Oral Ulcers in Infants and Children - Part I: General Points and Clinical Examination

Dr. Sawsan Nasreddine, BDS, DESS Pediatric Dentistry, DESS Public Health Dentistry, Department of Public Health Dentistry.

Dr. Antoine Cassia, Dr. Chir. Dent., Dr. Sc. Odont., DUPRMF, Associate Professor and Former Chairperson, Department of Oral Pathology and Diagnosis, Director of LASER Unit.

Lebanese University School of Dentistry, Beirut.


Abstract

This paper describes the basic principles of assessing pediatric dental patient with oral isolated or multiple oral ulcers. History should include significant medical and social facts as well as dental problems. Initial extra-oral examination covers visual appearance of patient’s Head and Neck region. Intra-oral examination let us understand the significance of features of ulcers such as form, site and pain. 

Keywords

Ulcer, etiology, generalities, extra-oral examination, intra-oral examination, diagnosis, and clinical features.


Introduction

Oral ulcers in infants and children are observed in dental office settings: they are source of discomfort and frustration for patients; it is often a challenge to distinguish one type of ulcer from another. 
Because many ulcers share many similarities, they are easy to misdiagnose. 
The diagnosis requires a systematic approach based on taking an adequate history, clinical examination, investigations as needed, treatment planning and, finally, examination allows for any necessary modifications of that management.1

Definition

An ulcer (Fig. 1a) is a complete breach of the epithelium1, an uncovered wound of mucosal tissue that exhibits gradual tissue disintegration and necrosis. It extends beyond the basal layer of the epithelium into the connective tissue.2
It is either a primary lesion or secondary to vesicles or bullas.
A vesicle (Fig. 1b) is a small, fluid filled elevation in the epithelium that is less than one centimeter in diameter. The epithelial lining of a vesicle is thin and will eventually break down, thus causing an ulcer.2
A bulla (Fig. 1c) is termed when a vesicle achieves a diameter greater than one centimeter. This condition develops from the accumulation of fluid in the epithelium connective tissue junction or a split in the epithelium.2



Ulcer

Vesicle

Bulla


Fig. 1: a - ulcer, b - vesicle, c - bulla


Pathway to diagnosis

We should go up gradually via several steps to reach the differential diagnosis, top of the pyramid (Fig. 2), which leads us to attempt in most cases or not the definitive diagnostic.
These steps are:
- History of present illness (HPI)
- General information
- Medical observation
- Extra-oral examination
- Intra-oral examination


Fig. 2


History of present illness (HPI)

“What is the problem?” Record his/her patient’s symptoms.3 When a child presents in pain or has a particular concern, complaint should be recorded in the child’s own words.4 It should be obviously an ulcer.
A full and accurate history is of primordial importance in assessment of a pediatric patient. In some cases, history may provide diagnosis while in the remainder it will provide essential clues to the nature of the problem. The approach to history taking needs to be tailored to the type of complaint being investigated.3 It is also an excellent opportunity for the dentist to establish a relationship with the child and his/her parent.4
A priority should be given to patients who have pain. A patient who has oral ulcer should be examined as soon as possible, because the more time, we loose the less accurate diagnosis we get.

Onset

Oral ulcer which appears after dental treatment is usually an indicator of minor recurrent aphthous ulcer. Minor trauma to tissues can precipitate ulcers in susceptible patients. Some patients may report many ulcers (at the same site in the mouth) occurring after dental treatment.1 
“When did the problem start?” Identify the duration, mode of onset and progression of the problem. Also remember to ask whether this is the first incidence of the problem or the latest of a series of recurrences.3, 4

Evolution

The progression of the oral ulcer since onset can be helpful in establishing whether the ulcer is becoming more severe or not.1

Duration

Duration of the ulcer is partly related to the age of onset and age at presentation and will also depend upon whether ulcer is persistent or intermittent.1
While examining the patient we should ask if it is the first time of ulcer’s appearance if no, we should ask about the number of reoccurrence and duration of each one. A more typical pattern of recurrent oral ulcer will be characterized by periods of ulcer with remissions between phases of ulcer. The progression of the ulcer since onset can be helpful in establishing whether the ulcer is becoming more severe.1

Localization

Assuming that there are multiple ulcers, their location (Fig. 3) are important factors in establishing a diagnosis.1


Fig. 3 (from Bengel et al. 2006)


Previous treatment

Sometimes, taking any medicines (for instance Zovirax®) give us a key in producing our diagnosis. Because any acyclovir medicine is prescribed for Herpes.

