Clinical Evaluation & Management of Repeated Oral Ulcers in Children
Clinical History Assessment
Systematic approach to history taking for a child presenting with repeated oral ulcers
Physical Examination Guide
Systematic approach to examining a child with repeated oral ulcers
Diagnostic Approach
Initial Assessment
For a child presenting with repeated oral ulcers, the initial assessment should include:
- Detailed history focusing on frequency, duration, and pattern of ulcers
- Complete oral examination to characterize ulcers and identify other oral manifestations
- Systemic examination for associated symptoms
- Assessment of impact on nutrition and hydration
Diagnostic Criteria for Common Causes
Different diagnostic criteria for conditions causing repeated oral ulcers:
| Condition | Definition | Key Features |
|---|---|---|
| Recurrent Aphthous Stomatitis (RAS) | Recurrent, painful ulcers with no identifiable systemic disease | Minor (<1cm), major (>1cm), or herpetiform types; spontaneous healing; non-keratinized mucosa |
| Behçet's Disease | Multisystem inflammatory disorder with recurrent oral ulcers | Oral plus genital ulcers, ocular inflammation, skin lesions, other systemic features |
| PFAPA Syndrome | Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis | Regular periodicity of symptoms, complete wellness between episodes, consistent duration |
| Hand, Foot and Mouth Disease | Viral infection causing oral ulcers with skin lesions | Characteristic distribution on hands/feet, vesicular eruptions, self-limiting |
Differential Diagnosis
| Category | Conditions | Red Flags |
|---|---|---|
| Idiopathic |
- Recurrent Aphthous Stomatitis (Minor/Major/Herpetiform) - Sutton's Disease (Major Aphthous) - Cyclic Neutropenia |
- Family history of autoimmune disease - Persistent ulcers (>3 weeks) - Concomitant systemic symptoms - Growth failure |
| Infectious |
- Herpes Simplex Virus (HSV) - Coxsackie Virus (Hand, Foot and Mouth Disease) - HIV-associated ulcers - Bacterial infections (including Vincent's angina) - Mycotic infections (Candidiasis) |
- Fever - Generalized viral exanthem - Lymphadenopathy - Exposure to infectious contacts - Immunocompromised state |
| Systemic Disease |
- Inflammatory Bowel Disease (Crohn's, Ulcerative Colitis) - Celiac Disease - Behçet's Disease - PFAPA Syndrome - Sweet's Syndrome |
- Gastrointestinal symptoms - Periodic fevers - Growth failure - Ocular inflammation - Genital ulceration |
| Nutritional/Hematologic |
- Iron Deficiency - Vitamin B12 Deficiency - Folate Deficiency - Neutropenia - Leukemia |
- Pallor - Fatigue - Bruising/petechiae - Poor diet history - Failure to thrive |
| Allergic/Hypersensitivity |
- Contact Stomatitis - Food Allergen Reactions - Drug Reactions (including Stevens-Johnson Syndrome) - Erythema Multiforme |
- Recent medication changes - Accompanying skin lesions - Involvement of multiple mucosal surfaces - Rapid onset after exposure - Severe systemic symptoms |
| Other |
- Trauma (physical/chemical/thermal) - Lichen Planus - Pemphigus/Pemphigoid - Reactive Arthritis |
- Joint symptoms - Skin lesions - Dental appliances - Refractory to standard treatment - Unusual distribution of lesions |
Laboratory Studies
Consider these studies when red flags are present:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Complete Blood Count | Assess for anemia, neutropenia, leukemia | Frequent/severe ulcers, systemic symptoms, pallor |
| Iron, B12, Folate Levels | Evaluate nutritional deficiencies | Recurrent ulcers without clear cause, restricted diet |
| Erythrocyte Sedimentation Rate (ESR) / C-Reactive Protein (CRP) | Assess for inflammatory conditions | Suspected systemic disease, periodic fever syndromes |
| Viral Studies (HSV PCR/Culture) | Confirm viral etiology | Vesicular lesions, suspected primary HSV infection |
| Celiac Screening | Identify celiac disease | Refractory ulcers, gastrointestinal symptoms, failure to thrive |
Advanced Studies
Reserve for concerning presentations:
| Investigation | Clinical Utility | When to Consider |
|---|---|---|
| Autoimmune Panel (ANA, RF, HLA-B51) | Evaluate for autoimmune conditions | Suspected Behçet's disease, systemic features, family history |
