OralMedicine

Jodie A Montgomery-Cranny
Ann Wallace, Helen J Rogers, Sophie C Hughes, Anne M Hegarty and Halla Zaitoun

Management of Recurrent
Aphthous Stomatitis in Children
Abstract: Recurrent oral ulceration is common and may present in childhood. Causes of recurrent oral ulceration are numerous and there
may be an association with underlying systemic disease. Recurrent aphthous stomatitis (RAS) is the most common underlying diagnosis in
children. The discomfort of oral ulcers can impact negatively on quality of life of a child, interfering with eating, speaking and may result in
missed school days. The role of the general dental practitioner is to identify patients who can be treated with simple measures in primary
dental care and those who require assessment and treatment in secondary care. Management may include topical agents for symptomatic
relief, topical corticosteroids and, in severe recalcitrant cases, systemic agents may be necessary.
CPD/Clinical Relevance: Children and young people frequently suffer from recurrent oral ulceration; with recurrent aphthous stomatitis
being the most common diagnosis.
Dental Update 2015; 42: 564–572

In simple terms, an ulcer is a full thickness
breach of the epithelium. There are
numerous causes of oral ulceration in
both adults and children, with recurrent
aphthous stomatitis (RAS) being the most
common cause; it is reported to affect up
to 40% of children.1 The degree of pain
and psychological distress caused by
Jodie A Montgomery-Cranny,
BDS(Hons), BSc(Hons), MBCHB(Hons),
Specialty Registrar in Oral Medicine,
Ann Wallace, BDS, MFDS RCS(Edin),
Specialty Registrar in Paediatric Dentistry,
Helen J Rogers, BDS, MFDS RCS(Edin),
DipConSed, Academic Clinical Fellow in
Paediatric Dentistry, Sophie C Hughes,
BDS, MFDS RCS(Edin), Dental Core
Trainee in Paediatric Dentistry, Anne M
Hegarty, MSc(OM), MBBS, MFD RCSI,
FDS(OM) RCS, Consultant and Honorary
Senior Clinical Lecturer, Oral Medicine
Unit and Halla Zaitoun, BDS(Hons)
MFDS, MPaedDent, MDentSci, FDS(Paed
Dent), Consultant in Paediatric Dentistry,
Charles Clifford Dental Hospital, Sheffield,
S10 2SZ, UK.
564 DentalUpdate July/August 2015
ulcers is variable and management should
encompass acknowledgement of their
impact on quality of life.2
RAS represents a genetic
predisposition to oral ulceration.
Inheritance is thought to be polygenic
with no specific genes or HLA types yet
identified.3 Identifying those for whom the
possibility of undiagnosed systemic disease
needs to be investigated and those who
do not respond to simple management
strategies is of crucial importance to
reduce patient morbidity and maintain
high standards of care.3
Diagnosis
A diagnosis of recurrent
aphthous stomatitis (RAS) is usually
reached following a thorough clinical
history (Table 1), together with the physical
appearance of the ulcer, if present at the
time of examination.4,5 Predisposing factors
in children and young people include
trauma, stress, hormonal imbalance3 and
certain foods and history-taking should
assess these factors (Table 1). A family
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history of RAS is often evident. Typically,
aphthous ulcers are round or ovoid in
shape with a grey or yellow base and have
a varying degree of perilesional erythema.3
There are three distinct patterns of RAS
(Table 2):3
 Minor (Figures 1 and 2);
 Major (Figures 3 and 4); and
 Herpetiform (Figures 5 and 6).
Aetiology of recurrent oral
ulceration in children
The various causes of oral
ulceration in children are summarized in
Table 3.6
Most common
Recurrent aphthous stomatitis
is the most common and is a diagnosis of
exclusion.3 Haematinic deficiencies, such
as low vitamin B12, folate or ferritin and
anaemia have been linked with worsening
of aphthous ulceration.7,8 Traumatic ulcers
are also common in children, may be
recurrent and often present similarly to
aphthous ulcers (Figure 7).9