Past dental history

“Do you consult your dentist regularly?”. It is an opportunity to evaluate the attitude of the parents to their child’s dental treatment.4 Obtain a general picture of his treatment experience (fillings, dentures, local analgesia and general anaesthetic experience).3

General information

A note should be written of the patient’s name, age, address and telephone number. Details of the patient’s medical practitioner should also be noted.4
The age of the patient may be of relevance in relation to the age of onset of the ulcer. A child or adolescent presenting a recurrent oral ulcer may be evocative of a different diagnostic and management dilemma compared to an older patient. Some types of recurrent oral ulcer have a typical onset in childhood or adolescence, such as recurrent aphthous ulcer and stomatitis. This pattern of oral ulcer can sometimes be present in later life, but a middle-aged or elderly patient presenting with recurrent oral ulcer should also raise other diagnosis possibilities such as oral lichen planus and vesiculobullous disorders.1 
A child is a product of his environment. Factors such as whether both parents are alive and well, number and age of siblings, parent’s occupations, ease of travel, as well as attendance at school or day-care facilities are all important if a realistic treatment plan is to be settled. 
This step of history-taking also presents an opportunity to engage the child in conversation.4

Medical observation

Some medical conditions may have oral manifestations while others will affect the manner in which dental treatment is delivered.3
Asking a mother about her child’s health since birth will not infrequently stimulate the production of a complete medical history! Previous and current problems associated with each of the major systems should be elicited through careful questioning.4
It’s important to report the presence of general signs, because they can guide our diagnosis, for example in case of varicella.
Details about hospitalizations, operations (or planned operations), illness, allergies (particularly adverse reactions to drugs) and traumatic injuries should be recorded, as well as those related to previous and current medical treatment: a negative response should be further confirmed by asking if the patient has visited their general medical practitioner recently.4
The medical history will include ascertaining any medication taken by the patient. Some medications are associated with oral ulcer, (for example, methotrexate, used for some forms of childhood arthritis).1

However, do not automatically assume that any medication being taken by a patient with oral ulcer is the cause of their ulcers.1
A nutritional deficiency such as a deficiency of iron, folate or vitamin B12 may predispose the patient to recurrent oral ulcer and it may aggravate it.1

Extra-oral examination

It is of utmost importance to reach the top of pyramid, by reaching the differential diagnosis.
As a general rule, use your eyes first, then your hands to examine a patient. Start with the extra-oral examination before proceeding to examine the oral cavity. Take time to look at the patient. This process of medical observation will start while you are taking the history.3 

Visual areas should cover:
- general patient condition
- lips
- skin.

Palpation should cover:
- lymph nodes of the head and neck
- temporomandibular joint (TMJ)
- salivary glands (major and minor).3

General patient condition (Tab.1)

a- Fever, malaise and anorexia are described in case of:
- primary herpetic gingivostomatitis
- varicella
- herpangina
- hand, foot and mouth disease5

b- Pharyngitis is described in case of:
- primary herpetic gingivostomatitis
- varicella5

c- Vomiting, diarrhea, headache, myalgia and rhinorrhea are reported in case of:
- herpangina
- hand, foot and mouth disease5

d- Dysphagia is described only in case of:
- herpangina5

Tab. 1: General patient condition



Lips

We can find ulcers on lips in case of :
- traumatic ulcer
- hand, foot and mouth disease
- primary herpetic gingivostomatitis
- tuberculosis

