Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Aphthous Stomatitis
APHTHOUS STOMATITIS
Aphthous stomatitis ulcers are recurrent small, painful ulcers on the oral mucosa, commonly known as “canker sores.”
I. Etiology
A. Cause unknown
B. Emotional and physical factors often precede eruptions and have been implicated in the etiology, but no definite proof is available.
C. Certain foods, especially chocolate, nuts, and fruits, can precipitate lesions, as can trauma from biting or dental procedures.
D. Herpes simplex is not the cause.
II. Incidence
A. Most commonly seen between the ages of 10 and 40.
B. Estimated prevalence is about 20% of the general population.
III. Subjective data
A. History of tingling or burning sensation preceding eruption for up to 24 hours
B. Complaint of canker sores or recurrent painful oral lesions
C. Pertinent subjective data to obtain: Lesions occur after a specific triggering factor.
1. Trauma
2. Ingestion of certain foods, e.g., chocolate, tomatoes, nuts
3. Ingestion of drugs
4. Stress: Emotional or physical
5. Premenstrually
IV. Objective data
A. Lesions
1. Single or multiple
2. Small: 1 to 10 mm
3. Oval, shallow erosions
4. Light yellow or gray
5. Clearly defined erythematous border
B. Distribution: Buccal or labial mucosa, lateral tongue, palate, pharynx
C. Rarely, extremely large or numerous lesions
D. Rarely any systemic symptoms or adenopathy
V. Assessment
A. Diagnosis is made by the characteristic appearance of the lesion, its recurrent nature, and the absence of systemic symptoms.
B. Differential diagnosis
1. Herpes simplex: Lesions are on the skin, most commonly at the mucocutaneous junction.
2. Herpangina: Elevated temperature, sore throat, vesicular eruptions on an erythematous base on the anterior pillars; no lesions on gingival or buccal mucosa
3. Acute herpetic gingivostomatitis: Vesicles, erosions, maceration over entire buccal mucosa; marked erythema and edema of gingiva, submandibular adenopathy
VI. Plan: Objective of treatment is to control pain, to shorten duration of lesions and to abort new lesions.
A. Kenalog in Orabase: Applied to lesion qid
B. Topical anesthetics for pain
1. Dyclone 1% solution
a. Apply directly to lesion
b. Rapid action
c. Numbs lesion for up to an hour
2. Benadryl elixir
a. Apply directly to lesion
b. May be mixed with kaopectate or
3. Xylocaine Viscous solution
a. Apply directly to lesion or
b. For children 5 to 12: 3⁄4 to 1 tsp every 4 hours. Over 12 years of age, 1 tbsp (15 mL or 300 mg) swished around mouth every 4 hours (dosage is 4.5 mg/kg)
or
4. Ora-Jel (20% benzocaine), prn
C. Tetracycline compresses (250 mg/30 mL water): 4 to 6 times a day for 5 to 7 days, for children over 8 years of age
D. Toothpaste swish: Brush teeth and swish the toothpaste around in the mouth after meals and at bedtime.
E. Oral hygiene: Rinse mouth gently with warm water.
VII. Education
A. With recurrent lesions, use Kenalog in Orabase as soon as tingling or burning is felt. This may be useful in aborting aphthae or shortening duration of ulcers.
B. Topical anesthetics
1. Dry lesion before using topical anesthetic.
2. Apply to lesion only; do not use on surrounding skin or mucous membrane.
3. Topical anesthetics provide pain relief for about 1 hour; do not overuse. Do not eat within 1 hour after using.
4. Do not use more than 120 mL (approximately 8 tbsp of Xylocaine Viscous) in 24 hours for children over 12 years. Maximum 40 mL for children ages 5 to 12 years.
C. Tetracycline compresses abort lesions, shorten healing, and prevent secondary infection.
1. Dissolve 250 mg tetracycline in 30 mL water. Apply for 20 to 30 minutes using gauze pledgets.
2. Do not eat or drink for 1/2 hour following treatment.
D. Identify triggering factor if possible; avoid specific foods or drugs felt to be precipitating factors.
E. Use soft toothbrush if trauma seems to precipitate lesions.
F. Encourage liquids.
G. A bland diet is helpful; avoid salty or acidic foods.
H. Recurrences are common.
I. Lesions heal in 1 to 2 weeks.
J. Lesions are not the same as cold sores.
VIII. Follow-up
A. Telephone follow-up in 24 hours if child is not taking liquids well
B. Routine follow-up visit not indicated
IX. Complications: Dehydration in a small child with several lesions
X. Consultation/referral
A. Infants
B. Any signs or symptoms of dehydration
C. Child with very large or many lesions, or with concurrent skin, ocular, or genital lesions