Tuesday, 26 July 2011

Mouth Ulcers in Children

Published in Panorama



What causes mouth ulcers in children

Today, recurrent aphthous ulceration (RAU), or recurrent aphthous stomatitis (RAS), is recognized as the most common oral mucosal disease known to human beings affecting people of all ages and races cross the world. It is estimated that at least 1 in 5 individuals has at least once been afflicted with aphthous ulcers, or what in common parlance is refered to as mouth ulcers. While there is no age bar to the condition occurring, the peak age for RAU is between 10 and 19 years of age. RAU represent a very common but poorly understood mucosal disorder which can cause considerable pain and may interfere with eating, speaking, and swallowing, explains Dr.Uma Easwara, Specialist Pedodondist, Canadian Specialist Hospital.

With regards to the percentage of children in any general population suffering from this condition, the prevalence among differing populations has been documented as 5-66% and in schoolchildren the prevalence is found to be 37%.

Since no specific cause may be attributed to the condition, it is not possible to identify categories of children at risk of this condition. Dr.Uma responds, “There is no predilection for the ulcers in children. Students seem to get RAU more often than others though. In medical and dental students the prevalence stands between 50%-60%.”

What are the causes of aphthous ulcers? Despite the fact that Aphthous stomatitis is the most common oral mucosal disease, its cause is poorly understood or known. However, certain precipitating factors or triggers are seen as contributing to the condition. These include stress, nutritional deficiencies, trauma, hormonal changes, diet and immunological disorders. Food allergies, progesterone levels, psychological factors and a familiar history are also associated with RAU. While heredity has been considered as the causative factor of RAU, this is not conclusive, adds Dr.Uma.

Is it true that faulty brushing habits may play a role in RAU? Dr.Uma clarifies, “Minor trauma in the form of cheek biting and minor facial irritations is a precipitating factor in 75% of the episodes. Faulty brushing per se will not cause RAU but may cause minor trauma leading to ulceration.”

What is the precise role of diet and stress in aphthous ulcers in children? In general nutritional deficiencies are found in 20% of people with RAU. The deficiencies include that of iron, vitamin B12, and folic acid. Stress too has been found to be a precipitating factor especially in stress-prone groups, like students in professional schools. All the precipitating factors that have been studied are across the age groups therefore whether diet and stress cause aphthous ulcers in children exclusively is not clearly documented, explains Dr.Uma.

Are there varieties or categories of aphthous ulcers? Aphthous stomatitis is divided into three clinical presentations on the basis of ulcer size and number. It is unclear whether these presentations are manifestations of one disease or represent other oral disorders characterized by recurrent ulcers. The three designations are aphthous minor, aphthous major and herpetiform ulcers, explains Dr. Uma.

How do these ulcers seem in appearance and what are the symptoms they cause? The ulcers occur repetitively (recurrent) on the moist mucous membranes of the mouth. The ulcers are round or oval in shape, with raised red margins and are associated with pain. During an attack of minor aphthous, ulcers may occur singly or up to five or more concurrent ulcers. Each ulcer typically lasts 10-14 days. Ulcers may continually appear and heal spontaneously during a 3-4 week period.

Aphthous major, which accounts for about 10% of cases of Aphthous Stomatitis, is characterized by large ulcers which vary from 5-20 mm or more in size. Usually only 1-2 ulcers occur at a time and primarily in two locations, lip mucosa and posterior palate area. The ulcers are much more severe than that of minor aphthae and are associated with severe pain. The ulcers are crater like and deep, involving much tissue necrosis, often resulting in scarring upon healing. Aphthous major can last 6 weeks or more and can become secondarily infected with bacterial and fungal organisms.

Herpetiform aphthous is the least common variety comprising about 10% of occurrences. The name is misleading since it suggests a herpetic infection. However the appearance of the ulcers is similar to that of primary herpetic gingivostomatitis. Though it most commonly occurs on mobile mucous membranes like, inner surface of cheek, lips, herpetiform aphthae can infrequently appear on fixed mucosa e.g. palate, just as in primary herpetic gingivostomatitis. Herpetiform aphthous is characterized by multiple recurrent crops of 10 or more small crater like ulcers of variable size. The episodes may last several weeks or months with individual ulcers healing after 1-2 weeks. The ulcers are shallow, like aphthous minor, and heal without scarring. The age of onset of herpetiform aphthous is later than with the other types, with the initial episode usually presenting in the second or third decade of life.

