A 10-year-old boy visited Prof. Soedomo Dental Hospital at Universitas Gadjah Mada (RSGM UGM) with a complaint that had become all too familiar to him: painful ulcers on his lower left lip, the floor of his mouth, and his tongue. It was not the first occurrence, nor was it a coincidence. The ulcers appeared almost every month, always in the same locations and typically after prolonged chewing or speaking. This time, the trigger was a mandibular space maintainer that had been fitted just three days earlier—and had shifted slightly out of position.
The case was subsequently documented and published in Improve Quality in Dentistry (IMUNITY) , Volume 2 (2025), by dr. drg. Faisal Rizki and Dr. drg. Indra Bramanti, M.Sc., Sp.KGA(K), a pediatric dentistry specialist and faculty member at the Faculty of Dentistry, Universitas Gadjah Mada. Their findings highlight an often-overlooked fact: recurrent aphthous stomatitis (RAS) in children is not merely the result of impaired immunity. Rather, it is a multifactorial condition that may be triggered by something as seemingly insignificant as a misaligned orthodontic wire.
A Condition That Keeps Returning
Recurrent aphthous stomatitis (RAS) is the most common cause of oral ulceration, affecting approximately 5–25% of the general population. The condition most frequently occurs between the ages of 10 and 19, making school-aged children and adolescents particularly susceptible. Ironically, this is also the period during which many children undergo orthodontic treatment, experience mixed dentition, and are still developing good oral hygiene practices.
In this patient, clinicians identified two primary mechanical factors contributing to the recurrent ulcers. First, the removable acrylic space maintainer had sharp edges that repeatedly irritated the soft tissues of the floor of the mouth and the lower lip. Second, the patient had developed a longstanding habit of chewing exclusively on the right side because he had experienced discomfort during the eruption of his permanent molars. As a result, he repeatedly bit his tongue while chewing and speaking.
"Mechanical trauma caused by the use of the space maintainer, combined with unilateral chewing habits, constituted the primary predisposing factors for recurrent aphthous stomatitis in this patient."
The unilateral chewing habit was objectively assessed using a standardized chewing gum test, during which the patient chewed gum 20 times. The result—a score of 3—indicated only minimal mixing of the food bolus, suggesting poor bilateral masticatory function. Clinical examination also revealed mandibular deviation during mouth closure.
Measuring Ulcers with Numbers
One notable aspect of this case report is the use of the Ulcer Severity Score (USS), an assessment tool that quantifies ulcer severity using six clinical parameters: the number of ulcers, ulcer size, duration, ulcer-free period, lesion location, and pain intensity. The patient's initial USS was 23, reflecting a relatively severe presentation with three active ulcers located in different areas of the oral cavity.
Management consisted of two complementary approaches. The first focused on lifestyle and mechanical modifications. The patient was instructed to chew using both sides of the mouth, maintain good oral hygiene, and take vitamin C supplements to support tissue regeneration. The space maintainer was also adjusted by smoothing its acrylic edges and repositioning the labial wire so that it no longer irritated the lip mucosa.
The second approach involved topical therapy using 8 mg Aloclair® Gel, applied as a thin layer twice daily. The gel contains polyvinylpyrrolidone (PVP), which acts as an anti-inflammatory agent while maintaining moisture over the ulcer surface. This mechanism is particularly relevant because RAS is characterized by an acute inflammatory response involving vasodilation, plasma exudation, and leukocyte accumulation within the affected tissue.
The therapeutic outcome was measurable. Three days after treatment, the USS decreased from 23 to 22. Seven days later, it declined further to 18. The greatest improvement was observed in the pain component, which reached a score of zero by the second follow-up visit.
More Than Just a Common Mouth Ulcer
The significance of this report lies not only in its treatment strategy but also in its clinical perspective. Dr. drg. Indra Bramanti, M.Sc., Sp.KGA(K), and dr. drg. Faisal Rizki emphasize that recurrent aphthous stomatitis should not be managed as an isolated complaint that can simply be treated with topical medication. Instead, clinicians should investigate the multiple local factors that may collectively contribute to the condition.
may collectively contribute to the condition. In this case, several contributing factors were identified simultaneously: a displaced space maintainer, a poorly positioned labial wire, an asymmetrical chewing pattern, poor oral hygiene (OHI-S score of 3.5, classified as poor), and chronic gingivitis in the anterior mandibular region. These were not isolated findings but rather interconnected factors that reinforced one another and perpetuated the patient's recurrent oral ulcers.
The authors also acknowledge the study's limitations. Other factors known to contribute to RAS—including nutritional status, psychological stress, and immune function—were not investigated in depth. They recommend that future studies employ multivariable analyses to better clarify the relative contribution of these factors.
For dental practitioners, the message from this case is straightforward: every orthodontic appliance placed in a child's mouth requires careful monitoring. Sharp appliance edges, improperly positioned wires, or oversized acrylic plates are not merely minor sources of discomfort—they can become persistent triggers for recurrent oral ulcers lasting months or even years if the underlying cause is not addressed.
For this 10-year-old patient, meaningful improvement began with a surprisingly simple change: learning to chew on both sides of the mouth.
Authors: Nanda Ayu; drg. Achmad Zam Zam Aghasy, M.Kes.
Photo: Pexels