Peer Reviewed

Photo Essay

An Atlas of Lingual Lesions, Part 3

  • Alexander K. C. Leung, MD
    Clinical Professor of Pediatrics, University of Calgary; Pediatric Consultant, Alberta Children’s Hospital, Calgary, Alberta, Canada

    Benjamin Barankin, MD
    Dermatologist, Medical Director, and Founder, Toronto Dermatology Centre, Toronto, Ontario, Canada

    Kin Fon Leong, MD
    Pediatric Dermatologist, Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur, Malaysia

    Amy Ah-Man Leung, MD
    Resident Physician, Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada

    Leung AKC, Barankin B, Leong KF, Leung AA-M. An atlas of lingual lesions, part 3. Consultant. 2019;59(7):210-213.

    EDITOR’S NOTE: This article is part 3 of a 5-part series of Photo Essays describing and differentiating conditions affecting the tongue and related structures in the oral cavity. Part 1 was published in the May 2019 issue (, and part 2 was published in the June 2019 issue ( Parts 4 and 5 will be published in upcoming issues of Consultant.


    Aphthous Stomatitis

    Aphthous stomatitis (also known as aphthous ulcers, aphthae, or canker sores) is characterized by painful solitary or multiple ulcers with well-defined erythematous margins and an ulcerated center covered by a yellowish gray fibrinous pseudomembrane.1,2 Prodromal sensations such as stinging, burning, or paresthesia may precede the appearance of the lesions.1,3,4 The lesions usually develop on the nonkeratinized oral mucosa such as the buccal and labial mucosa, the floor of the mouth, the soft palate, and the lateral and ventral surface of the tongue (Figure).1-7 They are rarely seen on the dorsum of the tongue, the hard palate, or the gingiva.5 Stretching the lesion may cause the ulcer to break down and bleed.2 Aphthous lesions are rarely documented as a single episode in the clinical history of patients; recurrence is the hallmark of the disease, hence the term recurrent aphthous stomatitis.2,8 Fever, headache, rash, and lymphadenopathy are characteristically absent.6

    Aphthous stomatitis

    Aphthous stomatitis can be classified by the clinical characteristics of the ulcers: minor, major, and herpetiform.2,8,9 Minor aphthae represent the most common variety, accounting for 80% to 85% of all aphthae.4,8 Minor aphthous ulcers are superficial in nature, small in size (<1 cm in diameter), few in number (<3), and heal without scarring within 10 days.1,10 Major aphthae (Mikulicz aphthae, Sutton aphthae, periadenitis mucosa necrotica) are deeper and larger (≥1 cm) than minor aphthae and may have irregular raised borders.3,6-10 These lesions have a predilection for the lips, soft palate, and fauces.7,11 Major aphthae often take weeks or months to heal and may heal with scar formation.6 Herpetiform aphthae are the least common variety and are characterized by multiple recurrent crops of 10 or more small ulcers of 1 to 3 mm in diameter that may coalesce into larger ulcers with an irregular contour.1,8,9 Healing time for an individual lesion is 7 to 10 days with no scar formation.12

    The prevalence of aphthous stomatitis is approximately 20% of the general population.1,6 The onset is typically during childhood, peaks during adolescence and young adulthood, and becomes less common with advancing age.6,8,13 The condition is slightly more common in females.8

    Most cases of aphthous stomatitis are idiopathic.5,7 While the exact etiology is not known, it is likely multifactorial with various precipitating factors. A genetic predisposition is present, as shown by an increased frequency of certain human leukocyte antigen (HLA) subtypes and a positive family history in some affected patients.11,12 The most common precipitating factors are emotional/physiological stress and local trauma.2,3,6 Other predisposing factors that might account for recurrent aphthous stomatitis in a minor subset of patients include allergy, food sensitivity, hormonal changes during the menstrual cycle (related to the onset of menstruation or the luteal phase of the menstrual cycle), hematinic (iron, vitamin B6, vitamin B12, folic acid) deficiencies, and drugs (eg, chemotherapeutic agents, nonsteroidal anti-inflammatory drugs, β-blockers, angiotensin-converting enzyme inhibitors).1,3,6,9,13 Medical conditions associated with recurrent aphthous stomatitis include Behçet syndrome, Crohn disease, ulcerative colitis, celiac disease, and systemic lupus erythematosus.1

    Aphthous stomatitis can cause considerable pain and may interfere with talking, eating, and swallowing.7,8 The major complication, albeit uncommon, is dehydration from poor fluid intake.