Are there specific regions in the mouth where they mostly occur? Usually these ulcers appear on unattached mucous membranes of the mouth i.e. inner surface of the lips, cheeks, the fold between the cheek and the teeth (buccal sulcus) ,soft palate and the tongue.

Are there other disease conditions which mimic aphthous ulcer? The most common condition that mimics RAU in children is Primary herpetic gingivostomatitis, which is viral in origin. Other viral conditions like recurrent Herpes simplex, Herpangina, Hand, foot and mouth disease also mimic RAU. However these conditions have specific symptoms and presentation. Recurring oral ulcers are also seen in conditions such as Behcet's syndrome, systemic lupus erythematosus, and Crohn's disease. RAU must be distinguished from these diseases.

How are aphthous ulcers different from other similar conditions and what is the confirmatory diagnosis? Since the cause of RAU is unknown, diagnosis is entirely based on history and clinical criteria and no laboratory procedures exist to confirm the diagnosis. In case of ulcers due to viral conditions like Primary herpetic gingivostomatitis laboratory tests can be done to confirm the diagnosis. RAU may be a marker of an underlying systemic illness such as coeliac disease, or may present as one of the features of Behcet's disease. However in most cases of RAU no additional body systems are affected and patients remain otherwise fit and well.

Can aphthous ulcers lead to other complications? Painful lesions can cause interruption in eating and drinking, leading to dehydration and, perhaps, nutritional deficiencies. The ulcers otherwise heal without any complications in case of minor aphthous. However in case of major aphthous ulcers secondary infection of the ulcers can occur along with scarring of the area.

Can aphthous ulcers be considered precursors to other serious systemic disorders? They are not considered to be precursors to other systemic diseases; however, RAU also occurs in association with some systemic disorders that are associated with chronic gastrointestinal malabsorption disturbances such as Crohn's disease and celiac disease. Another systemic disorder associated with aphthous ulceration is Behcet syndrome that is characterized by recurrent attacks of genital and oral ulcers.

What is the treatment for these ulcers and what are the chances of their repeated recurrence in an individual? The primary goals of therapy for RAU are relief of pain, reduction of ulcer duration, and restoration of normal oral function. Secondary goals include reduction in the frequency and severity of recurrences and maintenance of remission. Topical medications, such as antimicrobial mouthwashes, topical anesthetics and topical corticosteroids, can achieve the primary goals but have not been shown to alter recurrence or remission rates. Systemic medications can be tried if topical therapy is ineffective.

Patients with frequent or severe outbreaks of aphthae should be counseled regarding the advisability of a medical screening for diabetes, various forms of anemia, gastrointestinal disease, food "allergies," and other diseases potentially affecting the immune system.

Supportive care includes rest, increased fluid intake, adequate nutritional intake, multi-vitamin and mineral therapy. Aphthae are not communicable. When conservative, care such as eliminating trauma (where possible), avoiding exposure to identified causative factors, and stress reduction are not enough, steroids of various types can be utilized. Aphthae are expected to respond quickly to steroid therapy. It must be emphasized that when an intraoral ulcer does not heal after potential causes have been addressed and/or after steroid therapy, the ulcer should be re-assessed to rule out any malignancies.

Can we talk in terms of a cure for these ulcers? Since the cause of the RAU is not clear all we can do is give a symptomatic treatment and supportive therapy.

Can aphthous ulcers be prevented? If yes, how?
If an individual has clear precipitating factors (e.g. Allergy, Stress) for RAU, avoiding the specific factors could prevent the ulcers. However in most individuals there is no clear cut precipitating factor and for them there is no curative therapy to prevent the recurrence of ulcers, and all available treatment modalities can only reduce the frequency or severity of the lesions.

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