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.

Aphthous Stomatitis

Recurrent aphthous stomatitis, or canker sores, is the most common ulcerative condition of the oral cavity ^1–3 (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.^1–4 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.^1–3 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.^5–7 Opportunistic infection can occur secondary to oral or inhaled corticosteroid use, immunocompromise, diabetes mellitus, malnourishment, antibiotics, and denture use.^5–7 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).^5–7 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.^5–7