Management of recurrent aphthous stomatitis in children

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 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

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

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:

Management of RAS in children should begin with education to explain the natural history of the disease and the scope of management.^1,2,3,4,5 An ulcer diary can be helpful for the clinician and also allows the child to participate in his/her own management.2

Certain factors can aggravate RAS, therefore identifying these may help prevent further ulceration. Sources of trauma or parafunctional habits which may contribute to ulcer experience should be addressed, if necessary, by making a soft splint, polishing sharp teeth, coating orthodontic appliances with wax or counselling regarding tongue thrusting and bruxism.9 Exacerbation of ulcers is often noted by patients secondary to stress, such as school examinations, exposure to certain food substances, toothpaste additives and menstruation.1^,18^,19^,20

Treatment options vary (Figure 8), from the use of ‘Over The Counter’ preparations to topical and/or systemic prescribed therapies. In primary dental care, the prescription of several topical therapies is appropriate and may include antimicrobial mouthrinses, such as 0.2% chlorhexidine gluconate (Corsodyl® GlaxoSmithKline, Brentford, Middlesex), which will help with plaque control and reducing superinfection.11^,21 Other useful agents include protective pastes, such as Orabase (active ingredient carmellose), Gengigel (active ingredient hyaluronate), Gelclair (active ingredient hyaluronate) and topical analgesics including 0.15% benzydamine hydrochloride (Difflam) or a 5% lidocaine spray or mouthwash useful prior to eating or toothbrushing.11^,22 Advising patients to use sodium lauryl sulphate-free toothpastes may be beneficial in reducing the number of ulcers.20

Those patients with RAS severely impacting on quality of life, not responding to topical analgesics or antiseptics, or where there is a suspicion of an underlying systemic disease, should be referred to a specialist clinic or to Departments of Oral Medicine or Paediatric Dentistry. Regular and supervised use of topical corticosteroid may be introduced to reduce inflammation, promote healing and reduce the frequency of new ulcerations. Betamethasone sodium phosphate (Betnesol) 500 microgram tablets may be dissolved in water as a mouthwash.9 Another useful topical corticosteroid used is fluticasone propionate (Flixonase), which is available as a spray (50 microgram per actuation).6 It is important that the child is mature enough to use a mouthrinse correctly to avoid swallowing the solution (usually 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 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, then a spray can be useful. When there are 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 neuropathy must be discussed with the parents.^{1,27,28,29,30}

Quality of life impacts

Episodes of oral ulceration in children have been shown to have a significant impact on various activities in daily life, including eating, speaking and toothbrushing.31^,32 The overall impact of oral ulceration on these activities is reported to be similar to that of toothache.32 Despite this knowledge, there is limited evidence to identify the extent of these impacts.2

Oral ulcer diaries have been previously suggested as a successful means of recording both the incidence of oral ulceration and the impact on quality of life.2 Use of a diary enables accurate and contemporaneous recording of events between appointments and reduces the need for reliance on the child's and 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 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.