Paeds · ent-hearing-and-oral-health

Oral ulcers and mucosal disease

Also known as Recurrent aphthous stomatitis · Herpetic gingivostomatitis · Oral candidiasis · Oral thrush · Hand-foot-and-mouth disease · Oral mucositis · Geographic tongue · Benign migratory glossitis

Fellowship topic on oral ulcers and mucosal disease in children. Covers primary herpetic gingivostomatitis with early oral aciclovir, recurrent aphthous stomatitis and its deficiency, coeliac and autoinflammatory associations, oral candidiasis and nystatin dosing in infants, hand-foot-and-mouth disease and herpangina, oral mucositis in oncology with WHO grading and prevention, the PFAPA syndrome triad, and benign geographic tongue. Builds the single-most-important skill of distinguishing the common self-limiting ulcer from the one that signals immunodeficiency, cytopenia, Behcet disease or a dehydrating viral gingivitis, with ANZ, UK, US and Canadian guidance.

high10 referencesUpdated 16 July 202613 min readVerification in progress

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RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

A young child with high fever, diffuse painful gum and mouth ulceration, drooling and refusal to drink — primary herpetic gingivostomatitis with dehydration risk; weigh early oral aciclovir within 72 hours and assess hydration, because the danger is fluid and electrolyte loss rather than the lesions themselves.Large, persistent or unusually sited oral ulcers recurring with genital ulcers, eye inflammation, skin lesions or joint pain — Behcet disease, inflammatory bowel disease or a systemic vasculitis rather than simple aphthae; these need subspecialty work-up, not topical rinses alone.Major aphthous ulcers exceeding ten millimetres, lasting weeks, healing with scarring, or occurring with recurrent infection, failure to thrive or cytopenias — an underlying iron, folate or vitamin B12 deficiency, cyclic neutropenia, coeliac disease, HIV or a primary immunodeficiency driving the ulcers.Pseudomembranous thrush in an infant beyond the neonatal period without an obvious antibiotic or inhaled-steroid cause, or thrush refractory to first-line topical therapy — immunodeficiency or untreated maternal nipple candidiasis; investigate and treat the source rather than repeatedly prescribing topical antifungal.

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescent

Care settings

community-schooloutpatiented-acutewardrural-remotetelehealth

Clinical exam formats

written-only

Board mappings

General Paediatrics and ENT: oral ulcers and mucosal disease — primary herpetic gingivostomatitis, recurrent aphthous stomatitis, oral candidiasis, hand-foot-and-mouth disease and oral mucositis, and the red flags that demand a systemic work-up.Infectious diseases and prevention: the viral, fungal and inflammatory causes of paediatric oral ulceration, hydration and aciclovir in herpetic gingivitis, and the benign lesions that only need reassurance.Renewed curriculum — ENT, immunology and rheumatology: the deficiency, coeliac and autoinflammatory associations of recurrent aphthae, the WHO grading and prevention of oral mucositis, and the PFAPA syndrome.Public health and regional practice: the burden of enteroviral and herpetic oral disease in remote and underserved communities, oral-care health promotion, and antimicrobial stewardship for self-limiting viral causes.General Paediatrics: recognition of primary herpetic gingivostomatitis with dehydration risk, the distinction between aphthous and herpetic ulcers, and the topical-first management of candidiasis and minor aphthae.Public health: supportive and antiviral care of self-limiting viral oral disease, oral-care advice, and the safety-net for dehydration, refractory lesions and systemic illness.Long Case / Structured discussion: a child with painful oral ulcers — classification, the focused examination of site and distribution, the deficiency and systemic work-up, and the stepwise management from topical care to early aciclovir.Communication station: explaining to a parent why most oral ulcers are self-limiting, when dehydration brings a child back, and why some recurrent ulcers need blood tests and subspecialty review.Level 2 / 3 — ENT, infection and immunology: the causes of paediatric oral ulceration by age, the herpetic and enteroviral patterns, and the red flags of immunodeficiency and systemic disease.Public health and health improvement: oral-care promotion, hydration in the drooling febrile child, and antimicrobial stewardship for viral and fungal causes.Foundation of Practice (FOP): the common and dangerous causes of oral ulcers in infants and children, and the bedside distinction between aphthous, herpetic and candidal lesions.Applied Knowledge in Practice (AKP): early oral aciclovir in herpetic gingivostomatitis, nystatin dosing for infantile thrush, the deficiency work-up of recurrent aphthae, and the WHO grading of oral mucositis.History-taking and management: the child with painful mouth ulcers and drooling, the focused oral examination, and the hydration, analgesia and antiviral or antifungal plan.Communication: explaining why most oral ulcers settle with supportive care, when to return for dehydration, and why some recurrent ulcers need blood tests.General Pediatrics Content Outline: oral ulcers and mucosal disease — herpetic gingivostomatitis, aphthous stomatitis, candidiasis, hand-foot-and-mouth disease and mucositis, with the systemic associations of recurrent disease.Infectious Diseases and Immunology: HSV gingivostomatitis and aciclovir, enteroviral oral ulcers, oral candidiasis, and the immunodeficiency and cytopenic causes of persistent ulceration.Patient Care: evidence-based, hydration-led, analgesia-first management of paediatric oral ulceration with prompt use of aciclovir where indicated and recognition of systemic disease.Systems-Based Practice and Population Health: oral-care promotion, supportive care of self-limiting viral causes, antimicrobial stewardship, and coordination of oncology mucositis prevention.Medical Knowledge: the viral, fungal and inflammatory pathophysiology of oral mucosal disease, the deficiency and autoinflammatory associations of aphthae, and topical and systemic pharmacology.Medical Expert: oral ulcers and mucosal disease diagnosis, hydration and aciclovir in herpetic gingivitis, topical antifungal and corticosteroid therapy, and the systemic work-up of recurrent disease.Health Advocate and Collaborator: oral-care promotion, hydration advice in remote communities, and antimicrobial stewardship for self-limiting causes.Communicator: explaining why most oral ulcers are benign, when dehydration is the danger, and why some recurrent ulcers need blood tests and subspecialty review.