    Alleviating pain, expediting resolution of ulcers, and preventing dehydration are the goals of treatment. Predisposing factors should be eliminated if possible. Patients should avoid alcohol, carbonated beverages, and foods that are hard, acidic, spicy, or salty.13 Simple measures to maintain good oral hygiene are important for symptom relief.7 Chlorhexidine gluconate mouthwash has been used to decrease mucosal pain and to prevent secondary infection of the ulcers. Topical corticosteroids, typically in a paste or ointment vehicle, such as triamcinolone acetonide and clobetasol propionate, have a very safe profile when used for a short period and are the mainstay of treatment.5,11,14 Triamcinolone acetonide with carboxymethylcellulose paste (Kenalog in Orabase, 0.1%) is the drug of choice, since the tissue adhesive prevents it from being rapidly washed away, thereby increasing its therapeutic efficacy.15 Topical analgesics such as lidocaine, polidocanol, or benzocaine can be used for pain relief. If necessary, oral ibuprofen or acetaminophen can also be used to relieve the pain.


    1. Akintoye SO, Greenberg MS. Recurrent aphthous stomatitis. Dent Clin North Am. 2014;58(2):281-297.
    2. Hargitai IA. Painful oral lesions. Dent Clin North Am. 2018;62(4):597-609.
    3. Cui RZ, Bruce AJ, Rogers RS III. Recurrent aphthous stomatitis. Clin Dermatol. 2016;34(4):475-481.
    4. Edens MH, Khaled Y, Napeñas JJ. Intraoral pain disorders. Oral Maxillofac Surg Clin North Am. 2016;28(3):275-288.
    5. Scully C. Aphthous ulceration. N Engl J Med. 2006;355(2):165-172.
    6. Plewa MC, Chatterjee K. Aphthous stomatitis. StatPearls. Updated June 12, 2019. Accessed June 17, 2019.
    7. Leung AKC. Aphthous stomatitis. Consultant. 2011;51(11):817-819.
    8. Femiano F, Lanza A, Buonaiuto C, et al. Guidelines for diagnosis and management of aphthous stomatitis. Pediatr Infect Dis J. 2007;26(8):728-732.
    9. Edgar NR, Saleh D, Miller RA. Recurrent aphthous stomatitis: a review. J Clin Aesthet Dermatol. 2017;10(3):26-36.
    10. Bruce AJ, Rogers RS III. Acute oral ulcers. Dermatol Clin. 2003;21(1):1-15.
    11. Jurge S, Kuffer R, Scully C, Porter SR. Recurrent aphthous stomatitis. Oral Dis. 2006;12(1):1-21.
    12. Natah SS, Konttinen YT, Enattah NS, Ashammakhi N, Sharkey KA, Häyrinen-Immonen R. Recurrent aphthous ulcers today: a review of the growing knowledge. Int J Oral Maxillofac Surg. 2004;33(3):221-234.
    13. Shah K, Guarderas J, Krishnaswamy G. Aphthous stomatitis. Ann Allergy Asthma Immunol. 2016;117(4):341-343.
    14. Rodríguez M, Rubio JA, Sanchez R. Effectiveness of two oral pastes for the treatment of recurrent aphthous stomatitis. Oral Dis. 2007;13(5):490-494.
    15. Eisenberg E. Diagnosis and treatment of recurrent aphthous stomatitis. Oral Maxillofac Surg Clin North Am. 2003;15(1):111-122.

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