Figure 1. Minor aphthous ulcer, left lateral border
of the tongue.
Figure 2. Minor aphthous ulcers, left upper labial
mucosa.
Figure 3. Major aphthous ulcer, left lateral border
of the tongue.
Systemic conditions
Coeliac disease and
inflammatory bowel disease, ie Crohn’s
disease and ulcerative colitis may be
associated with aphthous-like ulcers10
and may present with various nutritional
deficiencies secondary to malabsorption.11
Similar ulcers may be seen in orofacial
granulomatosis, a granulomatous
inflammation of the orofacial tissues,
sometimes triggered by dietary exposure
to cinnamon and benzoates.12 Behçet’s
disease, cyclic neutropenia and rare
syndromes, such as MAGIC (mouth and
genital ulcers with inflamed cartilage) and
PFAPA (periodic fever, aphthous stomatitis,
July/August 2015 DentalUpdate 565
Figure 4. Major aphthous ulcer, right anterior
pillar of the fauces.
Figure 5. Herpetiform aphthous ulceration
affecting lower labial mucosa and attached
gingivae.
Figure 6. Herpetiform aphthous ulceration
affecting the ventral surface of the tongue.
pharyngitis and cervical adenitis) are also
characterized by recurrent aphthous ulcers.1
Infections
Common childhood viral
illnesses (Table 3) can present as a single
episode of multiple oral ulcers.9 These
are self-limiting illnesses, expected to be
managed in primary care without a need
to refer for specialist opinion. Recovery is
normally within 7−10 days.13,14
Mucocutaneous disease
Mucocutaneous conditions
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OralMedicine
Figure 7. Traumatic ulceration left lateral border
of tongue related to sharp lower incisal edges.
(Table 3), such as mucous membrane or
bullous pemphigoid, pemphigus vulgaris,
linear IgA disease and erythema multiforme,
generally require referral to secondary or
tertiary care, with occasional inpatient
management required.4,15,16
Investigations
Each case should be judged
individually and investigations carefully
selected to confirm or refute the diagnosis
as appropriate. Undertaking full blood
count and haematinics is standard practice
when assessing patients with suspected
RAS and these can be arranged in primary
care by the patient’s general medical
practitioner. Other investigations, such as
serology for Coeliac disease or inflammatory
markers (Table 4) are best arranged
following referral to secondary or tertiary
care.
Management
Management of RAS can be
difficult and, as yet, there are no consensus
guidelines on the best therapy option, as
highlighted in a recent Cochrane review
of systemic agents in RAS.17 There are a
number of possible pharmacological agents
which can be utilized in the treatment of
RAS.18 Presently, there is no evidence to
support the efficacy of one single agent
over others. Successful management will
usually employ more than one strategy at a
time, individualized to each patient’s needs.
The aims of treatment are to:
 Reduce symptoms;
 Reduce secondary infection;
 Increase ulcer-free periods;
 Reduce the number and size of ulcers.4
 OralMedicine

trauma or parafunctional habits which

Number How many ulcers do you get at any one time?
may contribute to ulcer experience
should be addressed, if necessary, by
Size How big do they get? eg pin head, grain of rice, 5 pence piece making a soft splint, polishing sharp
teeth, coating orthodontic appliances
Site Where in the oral mucosae do they effect? with wax or counselling regarding tongue
thrusting and bruxism.9 Exacerbation
of ulcers is often noted by patients
Frequency How often do you get the ulcers? secondary to stress, such as school
examinations, exposure to certain food
Duration How long does each ulcer last for? substances, toothpaste additives and
menstruation.1,18,19,20
Treatment options vary (Figure
Ulcer-free period How long between ulcer episodes?
8), from the use of 'Over The Counter'
preparations to topical and/or systemic
Any extra-oral Do you get ulcers elsewhere on the body? eg genitalia, eyes, skin prescribed therapies. In primary dental
ulcers? care, the prescription of several topical
therapies is appropriate and may include
Pain Are the ulcers painful − do they effect eating, talking, etc?
antimicrobial mouthrinses, such as 0.2%
chlorhexidine gluconate (Corsodyl®
Habits Do you clench or grind your teeth? Are you aware of tongue GlaxoSmithKline, Brentford, Middlesex),
thrusting? which will help with plaque control and
reducing superinfection.11,21 Other useful
agents include protective pastes, such as
Any associations Are the ulcers associated with any particular foodstuffs? Any
relation to the menstrual cycle in females? Any stresses such as Orabase (active ingredient carmellose),
links with onset of ulcers during school examination periods? Gengigel (active ingredient hyaluronate),
Gelclair (active ingredient hyaluronate)
and topical analgesics including 0.15%
Effect on life/ How do the ulcers affect you? What is their effect on eating and benzydamine hydrochloride (Difflam)
schooling drinking? How much school has been missed due to oral ulcers? or a 5% lidocaine spray or mouthwash
useful prior to eating or toothbrushing.11,22
Advising patients to use sodium lauryl
Family history Do you have any first degree relatives with oral ulceration? Any sulphate-free toothpastes may be
inflammatory bowel disease (Crohn’s disease or ulcerative colitis) beneficial in reducing the number of
or any Coeliac disease in your family? Any other significant ulcers.20
illnesses?
Those patients with RAS
severely impacting on quality of life,
Medical history and Enquire about any related systemic systems, especially focusing not responding to topical analgesics
review of systems on any gastro-intestinal signs, eg abdominal pain, weight loss, or antiseptics, or where there is a
blood or mucus in the stools, altered bowel habit, nocturnal suspicion of an underlying systemic
defecation. disease, should be referred to a
specialist clinic or to Departments of
Oral Medicine or Paediatric Dentistry.
Medication history Enquire about prescribed medication, especially anything tried
Regular and supervised use of topical
so far to treat the oral ulceration and anything bought 'Over The
corticosteroid may be introduced to
Counter' (OTC) or abroad as ‘ulcer remedies’. Check compliance
reduce inflammation, promote healing
and correct usage technique to any medication tried so far.
and reduce the frequency of new
ulcerations. Betamethasone sodium
Table 1. Questions to ask a patient presenting with recurrent oral ulceration. phosphate (Betnesol) 500 microgram
tablets may be dissolved in water as
a mouthwash.9 Another useful topical
corticosteroid used is fluticasone
Management of RAS in children the child to participate in his/her own propionate (Flixonase), which is available
should begin with education to explain management.2 as a spray (50 microgram per actuation).6
the natural history of the disease and the Certain factors can aggravate It is important that the child is mature
scope of management.1−5 An ulcer diary can RAS, therefore identifying these may help enough to use a mouthrinse correctly to
be helpful for the clinician and also allows prevent further ulceration. Sources of avoid swallowing the solution (usually
566 DentalUpdate July/August 2015
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 OralMedicine

