How to Manage a Pediatric Patient with Oral Ulcers

Oral Ulcers

Oral ulcers are a common clinical problem in the pediatric population. Generally, an ulcer is defined as a well-circumscribed lesion with an epithelial defect covered by a fibrin clot (a pseudomembrane), giving the ulcer a yellow-white appearance.

Presentation

Population

• Any segment of the pediatric population, from infancy through adolescence
• Children of parents with recurrent oral ulcers due to genetic predisposition (i.e., recurrent aphthous stomatitis)
• Young children in group settings (e.g., daycare, shared play areas) developing oral ulcers secondary to an infectious (i.e., bacterial and/or viral) etiology due to the increased risk of oral fluid transfer in those settings

Signs

• Well-circumscribed lesions, often depressed, with an epithelial defect covered by a yellow-white pseudomembrane (Fig. 1)
• Single or multiple ulcers; may present in clusters (herpetiform)
• Intraoral/perioral location: nonkeratinized and/or keratinized oral mucosa, oropharynx, lips, perioral skin
• Variable size (most commonly measured in millimetres, but may be larger)
• General location: oral/perioral lesion(s) only or with involvement of other affected surfaces (i.e., skin, genitals, other mucous membranes)

NOTE: Click to enlarge figure.

Symptoms

• Pain severity: Can range from asymptomatic to severe discomfort
• Burning
• Irritation
• Pruritis (itching sensation)
• Systemic symptoms, such as fever, malaise, lymphadenopathy, difficulty swallowing and general irritability

Investigation

1. Ask the parent or patient (if the patient is old enough), about the history of the lesions.
   • Was the onset of oral lesions acute (e.g., over hours or days) or chronic (e.g., over weeks or months)?
   • Are there single or multiple lesions?
   • Is there a history of similar conditions (i.e., does the patient have recurring mouth ulcers)?
   • Where are the lesions located: in the oral/perioral regions only, or in the oral/perioral regions with involvement of additional surfaces?
   • Where are the oral/perioral lesions located (e.g., lips, cheeks, tongue, gingiva, palate, floor of mouth, oropharynx)?
   • Is there a history of oral/perioral trauma?
   • Are the lesions associated with systemic symptoms, such as fever, malaise, lymphadenopathy, gastrointestinal pain, nausea, vomiting, diarrhea, and/or generalized joint/muscle pain?
   • Does anyone else in the family (i.e., parents, grandparents, siblings) have a recent or chronic history of oral/perioral ulcers?
   • Did the child come into contact recently with anyone with visible oral/perioral ulcers? Did they share toys, utensils or cups with that individual?
2. Perform a clinical examination:
   • If possible, record patient’s weight and monitor weight for any significant changes during follow-up visits.
   • Review vital signs and monitor any significant abnormalities due to possible metabolic disturbances secondary to inadequate hydration and/or nutrition intake.
   • Complete a thorough head and neck exam for detection of lymphadenopathy and ulcers on exposed cutaneous and/or mucosal surfaces.
   • Complete a thorough oral/perioral examination to detect ulcers on any oral/perioral surfaces and/or oropharynx.
   • Overall, evaluate if the child looks ill.
3. Further Laboratory Testing:
   • Not usually done by general practitioners; if laboratory testing is indicated, patient should be referred to his/her family physician, pediatrician and/or oral medicine specialist.

Diagnosis

Given the nonspecific clinical presentation of many oral ulcerative conditions in the pediatric population, the clinician should consider the following differential diagnoses:

Single Ulcers

• Trauma
• Recurrent aphthous ulcer
• Deep fungal infection (rare)
• Cancer (rare)

Multiple Ulcers

Infectious Etiology

Bacterial

• Acute necrotizing ulcerative gingivitis
• Perioral impetigo

Viral

• Primary herpetic gingivostomatitis
• Recurrent herpes infections
• Herpangina
• Acute lymphonodular pharyngitis
• Hand-foot-and-mouth disease
• Varicella
• Measles

Chronic Ulcerative and Vesiculobullous Conditions

• Recurrent aphthous stomatitis
• Juvenile bullous pemphigoid
• Childhood linear IgA disease
• Hereditary epidermolysis bullosa
• Juvenile dermatitis herpetiform
• Riga–Fede disease

Associated with Systemic Conditions

• Congenital neutropenia
• Autoimmune disorders (e.g., lupus erythematosus, Crohn disease)
• Behçet syndrome
• PFAPA syndrome, a clinical disorder characterized by periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis.
• Metabolic deficiency diseases
• HIV/AIDS

Treatment

Common Initial Treatments

• Palliative treatment:
  • Monitor nutritional intake and ensure adequate hydration.
  • Manage fever with over-the-counter antipyretics (i.e., acetaminophen).
  • Consider use of antimicrobial mouthwash to prevent secondary infection of ulcers (if the patient can swish and spit).
• If you can confirm a specific diagnosis for the oral ulcers, consider treatment with appropriate medications, such as antibiotics, antiviral agents and topical corticosteroids, within your scope of expertise.
• If the patient appears to be significantly dehydrated, lethargic or demonstrates signs of failure-to-thrive, refer the patient to an acute care facility for urgent evaluation.
• The patient should be clinically re-evaluated 2 weeks after initial presentation.

Alternate Treatments

• If a systemic condition is suspected as the cause of oral ulcers, the patient should be referred to his/her primary care physician and/or pediatrician for further evaluation and management.
• Consider referring patients with organ-specific ulcers to medical subspecialists (i.e., dermatologist, gastroenterologist, otorhinolaryngologist) for evaluation and management, if necessary.

Advice

• Provide supportive advice to the patient and family.
• Encourage frequent hydration and nutritional intake.
• Monitor for resolution of oral lesions and/or systemic symptoms.
• If the patient appears to be significantly dehydrated, weak and/or demonstrates signs of failure-to-thrive, the patient should be taken to the family physician or an acute care facility for urgent evaluation.
• If the ulcers have not resolved in more than 2 weeks, refer the patient to his/her family physician, pediatrician and/or oral medicine specialist for further evaluation and management.

THE AUTHORS

	Dr. Stoopler is an associate professor of oral medicine and director, postdoctoral medicine program, department of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.
	Dr. Al Zamel is chief resident, department of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.

Correspondence to: Dr. Eric  T. Stoopler,  University of Pennsylvania School of Dental Medicine, 240 South 40^th St., Philadelphia, PA  19104, USA. Email: ets@detnal.upenn.edu

The authors have no declared financial interests.

This article has been peer reviewed.