| Tissue Biopsy | Histopathological diagnosis | Atypical presentation, suspected malignancy, vesiculobullous disease |
| Endoscopy/Colonoscopy | Diagnose inflammatory bowel disease | Abdominal symptoms, weight loss, rectal bleeding, family history |
| Neutrophil Function Tests | Evaluate for cyclic neutropenia | Cyclical pattern of oral ulcers with systemic symptoms |
| Allergy Testing | Identify allergic triggers | Temporal relationship with specific exposures, contact stomatitis |
Diagnostic Algorithm
A stepwise approach to diagnosing repeated oral ulcers in children:
- Characterize the ulcers (size, number, location, morphology, healing time)
- Document pattern of recurrence (frequency, duration, triggers, cyclical nature)
- Complete systemic review to identify associated symptoms
- Perform focused examination (oral cavity, skin, lymph nodes, genitalia if indicated)
- Consider initial labs (CBC, iron studies, ESR/CRP) in recurrent or severe cases
- Screen for common triggers (foods, dental products, medications)
- Trial empiric therapy if consistent with RAS and no red flags
- Advanced testing guided by specific clinical suspicions
- Regular follow-up to monitor response and evolution of symptoms
Management Strategies
General Approach to Management
Key principles in managing repeated oral ulcers in children:
- Identify and treat underlying cause: Address any systemic or local factors
- Pain management: Prioritize comfort and ability to maintain nutrition
- Prevent secondary infection: Maintain good oral hygiene
- Education: Inform about natural course and managing recurrences
- Regular follow-up: Monitor response to therapy and assess for developing systemic features
Topical Therapies
| Intervention | Description | Evidence Level |
|---|---|---|
| Topical Anesthetics |
- Benzocaine gels/sprays - Lidocaine 2% viscous solution - Diphenhydramine/lidocaine/antacid mixtures ("Magic mouthwash") |
Moderate; provides temporary symptomatic relief but no healing acceleration |
| Protective Barriers |
- Carmellose paste (Orabase) - Hyaluronic acid gel - Sucralfate suspension |
Low to moderate; physical protection improves comfort and may reduce secondary irritation |
| Antimicrobial Agents |
- Chlorhexidine mouthwash (0.1-0.2%) - Tetracycline mouthwash (not for children <8 years) - Hydrogen peroxide diluted solution (for short-term use) |
Low to moderate; may prevent secondary infection and provide mild anti-inflammatory effect |
| Topical Corticosteroids |
- Triamcinolone acetonide paste (0.1%) - Fluocinonide gel (0.05%) - Dexamethasone elixir as rinse |
High; multiple studies demonstrate reduced duration and pain, especially when applied early |
| Topical Anti-inflammatory |
- Amlexanox paste (5%) - Benzydamine hydrochloride rinse |
Moderate; studies show decreased pain and may accelerate healing |
Systemic Therapies
| Intervention | Approach | Evidence and Considerations |
|---|---|---|
| Nutritional Supplements |
- Vitamin B12 - Iron supplementation - Folic acid - Zinc |
- Moderate evidence when deficiency present - Some benefit of B12 even without deficiency - Consider trial in recurrent cases - Low risk intervention |
| Systemic Corticosteroids |
- Short course of prednisone/prednisolone - Typically 0.5-1 mg/kg/day for 5-7 days - Taper if longer course needed |
- Reserved for severe cases or underlying inflammatory disease - Moderate evidence for effectiveness - Consider side effects with repeated or prolonged use - Not for routine RAS |
| Colchicine |
- 0.5-1.2 mg/day (dose based on weight and age) - Used for prevention in recurrent severe cases |
- Moderate evidence for Behçet's disease - Limited evidence for severe recurrent aphthous stomatitis - Monitor for GI side effects - Requires specialist consultation |
| Immunomodulators |
- Thalidomide - Dapsone - Pentoxifylline - Biologics (anti-TNF agents) |
- Limited evidence in pediatric population - Reserved for severe refractory cases - Significant side effect profiles - Require specialist management |
Disease-Specific Management
| Condition | Management Approach | Follow-up Recommendations |
|---|---|---|
| Recurrent Aphthous Stomatitis |
- Topical corticosteroids as first line - Identify and avoid triggers (foods, trauma) - Nutritional supplements if deficiency present - Protective barriers for comfort |