Skin manifestations

In varicella, vesicular lesions on the skin, concentrated mainly on the trunk, head and neck then spreading all over the skin.6, 7, 8 
In hand, foot and mouth disease, rash is on the skin of the hands, fingers and soles of the feet. Rarely, the legs and lower trunk are involved.2 
A rash is not always present or may affect more proximal parts of the limbs or buttocks.8

Lymph nodes of the head and neck

The regional lymph nodes should be palpated as these may be enlarged in case of persistent or large ulcers.1 
The submental, submandibular and the internal jugular nodes are of particular importance because these collect lymph drainage from the oral cavity.3
A common sequence would be to start in the submental region, working back to the submandibular nodes then further back to the jugulo-digastric node. Then continue by palpation of the parotid region downwards to the retromandibular area and down the cervical chain of nodes. 
When a node is perceived as enlarged, record the texture: a hard node of a metastasizing malignancy contrasts well with a tender, softer node in an inflammatory process.3

Lymphadenopathy is found in case of:
-primary herpetic gingivostomatitis
-varicella
-herpangina
-hand, foot and mouth disease

-tuberculosis5

Temporomandibular joint

A detailed examination of the TMJ is probably only needed when a specific problem is suspected from the history.3 The TMJ can also be affected by diseases.4 The most frequent are rheumatoid arthritis3, juvenile idiopathic arthritis and traumatic injuries.4

Salivary glands

As with the TMJ, examination of the salivary glands is only required when the history suggests this is relevant. For example, bacterial sialadenitis, involves the parotid glands, is accompanied by swelling, pain, fever and erythema of the overlying skin.3

Intra-oral examination

Intraoral examination should assess first, at the present moment, the presence or absence of ulcers. 
If present, examination of an ulcer should include assessment of nine important features:
- Number
- Size
- Shape
- Base 
- Edge (margins) and surrounding tissues
- Pain
- Location
- Duration
- Etiologies
Visual inspection is essential but palpation is also an important part of the examination of an ulcer. Gloves must be worn for palpation and the texture of the ulcer base, margin and surrounding tissues should be ascertained by gentle pressure.1, 3


Characteristics of an ulcer

Number

There are two clinical situations; either there are one or multiple ulcers: so first, ulcers should be counted.
If one ulcer is present, the following diagnosis should be considered:
- Aphthous ulcer (Fig. 4)  
- Traumatic ulcer (Fig. 5)
- Rare tuberculosis and malignant ulcers
If more than one ulcer is present, the following diagnosis should be considered:
- Recurrent aphthous ulcers (Fig. 6)
- Traumatic ulcers (Fig. 7)
- Primary herpetic gingivostomatitis
- Varicella
- Herpangina
- Hand, foot and mouth disease (Fig. 8)
- Tuberculosis ulcer
For instance, recurrent minor aphthous ulcers tend to occur in crops of two to three but variable patterns are seen, ranging from occasional single ulcer to over 20 at any one time.2, 3, 9
The number of recurrent major aphthous ulcers varies between 2 to 510.
Herpetiform ulcers are characterized by multiple small ulcers (10 to 100).2, 5
In primary herpetic gingivostomatitis, is characterized by multiple ulcers.11

Oral lesions in herpangina consist of two to six red macules which form fragile vesicles that break up quickly leaving ulcers.8
Hand, foot and mouth disease has few vesicles (5 to 10) that break up quickly leaving a shallow ulcers.8, 10



Fig. 4: Minor aphthous ulcer


Fig. 5: Minor recurrent aphthous


Fig. 6: Major aphthous ulcer


Fig. 7: (a, b, c) Traumatic ulcers


Fig. 8: (a, b, c) Hand, foot and mouth disease (courtesy Dr. Hajj G.)


