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Oral Ulceration

Oral ulceration can occur in children and young people for the following reasons:

  • Viral infections; herpetic stomatitis, Varicella Zoster (Chicken pox or Shingles), hand, foot and mouth disease, herpangina, glandular fever, HIV
  • Recurrent Aphthous (oral) Stomatitis (RAS)
  • Trauma
  • Bacterial infections; necrotising gingivitis, syphilis, TB
  • Fungal infection
  • Cutaneous disease: lichen planus, pemphigus, pemphigoid, erythema multiforme, dermatitis herpetiformis, linear IgA disease, epidermolysis bullosa.

RAS is very common in childhood and usually not associated with other conditions. It is a clinical diagnosis of exclusion and can present in three forms:

  • minor (most common, affecting the non-keratinised mucosa only)
  • major
  • herpetiform.

The ulcers can range in size (0.5 to >10mm) and duration (1-12 weeks).

Assessment

  • Ask about location/site of ulcers, size, duration, symptom free periods, exacerbating and relieving factors, bowel problems, skin/genital blisters/ulceration.
  • Dietary triggers: tomatoes, spicy food, carbonated drinks. Ask the patient to complete a diet/ulcer diary for 4 weeks
  • Physical triggers: trauma, recent viral illness, lethargy/energy levels, height and weight disruption.
  • Stress: any recent major life events, problems at school.
  • Family history: parents, carers or siblings with similar oral ulceration history.
  • Clinical photographs, if appropriate, are useful (include a sizer if available) and can be attached if an onward referral is necessary.

PLEASE SEE PRIMARY CARE MANAGEMENT FOR DETAILS OF INVESTIGATION AND TREATMENT.

C.M & P.G, H.C 22-01-24

Who to refer:

Please refer:

  • any patient that has red flags (ulcer present for more than 3 weeks duration, struggling to maintain oral intake, involuntary weight loss, faltering growth, etc.)
  • any patient where there is a strong suggestion of organic disease, or repeated attendances at practice or A&E
  • ulceration with high suspicion of traumatic aetiology (refer to patient’s dentist)
  • any ulcer that has not resolved after 3 weeks for specialist assessment (ref to Paediatric Dental Team, Lothian Oral Health Service)
  • patients who also have genital ulceration
  • patients with abnormal tests as outlined in Primary Care Management.

Who not to refer:

Patients where:

  • no red flags exist and there is shared understanding with acceptance between family and healthcare provider, primary care assessment, investigation and simple treatment may well suffice.
  • all tests are normal, and patient’s symptoms have improved with simple treatment.

How to refer:

  • health visitors/school nurses should first refer to GP/primary care team/dentist
  • for oral ulceration restricted to the oral cavity where additional tests have ruled out a systemic cause for the oral ulceration – refer to Paediatric Dental Team in the Lothian Oral Health Service.
  • for ulceration with systemic problems please refer to general paediatric services at RHCYP or St John’s Hospital.

Please refer using SCI-Gateway – including ‘Advice only’ if this is more appropriate.

When oral ulceration occurs with a fever, it is likely to be of a self-limiting, viral aetiology.

Treatment

  • Reassure, advise routine analgesia, rest and soft diet until the ulcers have resolved.

Investigations

For patients with persistent, recurrent ulceration, a FBC and haematinic screen (ferritin, B12 and folate) are suggested as first line investigations. Where these prove normal, you may want to consider the following depending on the clinical presentation:

  • C&E, LFTs, glucose
  • ESR and CRP
  • Coeliac screen (anti-tTG)
  • TFTs
  • Faecal calprotectin – only where there is a clinical suspicion of Inflammatory Bowel Disease
  • If genital ulceration is also present, please seek specialist advice: HLA typing (HLA B51) testing may avoid the patient having to undergo repeat phlebotomy.

Treat: low Fe with age appropriate supplements for three months and review.

Refer for Specialist review (Medical): low Fe combined with low folic acid, low B12, abnormal ESR/CRP tests, coeliac screen, high IgA, abnormal TFTs, high faecal calprotectin. Please see Referral Guidelines for more detail.

Treatment for symptomatic relief of RAS

  • Brush with soft brush as atraumatically as possible
  • Avoid sharp foods (crisps, toast) and other mucosal trauma
  • Use benzydamine mouthwash or spray (0.15%) for pain relief.
    • Mouthwash: gargle 15mls every 1.5 hours (over 12yrs old)
    • Spray: 4 sprays every 4 hours (6-17yrs old), 1 spray/4kg body weight (6months-5yrs old)
  • Use chlorhexidine (0.2%) mouthwash 10mls for 1 minute twice daily. Can be diluted 1:1 with no loss in efficacy
  • Beclomethasone diproprionate MDI. 1-2 puffs spray directly on ulcers twice daily (over 2yrs old)
  • Oral steroid preparations (over 12yrs old):
    • Betamethasone Soluble Tablets as a mouthwash. Two tablets in 10mls water 2/day
  • Where an allergic component is suspected, advise the use of SLS-free toothpaste and a benzoate-free diet: primary care dentists can advise on this.

British and Irish Society for Oral Medicine – patient information and PILs

Oral Health Foundation – patient information on mouth ulcers

Crighton AJ. Oral medicine in children. Br Dent J. 2017 Dec;223(9):706-712. doi: 10.1038/sj.bdj.2017.892. Epub 2017 Nov 3. PMID: 29097798.

SDCEP Drug Prescribing for Dentistry 3rd Edition 2017