- Review in 2-4 weeks if no improvement - Consider diary to identify patterns/triggers - Reassess if increasing frequency or severity |
| Herpes Simplex Virus |
- Antiviral therapy (acyclovir) for primary infection - Consider prophylaxis for frequent recurrences - Supportive care for pain and hydration - Avoid triggers (sun exposure, stress) |
- Acute follow-up if not improving after 5-7 days - Consider prophylaxis if >6 episodes per year - Educate about viral shedding and transmission |
| PFAPA Syndrome |
- Single dose of corticosteroid at episode onset - Consider cimetidine prophylaxis - Tonsillectomy in severe refractory cases - Supportive care during episodes |
- Regular follow-up to document pattern - Reassess diagnosis if pattern changes - Monitor growth and development - Tapering frequency expected with age |
| Behçet's Disease |
- Multidisciplinary approach - Topical therapy for mild oral ulcers - Colchicine for moderate disease - Immunosuppression for severe disease - Monitoring for systemic involvement |
- Regular multidisciplinary follow-up - Ophthalmology evaluation - Monitor for vascular, neurological, GI involvement - Long-term surveillance needed |
| Inflammatory Bowel Disease |
- Treat underlying IBD with appropriate therapy - Topical therapy for symptomatic oral ulcers - Nutritional support - Consider exclusive enteral nutrition for Crohn's |
- Follow-up with gastroenterology - Monitor nutritional status - Assess response of oral lesions to IBD therapy - Watch for other extraintestinal manifestations |
Supportive Care and Prevention
| Intervention | Approach | Evidence and Recommendations |
|---|---|---|
| Oral Hygiene |
- Soft-bristled toothbrush - SLS-free toothpaste - Gentle cleaning techniques - Regular dental check-ups |
- Reduces bacterial load and secondary infection - SLS avoidance may reduce recurrences in some patients - Maintains overall oral health - Low-strength evidence but practical benefit |
| Dietary Modifications |
- Identify and avoid trigger foods - Avoid acidic, spicy, hard, or sharp foods during active ulcers - Soft, bland diet during outbreaks - Adequate hydration |
- Individual triggers vary widely - Common triggers: citrus, tomatoes, nuts, chocolate, strawberries - Food diary helpful for identification - Practical approach with clinical benefit |
| Pain Management |
- Acetaminophen/ibuprofen for moderate pain - Topical anesthetics before meals - Cold foods/beverages may be better tolerated - Drinking through straw to bypass ulcers |
- Essential to maintain nutrition and hydration - Pragmatic approach based on clinical experience - Individualize based on child's preferences and pain level - Consider pain scale for assessment |
| Stress Reduction |
- Age-appropriate stress management techniques - Regular sleep schedule - Physical activity - Psychological support if stress is major trigger |
- Stress identified as trigger in many patients - Limited evidence but clinical observation supports benefit - Holistic approach to management - May reduce frequency of recurrences |
Patient and Family Education
- Natural history: Expected course, typical recurrence patterns, benign nature (if applicable)
- Trigger identification: Keeping diary of food, stress, trauma, and correlation with outbreaks
- Early intervention: Applying treatments at first symptom for better results
- Warning signs: When to seek medical attention (fever, spread of lesions, inability to drink)
- Prophylaxis strategies: Based on identified triggers and pattern
- School accommodations: Water bottle access, medication administration if needed
When to Refer
- Specialist referral indications: Refractory to first-line therapy, systemic features, diagnostic uncertainty
- Oral Medicine/Dental: Severe or unusual oral manifestations, need for specialized topical therapy
- Gastroenterology: Suspected IBD, celiac disease, persistent nutritional deficiencies
- Rheumatology: Features of Behçet's disease, periodic fever syndromes, systemic vasculitis
- Hematology: Cytopenias, suspected hematologic disorder
- Infectious Disease: Recurrent severe viral infections, suspected immunodeficiency
- Allergy/Immunology: Suspected immunologic etiology, severe hypersensitivity reactions
