Private Higher Educational Institution “Kyiv

Medical University”

APPROVED BY
Department Chairman
M.D..,Professor.
Yakubova І. І.
As of August « 28 » 2019.

DEPARTMENT OF CHILDREN DENTAL THERAPY

Methodical Guidelines for Students
in discipline
“CHILDREN DENTAL THERAPY”
Subject № 12
“Chronic recurrent aphthous stomatitis in children. Clinical
presentation, diagnosis and pediatric dentist’s policy”.

For the students of the 5th year, the

9th semester Faculty of Dentistry
Duration of Practical Training – 2,5 academic
hours

KYIV-2019
Methodical guideline has been developed by the Associate Professor
of the Department of Children Dental Therapy Kochyn O.V.
Discussed and approved at the department meeting of children dental therapy
August 28 2019 (protocol №1)
 RELEVANCE OF THE SUBJECT:

Knowledge of the clinical progression peculiarities of chronic recurrent

aphthous stomatitis, principles of the child examination gives the dentist the
opportunity to determine a correct diagnosis, prescribe local treatment and take a
complex of preventive measures.

LEARNING GOALS AND OBJECTIVES

1. To know etiology, pathogenesis and clinical manifestations of chronic recurrent
aphthous stomatitis in children.
2. To know criteria for diagnosis and differential diagnosis of chronic recurrent
aphthous stomatitis in children.
3. To know groups of medicines used for local treatment of chronic recurrent
aphthous stomatitis in children, the mechanism of their action.
THE LIST OF THEORETICAL ISSUES
1. Name etiology, risk factors and pathogenesis of chronic recurrent aphthous
stomatitis.
2. Describe the lesion elements in case of сhronic recurrent aphthous stomatitis.
How many forms of chronic recurrent aphthous stomatitis exist depending on the
relapses frequency? Give a brief description of each one.
3. With what diseases it is necessary to perform differential diagnostics of chronic
recurrent aphthous stomatitis, substantiate your answer.
4. Describe the local treatment schedule for chronic recurrent aphthous stomatitis in
children.
5. Describe the general treatment schedule for chronic recurrent aphthous stomatitis
in children.

LEARNING MATERIAL CONTENT:

Chronic recurrent aphthous stomatitis is an autoallergic disease caused by
the sensitization pathogenic microorganisms of the gastrointestinal tract, viruses,
microbial and foodborne antigens. Chronic recurrent aphthous stomatitis occurrence
is facilitated by certain pathological processes, in particular, gastrointestinal tract -
dysbacteriosis, biliary tract dyskinesia, chronic gastritis, colitis, enteritis,
helminthiasis, as well as diathesis, bronchial asthma, diseases of ENT organs (otitis,
rhinitis, pharyngitis).
Clinical presentation – the most frequent localization of the aphthae are the
tongue, lips, transitory fold, mucosa, tongue frenulum, more rarely - cheeks, the hard
and soft palate. Aphtha looks like a small erosion, round or oval shaped, covered with
a yellowish or grayish-white plaque, surrounded by an inflamed vermillion border.
Size of the aphtha is 5-7 mm, sharply painful, accompanied with hyper salivation.
Depending on the frequency of relapses 3 forms of recurrent aphthous
stomatitis:
 Mild
 Moderate
  Severe

In case of mild form, aphthae relapses (individual) are occurred once every
few years.
In case of moderate form, aphthae relapses are occurred 1-3 times a year.
Severe forms are characterized by individual or multiple rashes, which are
located both in the anterior parts of the oral cavity and in the mucous membrane of
the hard and soft palate. Relapses occur more frequently 4 times a year, sometimes
occurring continuously. In severe cases, aphtha becomes a painful ulcer with high
edges, localized in association with inflammatory infiltrate (Setton aphtha). An
individual form of ulcer is Behçet's syndrome, which is manifested by occurrence of
ulcers of the oral, eyes, genitals mucosa. It differs from common aphthae in depth of
the mucosa lesion, in some patients, nervous system, skin and internal organs’ lesions
are observed.
Chronic recurrent aphthous stomatitis should be differentiated from:
 Acute herpetic stomatitis
 Chronic recurrent herpes
 Permanent injury to the oral cavity mucosa
Treatment: examination of a child by the dentist is performed simultaneously with a
pediatrician (or other related specialists - a gastroenterologist, allergist,
immunologist, ENT specialist). Identification and sanitation of chronic infection
lesions, treatment of concomitant diseases, immunobiological reactivity increase of
the body, treatment of local manifestations of the disease.
The purpose of local treatment is to relieve pain, prevent secondary infection of the
aphthae, and epithelialization process acceleration. To anesthetize the elements of the
lesions, oil emulsions containing Anaesthesinum, analgesic gels are used. To prevent
secondary infection of the aphthae, it is necessary to carry out daily hygienic
treatment of the oral cavity, mouth washing 3-4 times a day with antiseptic
solutions(0.1-0.5% Ethonium solution, Rotocanum solution, decoctions and herbal
tincture - chamomile, sage, gum tree (especially after meal) To clean the aphthae
surface and improve metabolic processes, it is advisable to use enzyme preparations
(Terrlityn, Trypsinum, Chymotrypsin, Chymopsinum). To accelerate epithelialization
processes of the lesion elements, keratoplastic remedies - vegetable oil, liposoluble
vitamins, Propolis ointment, and Trimethazole aerosol.