Size

Unique and multiple minor aphthous ulcers are relatively small in size (2 to 6 mm in diameter).10 
Unique and multiple major aphthous ulcers are large, more than 1cm in diameter and are often deeper.12
Herpetiform is a pinhead–sized ulcer.2, 3 Initially, ulcers are 1 to 3 mm in diameter.2, 10, 13, 14
The appearance of a mechanically induced traumatic ulcer varies according to the intensity and size of the agent.2
In primary herpetic gingivostomatitis, after 1-2 days small vesicles develop on the oral mucosa. They rupture, leaving ulcers with a diameter of 1-3mm.6
In varicella, lesions have varying degrees of development.6, 7 
In herpangina, they are 2 to 4 mm in diameter.7
Hand, foot and mouth disease show small ulcers (2 to 6 mm in diameter).8, 10 
The size of tuberculosis ulcer varies from 1 to 5 cm.10

Shape

Unique and multiple minor aphthous ulcers are round or oval, with a gray-white pseudo membrane.15 
Unique and multiple major aphthous ulcers are often ovoid ulcers.8 
Herpetiform ulcers occur in crops, gray-white erosions that enlarge, coalesce, and become ill-defined.2, 3
The shape of traumatic ulcers often gives a clue as to the cause.3 
Primary herpetic gingivostomatitis, is characterized by shallow ulcers that appear throughout oral cavity.11
In varicella, the typical rash goes through papules, vesicles, and pustules stages and then ruptures to produce round or ovoid ulcers.5, 8 
Oral lesions in herpangina consist of shallow and round ulcers.8

Base

In unique and multiple minor aphthous ulcers, there is little or no induration.15
Unique and multiple major aphthous ulcers are covered with a yellowish-white membrane necrotic tissue.10 
Typically, herpetiform ulcers become confluent.3,12,14
On gentle palpation, traumatic ulcers lack indurations and are tender.3 
There is no induration in traumatic ulcers unless the site is scarred from repeated episodes of trauma.13
The base of the ulcer is usually yellow-grey.2
The clinical appearance of traumatic ulcers is usually followed by the development of a whitish pseudo-membranous mucous lesion.6 
With a soft base, we should think about primary herpetic gingivostomatitis, herpangina and hand, foot and mouth disease are to be considered.10
The surface of tuberculosis ulcer has vegetation with coating is gray-yellowish. The surrounding mucosa is mildly indurated and inflamed.10
The deep ulcer of squamous cell carcinoma has large exophytic mass.10

Edge

The clinical examination of minor aphthous ulcers and minor recurrent aphthous ulcers usually shows a lightly erythematous lesion with regular borders.15
Unique and multiple major aphthous ulcers are with thin red (inflammatory) erythematous halo and irregular edges.10 
Herpetiform ulcers have thin red erythematous halo and irregular edges.2, 13, 14
The edges of the traumatic ulcers are raised and everted, and mild induration of the margins is palpable.16
Primary herpetic gingivostomatitis has edematous edges with fibrin (yellowish-gray) background.10 The lesion develops as intraepithelial vesicles that burst leaving areas of erosion and ulcers with erythematous margins.11
In varicella, the oral manifestations are ulcers with an inflammatory halo.8
Herpangina is circumscribed by a narrow red erythematous halo.8, 10
Tuberculosis ulcer is with an irregular outline and has no red erythematous halo.10 
Squamous cell carcinoma has a vegetative background with an elevated edge with an absence of erythematous halo.10

Pain

All following ulcers are painful:
- unique and multiple minor aphthous ulcers which recur at intervals of a few days or up to 2-3 months14
- unique and multiple major aphthous ulcers10
- herpetiform ulcers2, 13
- traumatic ulcers3
- primary herpetic gingivostomatitis6
- varicella: the lesions are also extremely pruritic6, 7 
- herpangina8
- hand, foot and mouth disease (slightly)10, 14
In tuberculosis, ulcer is painless.10

