What are the causes of coated tongue and oral ulcers in pediatric patients?

From the Guidelines

Coated tongue and oral ulcers in children can result from several causes, including poor oral hygiene, dehydration, mouth breathing, or as a side effect of certain medications, and oral ulcers are commonly caused by minor trauma, viral infections, bacterial infections, food allergies, or nutritional deficiencies. The most recent and highest quality study on this topic is from 2022, which provides an expert consensus guideline for the diagnosis of difficult and complicated oral ulcers 1. According to this study, oral ulceration is characterized by the persistent defect or destruction in the integrity of the oral epithelium, accompanied by variable loss of the underlying connective tissue, resulting in a crateriform appearance. The causes of oral ulcers are related to traumatic, infectious, allergic factors, and may be associated with skin disease, autoimmune disease, tumor, inflammatory bowel disease, and so on. For example, recurrent aphthous ulcers (RAU) may be caused by disturbed immune response, genetic predisposition, nutrient deficiency, oral trauma, anxiety or stress. Treatment depends on the cause but generally includes maintaining good oral hygiene by gentle brushing of the tongue, ensuring adequate hydration, and using age-appropriate mouthwash for children over 6 years. For painful ulcers, topical treatments like benzocaine gel (applied sparingly 3-4 times daily) can provide relief, as suggested by other studies 1. Avoiding spicy, acidic, or rough foods during healing is helpful. If ulcers persist beyond two weeks, are extremely painful, or are accompanied by fever or difficulty eating or drinking, medical evaluation is necessary as they could indicate more serious conditions like inflammatory bowel disease or autoimmune disorders. Some studies also suggest that systemic measures such as azathioprine, IFNa and TNFa antagonists may be considered in resistant cases, especially in patients with Behçet disease 1. However, the treatment should be tailored according to how it affects the patients’ quality of life, and oral hygiene is important. In summary, the diagnosis and treatment of coated tongue and oral ulcers in children require a comprehensive approach, considering the various causes and treatment options available.

From the Research

Causes of Coated Tongue and Oral Ulcers in Pediatric Patients

• Coated tongue, also known as dirty mouth, can be caused by various factors, including poor oral hygiene, infections, and certain medical conditions 2.
• Oral ulcers in pediatric patients can be caused by harmless conditions such as recurrent aphthous stomatitis, as well as severe systemic diseases 3.
• In children and adolescents, aphthous stomatitis, infections, and trauma are the most frequent causes of oral ulcerations or erosions of the mucous membranes 3.
• Viral oral ulcers are common presentations in pediatric clinics and can be caused by herpes simplex virus, herpangina, and herpetic gingivostomatitis 4.
• Other causes of oral ulcers in pediatric patients include:
  • Acute necrotizing ulcerative gingivitis
  • Allergies
  • Erythema multiforme
  • Recurrent aphthous ulcers
  • Infections such as bacterial and deep fungal infections
  • Gastrointestinal diseases such as inflammatory bowel disease
  • Systemic diseases such as immune disorders and rare syndromes 5, 6

Differential Diagnosis

• The diagnosis of oral ulcers in pediatric patients requires a systematic approach, considering factors such as patient's age, distribution of mucosal lesions, additional involvement of the skin, extracutaneous symptoms, general condition of the patient, comorbidities, and medication 3.
• Clinical criteria such as vesicles or bullae, constitutional signs and symptoms, and lesions on the skin and/or other mucosa can be useful in identifying the cause of oral ulcers 6.
• In some cases, diagnosis depends upon culture or biopsy, particularly with the application of immunofluorescence to the surgical specimen 6.