Minor Major Herpetiform

Male to female ratio M=F M=F F>M

Age at onset (years) 5−19 10−19 20−29

Number of ulcers 1−5 1−10 10−100

Size of ulcers (mm) <10 >10 1−2 (although may coalesce to larger lesions)

Duration (days) 4−14 >30 <30

Rate of recurrence 1−4 months but may be wide <Monthly but may be wide >Monthly but may be wide individual
individual variation individual variation variation

Site Lips, cheeks, tongue, floor of Lips, cheeks, tongue, palate, Lips, cheeks, tongue, pharynx, palate,
mouth pharynx gingivae, floor of mouth

Scarring Uncommon Common Uncommon

Children affected 75−85% 10−15% 5−10%

Table 2. Characteristics and presentation of recurrent aphthous stomatitis. Adapted from Porter, Scully and Pedersen, 1998.3

then a spray can be useful. When there are

Figure 8. Flow chart to guide selection of treatment of RAS in children.
suitable for children aged 8 and above).
Patients should be advised to commence
topical therapy as soon as an ulcer appears
or as soon as they start to feel an ulcer
July/August 2015 DentalUpdate 569
developing. The method of application
of these topical agents depends on the
number and site of the ulcers. If the
patient only suffers 1 or 2 ulcers at a time,
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multiple ulcers at different sites, then a
mouthwash is preferred. Doxycycline has
been shown to decrease healing time.23
The usual preparation is to dissolve a 100
mg tablet in 10 ml of water, hold in the
mouth for 3 minutes up to 4 times a day.23
It is important that only children over 12
are prescribed this owing to the adverse
effects of tetracycline in the developing
dentition.17,23
For severe RAS, that does
not respond to topical measures alone,
systemic immunosuppressants may
be required. A short course of oral
prednisolone may be required to gain
control of the flare13 and resume normal
oral intake.11 Systemic corticosteroids are
not a long-term solution and the potential
for stunting growth and development
in a child, along with the other well-
established risks, means that their use
is rationalized to only when absolutely
necessary.11
Steroid-sparing agents,
such as Thalidomide,23 Azathioprine,24,25
or Colchicine26 may be used in severe
recalcitrant cases (Figure 8). Thalidomide
can be very effective and fast-acting
in treating RAS. However, careful pre-
treatment counselling concerning its
well-established risks of teratogenicity
and possible irreversible peripheral
 OralMedicine
Infection
Immune-mediated disorders
Vesiculobullous disorders
Immunodeficiency
Trauma
Vitamin deficiencies
Neoplastic/Haematological
Recurrent aphthous stomatitis
Table 3. Common causes of oral ulceration. Adapted from Hullah and Hegarty, 2014.6
neuropathy must be discussed with the
parents.1,27−30
Quality of life impacts
Episodes of oral ulceration
in children have been shown to have a
significant impact on various activities in
570 DentalUpdate July/August 2015
Aetiology Associated Features Relevant Investigations
Viruses: Hand foot and mouth, Systemic features such as Full blood count
Coxsackie virus, Herpes simplex, fever, lethargy, weight loss, Swab +/- biopsy
Herpes zoster, Cytomegalovirus, prodrome Viral serology if indicated
Epstein Barr, HIV
Bacteria: Tuberculosis, Syphilis
Crohn’s disease, Behçet’s disease, Systemic features such Erythrocyte Sedimentation
Systemic lupus erythematosus, as weight loss, bleeding, Rate (ESR)
Coeliac disease, Periodic fever lethargy, cycles of fever, C-Reactive Protein (CRP)
syndromes diarrhoea, myalgia,
arthralgia
Bullous pemphigoid, mucous Systemic features such as Biopsy for H&E
membrane pemphigoid, pemphigus malaise, anorexia, weight Direct immunofluorescence
vulgaris, linear IgA disease, erythema loss; involvement of skin, Indirect immunofluorescence
multiforme eyes or genitalia (antibodies in peripheral blood)
Immunodeficiency disorders Recurrent infections, failure Full blood count
(inherited and acquired) to thrive Immunoglobulins
Lymphocyte subtypes
HIV test
Dental appliances, traumatic History of trauma
occlusion
Iron, B12, folate Poor diet, weight loss, skin Full blood count
and hair changes, pallor, Folate
tongue depapillation Iron/ferritin
Vitamin B12
All to be arranged in primary
care
Anaemia, leukaemia, Lethargy, fevers, pallor, Full blood count
agranulocytosis, cyclical neutropenia tongue depapillation LDH
Urate
Blood film
Idiopathic, normal haematology Recurrent and healing Full blood count
completely between Folate
episodes Iron/ferritin
Vitamin B12
All to be arranged in primary
care
daily life, including eating, speaking and previously suggested as a successful means
toothbrushing.31,32 The overall impact of oral of recording both the incidence of oral
ulceration on these activities is reported to ulceration and the impact on quality of
be similar to that of toothache.32 Despite life.2 Use of a diary enables accurate and
this knowledge, there is limited evidence to contemporaneous recording of events
identify the extent of these impacts.2 between appointments and reduces
Oral ulcer diaries have been the need for reliance on the child’s and
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 OralMedicine