Location

Some ulcers may have particular sites. 
Unique and multiple minor aphthous ulcers affect only the non-keratinized oral lining mucosa3
- buccal mucosa 
- labial mucosa17
- floor of the mouth 
- soft palate
- lateral borders of the tongue13, 14
Moreover, ulcers are usually concentrated in the anterior part of the mouth; the pharynx and tonsillar fauces are rarely implicated.14
Unique and multiple major aphthous ulcers involve the soft palate10, tonsil areas, labial mucosa, buccal mucosa, and dorsum of the tongue, occasionally extending onto the attached gingiva2,8,17, often the oropharynx is affected.1 
Herpetiform ulcers are seen on the non-keratinized mucosa with the possibility of more ragged ulcers by virtue of adjacent ulcers enlarging and fusing.1 But particularly affected the anterior tip of the tongue, margins of the tongue, floor of the mouth and labial mucosa.2,17
Traumatic ulcers are most common on the lateral border of the tongue and buccal mucosa1, 3, lips, gingiva and palate.18
The most common situation is cheek or lip bites after dental local analgesia.6, 13
If caused by the sharp edge of a broken tooth, they are usually on the tongue or buccal mucosa.13
Sublingual ulcer was noticed in a natal tooth, suggestive of the role of infantile swallowing and suckling.16
In primary herpetic gingivostomatitis, ulcers covere the gingival and the oral mucosa bilaterally.19 
In varicella, lesions are located mostly on the mucosa of the lips, buccal, and tongue.6
In herpangina, disease is limited to the oropharynx with vesicles/ulcers on the soft palate and faucal pillars.7, 10
In hand, foot and mouth disease, oral lesions are usually more anterior, primarily on the lips, tongue and buccal mucosa.7 
Tuberculosis ulcer may involve dorsal surface of the tongue, buccal mucosa, lips and palate.10
Most common site for intraoral squamous cell carcinoma is lateral border and ventral surface of the tongue, floor of the mouth, and lower lip. Other intraoral sites, in descending order of involvement, are the oropharynx, gingival, buccal mucosa, lip, and palate.2, 10

Duration

Unique and multiple minor aphthous ulcers heal within 4 to 14 days, rarely with scarring.12, 13
Unique and multiple major aphthous ulcers can persist for up to 3 months and often heal with scarring.2, 3, 17
Typically, herpetiform ulcers become confluent and heal with scar formation, but this is probably a result of coalescence, the healing takes up to 40-50 days.3, 8, 12
Lesion of traumatic ulcers is self-limiting may persist for just a few days or may last for weeks (especially ulcers of the tongue).6, 18 
In Varicella, infection generally resolves within 2 weeks.18

Etiologies

The cause of recurrent aphthous ulcers is yet unknown. There is some evidence that this disease could be an immunological hypersensitivity reaction to an L-form streptococcus. There is no reliable evidence of autoimmune disease.5 
Traumatic ulcers are usually caused by dental local analgesia, denture irritation or chemical, mechanical and thermal trauma, rough fillings and clumsy use of cutting dental rotating instruments, toothbrush trauma, tic, orthodontic treatment13 and presence of a natal or neonatal tooth.16
The traumatic incident is may be incidentally self-inflicted or iatrogenic.18
Herpetic gingivostomatitis is caused by herpes simplex virus-1 (HSV1) and communicated through personal contact, e.g., transmission via the saliva of the mother.
Primary oral infection occurs following the first exposure to the virus.6
Varicella is a highly contagious herpes virus infection of children, caused by Varicella-zoster virus (VZV).7, 8
Herpangina is a disease mainly of children and is caused by various strains of enterovirus mainly Coxsackie viruses A1-A6, A8, A10, A12 or A22, but similar syndromes can be caused by other viruses, especially Coxsackie B and echoviruses.7, 8
Hand-foot-and-Mouth disease is an enterovirus infection, caused by Coxsackie virus A.7, 8

When should you be alerted?

The below factors should determine if doctor needs to refer the patient. Time is very important in treating and relieving the patient.

Ulcer
- long-term ulcer
- if it grows in size, after removing the cause
- chronic ulcer
- elevated edge
- indurated base
- painless

General status

- fever
- dehydratation
- contagious disease diagnosed

When should you refer?