Your progress

Saved locally on this device.

Practise this topic

Target exams

RACP General PaediatricsRACP DWERACP DCERCPCH Progress+MRCPCH TheoryMRCPCH ClinicalABP General PediatricsACGME PediatricsRCPSC Pediatrics

Red flags

Life stages

neonateinfanttoddlerpreschoolschool-ageadolescent

Care settings

community-schooloutpatiented-acutewardrural-remotetelehealth

Clinical exam formats

written-only

Board mappings

The fellowship answer

Oral ulcers and mucosal disease span a spectrum from the trivial to the dehydrating to the systemic, and the fellowship skill is to triage along that spectrum at the bedside. A drooling, febrile toddler with diffuse painful gum and tongue ulceration is primary herpetic gingivostomatitis — assess hydration first and give early oral aciclovir within 72 hours of onset. [1] [2] A school-age child with a few shallow round ulcers on the non-keratinised mucosa that recur is recurrent aphthous stomatitis, usually benign, but recurrence with genital ulcers, eye, skin or joint involvement points to Behcet disease, inflammatory bowel disease or an autoinflammatory syndrome. [9]

A white, wipeable plaque on the buccal mucosa of an infant is oral candidiasis (thrush), treated with nystatin oral suspension 100,000 units per millilitre, 1 mL to each side of the mouth four times daily after feeds for seven days, and by treating any maternal nipple candidiasis. [8] Painful oral ulcers with a vesicular rash on the hands and feet mark hand-foot-and-mouth disease from Coxsackievirus or Enterovirus 71 — self-limiting, where the danger is dehydration and, rarely, neurological complications. [6]

Management is hydration-led and analgesia-first: soft diet, adequate analgesia, topical agents for the common lesions, antivirals only for HSV, and a focused systemic work-up — iron studies, folate, vitamin B12, coeliac serology and a full blood count — for the child with recurrent, major, persistent or unusually sited ulcers. The lesion that does not behave like the common ones is the one that earns the work-up. [9] [10]

The oral-ulcer red flags

A young child with high fever, diffuse painful gingival and oral ulceration, drooling and refusal to drink — primary herpetic gingivostomatitis with dehydration risk; weigh early oral aciclovir within 72 hours and assess hydration, because the danger is fluid and electrolyte loss. [1] [2]
Recurrent oral ulcers with genital ulcers, uveitis, skin or joint lesions — Behcet disease, inflammatory bowel disease or systemic vasculitis rather than simple aphthae; these need subspecialty work-up. [9]
Major aphthous ulcers over ten millimetres, lasting weeks, scarring, or with recurrent infection, failure to thrive or cytopenias — iron, folate or B12 deficiency, cyclic neutropenia, coeliac disease, HIV or a primary immunodeficiency driving the ulcers. [9] [10]
Thrush beyond the neonatal period without an antibiotic or inhaled-steroid cause, or thrush refractory to topical therapy — immunodeficiency or untreated maternal nipple candidiasis; investigate and treat the source. [8]
A single persistent oral ulcer lasting beyond two to three weeks despite removing obvious trauma — refer to exclude a non-healing or neoplastic lesion; the rule of three weeks is the safety-net. [9]

