{"id":17968,"date":"2024-01-22T14:02:22","date_gmt":"2024-01-22T14:02:22","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=17968"},"modified":"2024-08-30T15:36:58","modified_gmt":"2024-08-30T14:36:58","slug":"oral-ulceration-paediatric","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/paediatrics\/paediatricdentistry\/paediatric-oral-medicine\/oral-ulceration-paediatric\/","title":{"rendered":"Oral Ulceration"},"content":{"rendered":"\n<p class=\"wp-block-paragraph\">Oral ulceration can occur in children and young people for the following reasons:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Viral infections; herpetic stomatitis, Varicella Zoster (Chicken pox or Shingles), hand, foot and mouth disease, herpangina, glandular fever, HIV<\/li>\n\n\n\n<li>Recurrent Aphthous (oral) Stomatitis (RAS)<\/li>\n\n\n\n<li>Trauma<\/li>\n\n\n\n<li>Bacterial infections; necrotising gingivitis, syphilis, TB<\/li>\n\n\n\n<li>Fungal infection<\/li>\n\n\n\n<li>Cutaneous disease: lichen planus, pemphigus, pemphigoid, erythema multiforme, dermatitis herpetiformis, linear IgA disease, epidermolysis bullosa.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-081c988af941b0e7bc835ee724560c77 wp-block-paragraph\"><strong>Recurrent Aphthous Stomatitis (RAS)<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>minor (most common, affecting the non-keratinised mucosa only)<\/li>\n\n\n\n<li>major<\/li>\n\n\n\n<li>herpetiform.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">The ulcers can range in size (0.5 to &gt;10mm) and duration (1-12 weeks).<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Assessment<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Ask about location\/site of ulcers, size, duration, symptom free periods, exacerbating and relieving factors, bowel problems, skin\/genital blisters\/ulceration.<\/li>\n\n\n\n<li>Dietary triggers: tomatoes, spicy food, carbonated drinks. Ask the patient to complete a diet\/ulcer diary for 4 weeks<\/li>\n\n\n\n<li>Physical triggers: trauma, recent viral illness, lethargy\/energy levels, height and weight disruption.<\/li>\n\n\n\n<li>Stress: any recent major life events, problems at school.<\/li>\n\n\n\n<li>Family history: parents, carers or siblings with similar oral ulceration history.<\/li>\n\n\n\n<li>Clinical photographs, if appropriate, are useful (include a sizer if available) and can be attached if an onward referral is necessary.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">PLEASE SEE PRIMARY CARE MANAGEMENT FOR DETAILS OF INVESTIGATION AND TREATMENT.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.M &amp; P.G, H.C 22-01-24<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\"><strong>Who to refer:<\/strong><\/h4>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Please refer:<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>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.)<\/li>\n\n\n\n<li>any patient where there is a strong suggestion of organic disease, or repeated attendances at practice or A&amp;E<\/li>\n\n\n\n<li>ulceration with high suspicion of traumatic aetiology (refer to patient\u2019s dentist)<\/li>\n\n\n\n<li>any ulcer that has not resolved after 3 weeks for specialist assessment (ref to Paediatric Dental Team, Lothian Oral Health Service)<\/li>\n\n\n\n<li>patients who also have genital ulceration<\/li>\n\n\n\n<li>patients with abnormal tests as outlined in Primary Care Management.<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>Who not to refer:<\/strong><\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">Patients where:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>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.<\/li>\n\n\n\n<li>all tests are normal, and patient\u2019s symptoms have improved with simple treatment.<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\"><strong>How to refer:<\/strong><\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>health visitors\/school nurses should first refer to GP\/primary care team\/dentist<\/li>\n\n\n\n<li>for oral ulceration restricted to the oral cavity where additional tests have ruled out a systemic cause for the oral ulceration &#8211; refer to Paediatric Dental Team in the Lothian Oral Health Service.<\/li>\n\n\n\n<li>for ulceration with systemic problems please refer to general paediatric services at RHCYP or St John\u2019s Hospital.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\">Please refer using SCI-Gateway &#8211; including \u2018Advice only&#8217; if this is more appropriate.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-a70160016bd6a24851e3c161cac75fef wp-block-paragraph\"><strong>Viral Infections<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">When oral ulceration occurs with a fever, it is likely to be of a self-limiting, viral aetiology.