures: These may be necessary to exclude herpes simplex virus infection if the patient is severely immunocompromised, such as with advanced HIV disease.

Other Tests

The following procedures may be indicated if other disease is suspected:

Colonoscopy
Biopsy with hematoxylin and eosin stain and cultures
Skin pathergy test
Evaluation for uveitis
Laboratory studies for antinuclear antibody
Patch or sensitivity testing

Histologic Findings

Nonspecific ulcers with chronic mixed inflammatory cells are observed. The pseudomembrane covering of aphthae is a combination of oral bacteria and fungi, as well as necrotic keratinocytes and sloughed oral mucosa.

Treatment & Management

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Media Gallery

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

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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 Women's Association

Disclosure: Nothing to disclose.

Coauthor(s)

Heather C Rosengard, MPH Johns Hopkins University School of Medicine

Disclosure: Nothing to disclose.

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.

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: Received income in an amount equal to or greater than $250 from: Elsevier; WebMD<br/>Served as a speaker for various universities, dermatology societies, and dermatology departments.

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

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.

Aphthous Stomatitis Workup

Approach Considerations

Laboratory Studies

Other Tests

Histologic Findings

References

Tables

Contributor Information and Disclosures

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