PRACTICAL SKILLS (DENTISTRY MANIPULATIONS):

1. To perform differential diagnosis of chronic recurrent aphthous stomatitis in
children.
2. To perform local treatment of chronic recurrent aphthous stomatitis in children.
 EXAMPLES OF TEST TASKS FOR STUDENTS 'SELF-TRAINING
1. A child at the age of 10 has complained of the painful formation occurrence in
the oral cavity, bothering when having meal. The child felt this symptom first 2
years ago. According to the anamnesis: chronic colitis is occurred. Objectively:
Oral cavity has been sanitized, any orthodontic pathology has not been determined.
Painful oval shaped erosion with clear hyperemic contour covered with a grayish-
white plaque has been revealed on the oral cavity mucosa. Lymph nodes are not
enlarged. What is your medical diagnosis?

A. Chronic recurrent herpetic stomatitis

B. Setton Aphtha
C. Chronic recurrent aphthous stomatitis
D. Papular syphilis
E. Acute herpetic stomatitis
2. A girl at the age of 8 years old has complained of pain in the oral cavity during
meal. Objectively: oval shaped erosion, 5x7mm in size, covered with yellowish
plaque, having vermillion border has been revealed along the transitory fold in the
frontal part of the mandible. A similar erosion was observed a year ago. Determine
the most likely diagnosis.
A. Recurrent herpetic stomatitis
B. Chronic recurrent aphthous stomatitis
C. Behçet's syndrome,
D. Setton Aphtha
E. Acute herpetic stomatitis
3. A boy at the age of 11-year-old has complained of painful ulcers occurrence in
the oral cavity. Similar symptoms were determined last year. Objectively: 2 oval
shaped erosions, up to 0.5 cm in size, covered with fibrinous plaque, painful on
palpation have been revealed on the lateral surface of the tongue. Erosions are
surrounded by hyperemic border, their edges slightly rising above the surrounding
mucous membrane. According to the anamnesis, the child has got a chronic
gastroduodenitis. Determine the most likely diagnosis.
A. Chronic recurrent aphthous stomatitis of moderate severity
B. Erythema exsudativum multiforme
C. Behçet's syndrome
D. Chronic recurrent aphthous stomatitis of mild severity
E. Chronic recurrent aphthous stomatitis, severe degree
4. Parents of a child at the age of 11-year-old have complained of several painful
ulcers occurrence in the oral cavity that appear three times a year. Three oval
shaped erosions up to 0.7 cm in diameter with hyperemic border have been
revealed on the swollen mucous membrane of the lower lip and tongue. Erosive
elements have been covered with whitish-gray plaque, being sharply painful on
palpation. Erosion edges are slightly rising above the surrounding mucous
membrane. According to the anamnesis, the child has got a food allergy.
Determine a previous diagnosis.
A. Recurrent aphthous stomatitis
B. Moderate form of chronic recurrent aphthous stomatitis
C. Mild form of chronic recurrent aphthous stomatitis
D. Severe form of chronic recurrent aphthous stomatitis
E. There is no correct answer
5. A child at the age of 13 has complained of periodic (once every 3 months)
occurrence of very painful formations in the oral cavity. 2 Erosions 0.8x1 cm in
size on the infiltrated base with rising thick edges, covered with whitish-gray
plaque have been determined on the mucous membrane of the lower lip.
According to the anamnesis: exudative diathesis, chronic cholecystitis are
occurred. What is your expected diagnosis?
A. Chronic recurrent aphthous stomatitis
B. Recurrent herpetic stomatitis
C. Vincent's stomatitis
D. Erythema exsudativum multiforme
E. Setton stomatitis
6. A girl at the of 3 months old has been referred for consultation to the dentist in
connection with «ulcer" occurrence in the oral cavity. She was born prematurely,
receiving artificial feeding. Objectively: Erosion 1.2 × 1.0 cm in size, outstretched
anteroposteriorly, covered with yellow-gray plaque, surrounded by infiltrate in the
form of a low roller, has been found on the border of the hard and soft palate.
Determine a previous diagnosis.
A. Bednar’s Aphtha
B. Chronic recurrent aphthous stomatitis
C. Setton Aphtha
D. Decubital ulcer
E. Acute mycotic stomatitis
7. A 9 year old child has complained of pain in the oral cavity while talking and
having meal. Objectively: oval shaped erosion with size of 6 x8 mm, covered with
yellowish plaque, having vermillion border has been revealed on the lateral surface
of the tongue. Similar erosion was observed 6 months ago. Determine the
diagnosis.
A. Recurrent herpetic stomatitis
B. Chronic recurrent aphthous stomatitis
C. Behçet's syndrome,
D. Setton Aphtha
E. Acute herpetic stomatitis
8. Risk factors for the development of chronic recurrent aphthous stomatitis are
the following:
A. Diseases of ENT-organs
B. Diathesis
C. Biliary dyskinesia
D. Bronchial asthma
E. All answers are correct
9. A girl at the age of 10 years old complained of ulcers occurrence and pain in the
oral cavity, especially during meal. Objectively: 2 Aphthae up to 0.6 cm in size,
covered with yellowish plaque, sharply painful on the transitory fold of the mucous
membrane in the area of the front teeth of the mandible. Diagnosis of chronic
recurrent aphthous stomatitis has been determined. Which of the following drugs
should be prescribed to the child for local treatment in this case?
A.Imudon
B. Lysozyme solution
C. Enterosgelum
D. Zovirax ointment
E. Clotrimazolum ointment
10. A 14-year-old girl has complained of ulcers occurrence and pain in the oral
cavity, especially during meal. Objectively: 2 Aphthae up to 8 mm in size covered
with yellowish plaque, sharply painful have been revealed on the transitory fold of
the mucous membrane in the area of the front teeth of the mandible. Diagnosis of
a chronic recurrent aphthous stomatitis has been determined. What related
specialists should you consult to determine the cause of the disease?
A. Gastroenterologist
B. Allergist
C. ENT specialist
D. Immunologist
E. All answers are correct
RECOMMENDED LITERATURE:
І. Principal:
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