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Treatment<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Reassure, advise routine analgesia, rest and soft diet until the ulcers have resolved.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-alert-red-color has-text-color has-link-color wp-elements-40b1d9a331a5394606eb4e55c4a16878 wp-block-paragraph\"><strong>Recurrent Aphthous Stomatitis<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Investigations<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>C&amp;E, LFTs, glucose<\/li>\n\n\n\n<li>ESR and CRP<\/li>\n\n\n\n<li>Coeliac screen (anti-tTG)<\/li>\n\n\n\n<li>TFTs<\/li>\n\n\n\n<li><a href=\"https:\/\/apps.nhslothian.scot\/files\/sites\/2\/calprotectin-in-children-NHSL-Sept-2018.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">Faecal calprotectin<\/a> \u2013 only where there is a clinical suspicion of Inflammatory Bowel Disease<\/li>\n\n\n\n<li>If genital ulceration is also present, please seek specialist advice: HLA typing (HLA B51) testing may avoid the patient having to undergo repeat phlebotomy.<\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Treat:<\/strong> low Fe with age appropriate supplements for three months and review.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Refer for Specialist review (Medical):<\/strong> 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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Treatment for symptomatic relief of RAS<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Brush with soft brush as atraumatically as possible<\/li>\n\n\n\n<li>Avoid sharp foods (crisps, toast) and other mucosal trauma<\/li>\n\n\n\n<li>Use benzydamine mouthwash or spray (0.15%) for pain relief.<ul><li>Mouthwash: gargle 15mls every 1.5 hours (over 12yrs old)<\/li><\/ul>\n<ul class=\"wp-block-list\">\n<li>Spray: 4 sprays every 4 hours (6-17yrs old), 1 spray\/4kg body weight (6months-5yrs old)<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>Use chlorhexidine (0.2%) mouthwash 10mls for 1 minute twice daily. Can be diluted 1:1 with no loss in efficacy<\/li>\n\n\n\n<li>Beclomethasone diproprionate MDI. 1-2 puffs spray directly on ulcers twice daily (over 2yrs old)<\/li>\n\n\n\n<li>Oral steroid preparations (over 12yrs old):\n<ul class=\"wp-block-list\">\n<li>Betamethasone Soluble Tablets as a mouthwash. Two tablets in 10mls water 2\/day<\/li>\n<\/ul>\n<\/li>\n\n\n\n<li>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.<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/bisom.org.uk\/clinical-care\/patient-information\/\" target=\"_blank\" rel=\"noreferrer noopener\">British and Irish Society for Oral Medicine \u2013 patient information and PILs<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><a href=\"https:\/\/www.dentalhealth.org\/mouth-ulcers\" target=\"_blank\" rel=\"noreferrer noopener\">Oral Health Foundation \u2013 patient information on mouth ulcers<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">SDCEP Drug Prescribing for Dentistry 3<sup>rd<\/sup> Edition 2017<\/p>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Oral ulceration can occur in children and young people for the following reasons: Recurrent Aphthous Stomatitis (RAS) 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: The ulcers can range in size (0.5 to &gt;10mm) and duration (1-12<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":17948,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[1072],"class_list":["post-17968","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-oral-ulceration-paediatric"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/paediatric\/paediatric-gastrointestinal\/https-apps-nhslothian-scot-refhelp-paediatric-oral-medicine\/https-apps-nhslothian-scot-refhelp-oral-ulceration-paediatric\/\" rel=\"tag\">Oral Ulceration (Paediatric)<\/a>","rttpg_excerpt":"Oral ulceration can occur in children and young people for the following reasons: Recurrent Aphthous Stomatitis (RAS) 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: The ulcers can range in size (0.5 to &gt;10mm) and duration (1-12","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/17968","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=17968"}],"version-history":[{"count":4,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/17968\/revisions"}],"predecessor-version":[{"id":17997,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/17968\/revisions\/17997"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/17948"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=17968"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=17968"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}