Overview & Definition

A mother brings her two-year-old to the emergency department: three days of fever, drooling, and now refusing all fluids, with gums so inflamed they bleed when touched. Lift the lip and the picture is unmistakable — diffuse vesicles and shallow ulcers across the gingiva, tongue and lips. This is primary herpetic gingivostomatitis, and the fellowship skill is to see it as a hydration problem first and an infection second. [1]

Oral ulcers and mucosal disease in children cover any breach of the oral mucosa — vesicular, aphthous, candidal, traumatic or mucositic. The task is to separate the common self-limiting lesion from the one that dehydrates, recurs systemically, or signals a cytopenia, immunodeficiency or autoinflammatory syndrome. Most oral ulcers in childhood are viral, benign and settle with supportive care. A small minority are the mouth's first warning of systemic disease. The examining skill is to read the site, the distribution and the host, because that trio names the cause. [9] [6]

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References10Show ledger

[1]Amir J; Harel L; Smetana Z; et al Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ, 1997.PMID 9224082
[2]Coppola N; Cantile T; Adamo D; et al Supportive care and antiviral treatments in primary herpetic gingivostomatitis: a systematic review. Clin Oral Investig, 2023.PMID 37733027
[3]Anselmi F; Dusser P; Kone-Paut I Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) Syndrome in Children-From Pathogenesis to Treatment Strategies: A Comprehensive Review. Paediatr Drugs, 2025.PMID 40632467
[4]Mulinda C; Kinariwalla N; DeFelice AR; et al Management of Oral Mucositis in Pediatric Patients: A Practical Overview of Available Treatment. Pediatr Dermatol, 2025.PMID 40358941
[5]Dipasquale RF; Sinopoli P; Mendicino A; et al Colchicine prophylaxis in pediatric PFAPA: a systematic review. Eur J Pediatr, 2026.PMID 41495479
[6]Selene NB; Situmorang NY Preventive Strategies of Hand, Foot, and Mouth Disease in Children: A Review. Turk Arch Pediatr, 2025.PMID 42391430
[7]Bakshi SS Benign migratory glossitis. Turk J Pediatr, 2019.PMID 31990488
[8]Pankhurst CL Candidiasis (oropharyngeal). BMJ Clin Evid, 2013.PMID 24209593
[9]Lau CB; Smith GP Recurrent aphthous stomatitis: A comprehensive review and recommendations on therapeutic options. Dermatol Ther, 2022.PMID 35395126
[10]Barrons RW Treatment strategies for recurrent oral aphthous ulcers. Am J Health Syst Pharm, 2001.PMID 11194135

Oral ulcers and mucosal disease

high10 referencesUpdated 16 July 202613 min readVerification in progress

Practise this topic

Overview & Definition

Paediatrics Fellowship Pro

You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References10Show ledger

[1]Amir J; Harel L; Smetana Z; et al Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study. BMJ, 1997.PMID 9224082
[2]Coppola N; Cantile T; Adamo D; et al Supportive care and antiviral treatments in primary herpetic gingivostomatitis: a systematic review. Clin Oral Investig, 2023.PMID 37733027
[3]Anselmi F; Dusser P; Kone-Paut I Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis (PFAPA) Syndrome in Children-From Pathogenesis to Treatment Strategies: A Comprehensive Review. Paediatr Drugs, 2025.PMID 40632467
[4]Mulinda C; Kinariwalla N; DeFelice AR; et al Management of Oral Mucositis in Pediatric Patients: A Practical Overview of Available Treatment. Pediatr Dermatol, 2025.PMID 40358941
[5]Dipasquale RF; Sinopoli P; Mendicino A; et al Colchicine prophylaxis in pediatric PFAPA: a systematic review. Eur J Pediatr, 2026.PMID 41495479
[6]Selene NB; Situmorang NY Preventive Strategies of Hand, Foot, and Mouth Disease in Children: A Review. Turk Arch Pediatr, 2025.PMID 42391430
[7]Bakshi SS Benign migratory glossitis. Turk J Pediatr, 2019.PMID 31990488
[8]Pankhurst CL Candidiasis (oropharyngeal). BMJ Clin Evid, 2013.PMID 24209593
[9]Lau CB; Smith GP Recurrent aphthous stomatitis: A comprehensive review and recommendations on therapeutic options. Dermatol Ther, 2022.PMID 35395126
[10]Barrons RW Treatment strategies for recurrent oral aphthous ulcers. Am J Health Syst Pharm, 2001.PMID 11194135