Oral Medicine & Pathology

Aphthae ( Recurrent Aphthous Stomatitis ): Clinical Features, Incidence, Etiology, Diagnosis, Management



(Recurrent aphthous stomatitis – RAS)


Clinical features

– Recurrent ulcers.

– There are three distinct clinical patterns:



1. Minor


2. Major


3. Herpetiform ulcers

– Small ulcers (<4 mm) on mobile mucosa (mostly labial and buccal mucosae).

– Less than five ulcers at one time.

– Healing within 14 days.

– Erythematous borders.

– No vesicle formation.

– No scarring.

– large ulcers (may be >1 cm).

– any site including dorsum of tongue and hard palate.

– Healing within 1-3 months.

– With scarring.

– Extreme pain and lymph node enlargement are common.

– Multiple (10-100).

– Minute (1-2 mm) ulcers that coalesce to produce   ragged ulcers.

– Any part of the oral mcosa, more frequently tip of the tongue, labial mcosa, margins of the tongue.


– About 25% of population, mostly non-smokers.


– Unclear.

– No reliable evidence of autoimmune disease or any classical immunological reactions.

– May be cell-mediated immune responses with cross-reactivity between Streptococcus sanguis, heat shock protein and oral mucosal tissue.

Underlying predisposing factors seen in a minority include:

Haematinic deficiency (iron, folate or vitamin B12) in 10-20%.

– Relationship with luteal phase of menstruation (rarely).

– Stress.

– Food allergies.

HIV disease (major aphthae).

– Some drugs.

Onset is usually in childhood or adolescence.

Later onset may signify haematinic deficiency or HIV disease.


Diagnosed from history and clinical features.

– A blood picture is useful to exclude deficiencies.

There is no diagnostic test of value.

Differentiate from other causes of mouth ulcers, especially Behçet’s syndrome.


Treat any underlying predisposing factors.

– Treat aphthae with chlorhexidine 0.2% aqueous mouthwash or topical corticosteroids (hydrocortisone hemisuccinate 2.5 mg pellets or 0.1% triamcinolone acetonide in orabase) or tetracycline rinses.

– Rarely, more potent topical steroids or other agents such as thalidomide may be needed.Minor aphthaeMinor Aphthae of the tongueMajor Aphthae of the buccal mucosa.Herpetiform Aphthae of the palate.