How should I assess and manage a child presenting with oral sores?

Management of Pediatric Mouth Sores

Begin with a focused clinical assessment to determine if the oral ulcers are traumatic, infectious, or require systemic workup, and initiate symptomatic treatment immediately while pursuing definitive diagnosis for lesions persisting beyond 2 weeks or failing initial therapy.

Initial Clinical Assessment

History and Physical Examination

• Document the duration of ulcers, as lesions persisting >2 weeks require biopsy consideration 1
• Assess morphology: Look for well-demarcated oval/round ulcers with white/yellow pseudomembrane and erythematous halo (classic for recurrent aphthous ulcers), versus stellate ulcers with undermined edges (tuberculosis), versus location/shape corresponding to trauma 1
• Identify red flags for child abuse in children <5 years with trauma affecting lips, gingiva, tongue, or palate, especially with severe injury patterns inconsistent with developmental stage 2, 3
• Evaluate for systemic symptoms: fever, skin lesions, genital ulcers, eye involvement, arthritis, or gastrointestinal symptoms that suggest underlying systemic disease 4, 5

Common Etiologies by Pattern

• Traumatic ulceration: Diagnosed by location/shape corresponding to sharp edges, residual roots, or thermal/chemical injury 1
• Infectious causes: Primary HSV gingivostomatitis presents with fever, irritability, tender submandibular lymphadenopathy, and superficial painful ulcers in gingival/oral mucosa and perioral area 1
• Recurrent aphthous ulcers (RAU): Most common recurrent oral ulcer in children, presenting with characteristic morphology 1

Immediate Management

Symptomatic Treatment

• Provide pain management immediately as the priority for all oral ulcers, regardless of etiology 6
• Recommend soft diet for 10 days to avoid disrupting healing and minimize pain 2, 3
• Maintain good oral hygiene with gentle brushing to optimize healing 2, 3
• Restrict pacifier or digit sucking if applicable for first 10 days 2, 3

Specific Treatment by Etiology

• For HSV gingivostomatitis: Acyclovir is the drug of choice for treatment in infants and children; oral and intravenous preparations are available depending on severity 1
• For traumatic ulcers: Remove the causative irritant (sharp edges, residual roots) and provide supportive care 1
• For RAU: Symptomatic management with topical agents; consultation with primary care physician and pharmacist may be needed for immunosuppressive drugs in severe cases 6

Indications for Laboratory Testing

When to Order Blood Work

Order blood tests before biopsy for ulcers that cannot be diagnosed clinically, especially those >2 weeks duration or not responding to 1-2 weeks of treatment 1:

• Full blood count: To detect blood system diseases, anemia, or leukemia 1
• Coagulation studies and fasting blood glucose: To exclude biopsy contraindications and identify hyperglycemia as predisposing factor for fungal infection 1
• HIV antibody and syphilis serology: To rule out infection-associated ulceration 1
• Serum specific antibodies (Dsg1, Dsg3, BP180, BP230): Crucial in patients with suspected bullous diseases before biopsy 1

Indications for Biopsy

Perform biopsy for oral ulceration that cannot be diagnosed after clinical history and examination, especially those with course >2 weeks, or cases not responding to 1-2 weeks of treatment 1:

• Ensure blood tests are completed first to exclude contraindications and provide diagnostic clues 1
• Biopsy is essential to differentiate benign ulcerative lesions from neoplastic lesions, which can mimic benign conditions 4

Follow-Up and Monitoring

Signs Requiring Urgent Re-evaluation

• Monitor for signs of infection: gingival swelling, increased pain, purulent drainage, fever, or systemic symptoms 3
• Watch for signs of pulpal necrosis in dental trauma cases: gray tooth discoloration, gingival swelling near affected tooth, parulis, increased tooth mobility 2, 7
• Breathing difficulties with intraoral lesions require urgent re-evaluation 3

Referral Criteria

• Immediate dental referral for extensive gingival/facial swelling, multiple teeth moving together, tooth displacement interfering with occlusion, visible pulp exposure, or severe tooth extrusion/intrusion 2
• Refer to pediatric dental specialist for dental trauma including tooth fracture, intrusion, and luxation 2
• Refer to appropriate specialist for oral lesions not responding to therapeutic protocols for definitive diagnosis and treatment 6

Common Pitfalls to Avoid

• Do not replant avulsed primary teeth, as replantation risks damage to underlying permanent tooth germ 2
• Do not routinely prescribe antibiotics for oral trauma unless specific medical condition requires coverage 2
• Do not delay biopsy for atypical ulcers or those failing conservative management, as neoplastic lesions can mimic benign conditions 4
• Do not miss child abuse in young children with oral/facial trauma—always assess mechanism consistency with developmental stage 2, 3