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Am Fam Physician. 2022;105(4):369-376

Patient information: Handouts on this topic are available at https://familydoctor.org/symptom/mouth-problems and https://familydoctor.org/condition/canker-sores.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Familiarity with common oral conditions allows clinicians to observe and treat patients in the primary care setting or refer to a dentist, oral surgeon, otolaryngologist, or other specialist. Recurrent aphthous stomatitis (canker sores) is the most common ulcerative condition of the oral cavity. Recurrent herpes simplex labialis and stomatitis also commonly cause oral ulcers. Corticosteroids, immunocompromise, antibiotics, and dentures can predispose patients to oral candidiasis. Benign migratory glossitis (geographic tongue) occurs in up to 3% of the population but generally lacks symptoms, although some people experience food sensitivity or a burning sensation. Hairy tongue is associated with a low fiber diet, tobacco and alcohol use, and poor oral hygiene in older male patients. Generally, hairy tongue is asymptomatic except for an unattractive appearance or halitosis. Tobacco and alcohol use can cause mucosal changes resulting in leukoplakia and erythroplakia. These can represent precancerous changes and increase the risk of squamous cell carcinoma. Mandibular and maxillary tori are common bony cortical outgrowths that require no treatment in the absence of repeat trauma from chewing or interference with dentures. Oral lichen planus occurs in up to 2% of individuals and can present as lacy reticulations or oral erosions and ulcerations. Traumatic buccal mucosal fibromas and labial mucoceles from biting can be excised.

Patients with oral disease may present to their family physician before a dentist. Some lesions are purely localized to the mouth, and others have systemic manifestations; familiarity with these entities is important for providing comprehensive primary care. This article describes the etiology, presentation, and management of commonly encountered oral conditions.

Clinical recommendationEvidence ratingComments
Aphthous stomatitis may be treated with topical or, less commonly, intralesional corticosteroids.24 CGood clinical studies are lacking; Cochrane reviews indicate insufficient evidence to support any specific therapy
Oral antiviral therapies started at the onset of symptoms can modestly decrease pain and healing time in recurrent herpes labialis.1417 AConsistent findings from randomized controlled trials
Oral leukoplakia, erythroplakia, and erythroleukoplakia should be biopsied to identify oral epithelial dysplasia or malignancy.1821 CKnown rates of malignant transformation of these conditions
Symptomatic oral lichen planus can be treated with topical and systemic corticosteroids and calcineurin inhibitors.2527,29 BSystematic reviews and meta-analyses

Aphthous Stomatitis

Recurrent aphthous stomatitis, or canker sores, is the most common ulcerative condition of the oral cavity 13 (Figure 1). Prevalence in the general population has been reported at 20%, peaking between 10 and 20 years of age and decreasing after 50 years of age.14 A positive family history is found in 40% of patients suggesting a genetic predilection.2,4 The etiology is unknown.1,4

Minor aphthae comprise 75% to 85% of cases with lesions less than 1 cm in diameter that persist for seven to 14 days and heal without scarring. These present on mucosa that is not attached to a bony structure of the hard palate or gums.1,4 Major aphthae (e.g., Sutton disease) represent 5% to 10% of cases and are characterized by painful ulcers larger than 1 cm that may persist up to six weeks and often leave mucosal scarring. Major aphthae can occur at any oral site and in the oropharynx.1,2,4 Major aphthae are associated with HIV infection. The herpetiform type accounts for 5% to 10% of recurrent aphthous stomatitis; they occur in patches of up to 100 aphthae anywhere in the oral cavity, ranging in size from 0.1 to 0.3 cm. These heal within two weeks and appear similar to herpetic stomatitis.1,2

Treatment goals include reducing lesion frequency, pain, and size. Application of topical corticosteroid gels or rinses is the primary therapy; however, quality studies lack support for any specific treatment.2,4 Systemic corticosteroids or intralesional triamcinolone may be used for more severe presentations.13 Oral chlorhexidine (Peridex) rinse may decrease lesion severity and pain, but prolonged use stains the teeth.3 Patients should avoid foods that trigger ulcers. Sodium lauryl sulfate (a common ingredient in many types of toothpaste) may increase the irritation and pain from aphthous ulcers.1

Candidiasis

Approximately 30% to 60% of healthy individuals have oral Candida colonization, most commonly with C. albicans.57 Opportunistic infection can occur secondary to oral or inhaled corticosteroid use, immunocompromise, diabetes mellitus, malnourishment, antibiotics, and denture use.57 Oral candidiasis can present with white plaques that can be wiped off to reveal underlying erythematous mucosa (pseudomembranous candidiasis; Figure 2), generalized mucosal erythema (atrophic candidiasis), less commonly as hyperplastic nonwipeable plaques with a predilection for the lateral tongue and oral commissure (hyperplastic candidiasis), or depapillation and erythema of the dorsal tongue (median rhomboid glossitis).57 Patients may report oral burning, a metallic taste, or no symptoms.6

Denture stomatitis, a limited form of atrophic candidiasis, may be associated with dental prosthesis use attributed to restriction of salivary contact with its antimicrobial benefits. Removing oral appliances overnight and soaking in 0.1% sodium hypochlorite or 4% chlorhexidine (to avoid metal tarnishing) addresses appliance colonization.5 Brushing dentures with toothpaste should be avoided because this can cause surface scratching. An important differential diagnosis for hyperplastic candidiasis is leukoplakia, and if lesions do not completely resolve with antifungal therapy, then a biopsy is indicated.6,7 Accumulation of saliva in skin folds at the external corners of the mouth with Candida and Staphylococcus aureus infection can cause angular cheilitis (i.e., perleche) with pain and fissuring.57

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