Case #6

June 1, 1997
A 26-year-old male visited a general dentist for evaluation of multiple, tiny oral ulcerations scattered throughout the oral cavity.

A 26-year-old male visited a general dentist for evaluation of multiple, tiny oral ulcerations scattered throughout the oral cavity.

Joen Iannucci Haring, DDS, MS


The patient stated that the oral lesions first appeared several days earlier. He reported that, since the onset, the ulcers had increased in number. The patient described the ulcerations as "very painful."

When questioned about signs and symptoms, he denied any previous episodes as well as the presence of skin lesions, fever, or malaise. A review of the patient`s medical history revealed no significant findings. The patient was not taking any medications at the time of the dental examination.


Examination of the head and neck areas revealed several palpable, enlarged, and tender lymph nodes in the submandibular region. The patient`s vital signs were all found to be within normal limits. No skin lesions were detected in the head and neck areas.

The oral examination revealed multiple tiny ulcerations scattered throughout the oral cavity, the majority of which were located on movable tissues (see photo).

Clinical diagnosis

Based on the clinical information provided, which of the following is the most likely diagnosis?

* herpetiform aphthous ulcers

* herpangina

* primary herpes

* hand, foot, and mouth disease

* Fifth`s disease


__ herpetiform aphthous ulcers


Herpetiform aphthous ulcers are a recognized clinical form of recurrent aphthous ulcerations (RAU). The three forms of RAU are minor (RDH, February 1989), major (RDH, August 1991) and herpetiform. Of the three forms, herpetiform aphthous ulcers are the least common.

In contrast, minor RAU are very common. Approximately 40 percent of the United States population and 15 to 20 percent of the world population have RAU. Aphthous ulcers are often referred to as "canker sores" (canker meaning ulceration).

All three forms of RAU (minor, major, and herpetiform) share the same etiology. A variety of etiologic factors have been suggested, including the following: immunodysregulation, bacterial infection, nutritional deficiencies, hormonal imbalances, stress, trauma, and allergies.

At this time, no one unifying theory of pathogenesis exists other than the fact that lesions appear to be related to the immune system. Although an immunologic basis appears to be the primary cause of RAU, secondary causes, such as a decrease in the mucosal barrier or an increase in antigenic exposure, may also be involved.

Clinical features

Herpetiform RAU appear as multiple tiny (1-2mm) oral ulcerations. Hundreds of lesions may occur at once. These lesions may coalesce to form larger, irregular-shaped ulcerations. Herpetiform RAU occur with equal frequency in both men and women and can be seen at any age.

Herpetiform aphthous ulcers often are misdiagnosed. As the name "herpetiform" suggests, this form of RAU resembles acute herpetic gingivostomatitis (a.k.a. primary herpes).

Because of the widespread tissue involvement, the pain associated with herpetiform RAU may be considerable. Movable mucosa is predominantly affected, although the palate and gingiva may occasionally be involved. Healing occurs in seven to 14 days.

The frequency of recurrent episodes varies from patient to patient. Of the three forms of RAU, herpetiform aphthous ulcers recur most frequently.


The diagnosis of herpetiform RAU is established on a clinical basis. No special tests or laboratory studies are required. Herpetiform RAU can be differentiated from primary herpes on the basis of symptoms, history, and the presence of vesicles.

- Symptoms: Primary herpes is characterized by the presence of fever, malaise, and lymphadenopathy. No fever and malaise occur with herpetiform RAU; lymphadenopathy, however may be present.

- History: Primary herpes, by definition, occurs one time only. Herpetiform RAU can occur repeatedly as the term recurrent suggests.

- Vesicles: The lesions of primary herpes initially appear as multiple tiny vesicles. Herpetiform RAU do not have a vesicular component.


The treatment for herpetiform RAU is variable. In mild cases, palliative rinses may be recommended to alleviate pain and discomfort. In severe cases, topical corticosteroid rinses may be prescribed. Examples of topical corticosteroid rinses include the following:

* Rx: Dexamethasone (Decadron) elixir 0.5mg/5ml

- Disp: 100 ml

- Sig: Rinse with 1 tsp. for 2 minutes qid and expectorate. Discontinue when lesions become asymptomatic.

* Rx: Betamethasone (Celestone) syrup 0.6mg/5ml

- Disp: 300 ml

- Sig: Rinse with 2 tsp. for 2 minutes qid and expectorate. Discontinue when lesions become asymptomatic.

It is important to note that oral candidiasis may result from topical corticosteroid therapy. Consequently, patients with herpetiform RAU using topical corticosteroid medications must be monitored for the emergence of candidiasis.

Herpetiform RAU and the dental patient

Herpetiform aphthous ulcers are not contagious and cannot be spread to other areas of the mouth or to other individuals. As with all oral lesions, herpetiform aphthous ulcers should be carefully explained to the patient, and reassurance should be offered.

Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.