Investigation Healthcare Setting Information Obtained

FBC Primary care − general medical A full blood count will give much information about whether the
practice patient is anaemic or is suffering a clinical or subclinical infection
as well as give clues as to potential haematological causes for oral
ulceration

Haematinics Primary care − general medical Deficiencies in B12, folate and ferritin may cause worsening of oral
practice ulceration
Coeliac screen (endomysial Primary care − general medical If Coeliac is suspected, the first screening test is for these
antibodies, tissue practice autoantibodies before referral for OGD if they are positive
transglutaminase, gliadin
antibodies)
Serum ACE, ESR, CRP Oral Medicine Generic markers of generalized inflammation can be helpful in
the diagnosis and management of inflammatory bowel disease

Pathergy, HLA Oral Medicine If Behçet’s is suspected, a Pathergy test of the skin and HLA
typing can be informative
Microscopy, culture and Oral Medicine Occasionally, superinfection of persistent or recurrent ulceration
sensitivities can be a problem and swabs or oral rinses may be indicated

Indirect IF Oral Medicine Autoantibodies found in vesiculobullous conditions such as

pemphigus vulgaris can be detected indirectly by a simple blood
test
Incisional biopsy − H&E or DIF Oral Medicine Rarely necessary in all but those cases where the diagnosis is not
clear
Table 4. Possible investigations for patients with recurrent oral ulceration. FBC (full blood count); ACE (angiotensin converting enzyme); ESR (erythrocyte
sedimentation rate); CRP (c-reactive protein); HLA (human leucocyte antigen); IF (indirect immunofluorescence); H&E (haematoxylin and eosin); DIF (direct
immunofluorescence); OGD (oesophago-gastro duodenoscopy).

parent’s memory.33 This information allows
the clinician to tailor a management
programme to meet the individual’s
needs more effectively. In addition to
refining clinical management, it supports
recognition of the impact of the condition
on the patient’s quality of life and prompts
provision of suitable emotional support and
reassurance. This has, in itself, been shown
to be valued by children and can help
improve patient perception of the ‘process
of care’.33,34
Conclusion
Recurrent aphthous stomatitis
is a common condition general dental
practitioners will see regularly in their
young patients. Simple topical measures
can be employed before referral to
secondary care for assessment and
management. Better understanding of a
patient’s symptoms will support a more
July/August 2015 DentalUpdate 571
individualized management plan with the
aim to improve quality of life. Paediatric oral
medicine teams have a role in investigating
patients with RAS and providing topical and
systemic pharmacological management, as
appropriate.
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