- any ulcer persisting for more than 3 weeks
- general signs
- if diagnosis is hard to establish

To whom should you refer?

- Pediatrician
  With general signs
- Pathologist
  Without general signs

To remember

- Number of common infectious diseases in children is manifested by oral lesions, apart from specific skin lesions. Unnecessary dental treatment should be avoided during the child’s disease and the week following recovery due to risk of infectious transmission
- Any persistent ulcer (more than 3 weeks) despite the removal of its presumed cause, should be biopsied and suspected malignant until proven the contrary
- Where general signs are present, refer the patient to a pediatrician even though the diagnosis is established.


References

1. Talacko A.A., Gordon A.K., Alfred M.J. The patient with recurrent oral ulceration. Australian Dental Journal. 2010; 55 (1 Suppl):14-22

2. Langlais R.P., Miller C.S., Nield-Gehrig J.S. Color atlas of common oral diseases. Philadelphia, The Point, 4th edition, 2009:17-30

3. Coulthard P., Horner K., Sloan P., Theaker E. Oral and maxillofacial surgery, radiology, pathology and oral medicine. Master Dentistry. Edinburgh, Elsevier, 2nd edition, 2008, Vol.1:11-20

4. Welbury R.R., Duggal M.S., Hosey M.Th. Paediatric dentistry. Oxford, 3rd edition, 2005:41-62

5. Scully C., Cawson R.A. Oral disease. Edinburgh, 2nd edition, 1999:23-56

6. Koch G., Poulsen S. Oral mucous lesions and minor oral surgery. Pediatric dentistry (a clinical approach). Copenhagen, Munksgaard, 2nd edition, 2009:298-307

7. Lewis M. Herpangina: an enteroviral febrile associated vesiculo-bullous disease Oklahoma Dental Association Journal. March 2008:32-34

8. Scully C., Welbury R. Color atlas of oral diseases in children and adolescents. Europe, Mosby, 1994:82-108

9. Cameron A.C., Widmer R.P. Pediatric oral medicine and pathology; ulcerative and vesiculobullous lesions. Handbook of pediatric dentistry. Edinburgh, Mosby, 3rd edition 2008:177-180

10. Laskaris G. Atlas des maladies buccales. Paris, Flammarion, 2nd edition, 1994

11. Brugnera A. jr, Garrini dos Santos A. E. C., Bologna E. B., Pinheiro Ladalardo Th. Ch. C. G. Atlas of laser therapy applied to clinical dentistry. Chicago, quintessence editora, 2006:34-35

12. Altenburg A., Krahl D., Zouboulis C.C. Non infectious ulcerating oral mucous membrane diseases. Journal of the German Society of Dermatology. 2009(7):242-257.

13. Cawson R.A., Odell E.W. Diseases of the oral mucosa: introduction and mucosal infections. Oral pathology and oral medicine. 8th edition, 2008:206-216

14. Field E.A., Allan R.B. Review article: oral ulceration, aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment Pharmacol Ther. 2003, 18:942-962

15. Descroix V., Coudert A.E., Vigé A., Durant J.P., Touenay S., Molla M., Pompignoll M., Missika P., Allaert F.A. Efficacy of topical 1% lidocaïne in the symptomatic treatment of pain associated with oral mucosal trauma or minor oral aphthous ulcer: a randomized, double-blind, placebo-controlled, parallel-group, single-dose study. Journal of Orofacial Pain, 2011, 25(4):327-332

16. Padmanabhan M. Y., Pandey R. K., Aparna R., Radhakrishnan V. Neonatal sublingual traumatic ulceration-case report & review of the literature. Dental Traumatology. 2010, 26:490-495

17. Gurenlian J.R. Differentiating herpes simplex virus and recurrent aphthous ulcerations. Access, Feb 2003:30-34

18. Sällberg M. Oral viral infections of children. Periodontology 2000. 2009, Vol.49:87-95

19. Wood N.K., Goaz P.W. Differential diagnosis of oral lesions. USA, Mosby, 4th edition, 1991:195-221




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