Oral ulcers and mucosal disease

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Target exams

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

Care settings

Clinical exam formats

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.