1. Protecting All Children’s Teeth
Oral Findings

2. Introduction
A physician in practice is likely to encounter many oral findings. It is important to be familiar with the more common oral findings to ensure proper diagnosis, management, and reassurance or referral.
Common oral findings in pediatrics are reviewed in this
presentation and are divided into acquired and congenital
or developmental categories.
Notes: Additional information on oral pathology is available online at

3. Learner Objectives
Permission on ile from IStock
Upon completion of this presentation, participants will be able to:
Recognize and appropriately manage common pediatric oral findings.
State the 3 types of oral ulcers.
Discuss etiologies of parotitis and their management.
List indications for intervention with ankyloglossia.
Recall the management of angular cheilitis, ranulas, mucoceles, and diastema.

4. Acquired Oral Findings
Acquired oral findings include:
1. Benign Migratory Glossitis
2. Morsicatio Buccarum
3. Pyogenic Granuloma
4. Ulcers
5. Angular Cheilitis (Perleche)
6. Leukoplakia (“White Patch”) in the Oral Cavity
7. Oral Hairy Leukoplakia
8. Parotitis

5. Benign Migratory Glossitis
AKA “Geographic Tongue”,
Benign migratory glossitis includes
loss of filiform papillae on certain
areas of the tongue, making it
appear smooth, red, and shiny.
Usually noted on the dorsum of the
tongue, etiology is unknown and self-limiting. 
Treatment is unnecessary because it does not pose a problem. However, it may be irritated by acidic foods. 
Notes:
The areas “migrate” by progression of papillae loss at the leading edge and regeneration at the other end. 
Complete glossitis is associated with underlying systemic conditions, especially nutritional deficiencies of iron, folate, or B12. Refer to for more information.
Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center

6.
Morsicatio Buccarum
Chronic, often subconscious, cheek biting results in mucosal shredding, erythema, ulcers or leukoplakia in the areas of biting.
AKA “Frictional Hyperkeratosis”
Usually symmetric along the buccal mucosa. Biting may also involve the labial and lingual mucosal surfaces. 
Glossary:
Leukoplakia: A condition commonly considered precancerous in which thickened white patches of epithelium occur on the mucous membranes especially of the mouth
Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC
Diagnosis can be made on clinical findings. If cheek biting is a manifestation of anxiety, treatment for underlying trigger may be warranted. No need for treatment if asymptomatic.

7. Linea Alba
In contrast to Morsicatio Buccarum, linea alba is a single white line across the buccal mucosa
Results from irritation of the teeth against the buccal mucosa along the plane of occlusion. No need for treatment if asymptomatic.
Moriscatio Buccarum
Linea Alba
Photos used with permission of Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

8. Pyogenic Granuloma
Pyogenic granuloma refers to red, painless masses usually located on the gingiva.
Characterized by bleeding with minor trauma and caused by vascular overgrowth in response to a local irritant or trauma. Improving flossing and brushing can result in spontaneous regression.
Can be triggered by hormones, such as in pregnancy and puberty.
Pyogenic granuloma may require surgical excision and can recur.
Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

9. Ulcers There are 3 types of ulcers:
1. Traumatic: Typically result from mechanical or thermal injury. Located on the buccal mucosa, tongue, lips, or palate. 
2. Infectious: Usually caused by HSV (primary or recurrent) or Coxsackie infections. HSV ulcers can be seen on the gingiva, lips, tongue, buccal mucosa, palate, pharynx, tonsils and skin. Coxsackie ulcers are typically prominent over the posterior soft palate.
3. Aphthous: Known as stomatitis (“canker sores”), these ulcers are round, yellowish-grey ulcers with surrounding erythema (halo) usually located on mucous membranes.
Notes:
Refer to for more information on infectious ulcers, including Primary HSV gingivostomatitis and Coxsackie.

10. Primary Herpetic Gingivostomatitis
Primary Herpetic Gingivostomatitis
Primary Herpetic Gingivostomatitis is
caused primarily by herpes simplex
virus type 1. The primary infection is
most severe and usually seen in
children under age 6.
Gingiva is friable and bleeds
Used with permission from Rama Oskouian
Due to painful vesicles and ulcers, children often refuse to drink and are at risk for dehydration.
Used with permission from Martha Ann Keels, DDS, PhD; 10

11. Primary Herpetic Gingivostomatitis
Treatment is mainly supportive with hydration maintenance and pain control.
The acyclovir family of antiviral medications may be used, especially for immunosuppressed patients.
The infection is life-long, and recurrences occur as “cold sores” (herpes labialis), usually at times of stress or infection. 
Herpes Labialis
For more information
Used with permission from Rama Oskouian 11

12. Aphthous Ulcers Divided into 3 categories:
1. Aphthous Minor Ulcers: Characterized
by small (usually 1-5 mm) lesions that heal without scarring.  
2. Aphthous Major Ulcers: Recurrent major aphthae may take up to 4 weeks to heal and may scar.
3. Herpetiform Ulcers: Grouped 1-2 mm papules, vesicles, or ulcers. Often very painful.
Notes:
Aphthous minor ulcers are common, accounting for 80% of cases, and last 5 to 12 days.
Aphthous major ulcers account for approximately 15% of cases and are greater than 1 cm in diameter.
Herpetiform ulcers are the least common type.
Glossary:
Aphthae: A speck or blister on the mucous membranes characteristic of some diseases
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

13. Aphthous Ulcers, continued
The etiology of aphthous ulcers is
unknown, but they may be
infectious, autoimmune, allergic,
nutritional, or traumatic in nature.
Treatment includes supportive
care, bland diet (avoid spicy and
citrus), and topical anesthetic
creams or mouthrinses.
Recurrence is likely.
Notes:
Aphthous ulcers are more common in individuals with inflammatory bowel disease, celiac disease, immunosuppression, cyclic neutropenia, rheumatologic disorders (eg, JRA, SLE) or vitamin deficiencies (B12, folate, iron, zinc).
The benefits of using topical creams or mouthrinses for treatment of aphthous ulcers is not well established.
Common medication triggers are NSAIDs and ACE inhibitors.
Glossary:
Neutropenia: Leukopenia in which the decrease in white blood cells is chiefly in neutrophils
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

14. Angular Cheilitis (Perleche)
Angular cheilitis presents as erythema, fissures, and erosions at the corners of the mouth.
May be triggered by lip-licking, sensitivity to a compound, vitamin deficiency (riboflavin), or iron deficiency. 
Notes:
Angular cheilitis may cause a painful or burning sensation. 
It may be caused or worsened by candidal or staph superinfection.
Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham
Treatment includes topical yeast treatment (Nystatin), topical
antibiotic agents (Mupirocin), or low-dose topical steroids.

15. Leukoplakia in the Oral Cavity
In children, leukoplakia in the oral cavity is most often the result of chronic irritation, such as cheek or tongue biting.
Etiologies may also include vitamin deficiency and candidiasis. 
In adults, especially those who are chronic tobacco users, leukoplakia is considered a pre-malignant lesion, but this is not the case for children.
Notes:
If the lesions are unusual or persistent, or if the child has other unusual features, consider a genetic condition, such as dyskeratosis congenita.
Glossary:
Leukoplakia: A condition commonly considered precancerous in which thickened white patches of epithelium occur on the mucous membranes especially of the mouth
White plaques on undersurface of tongue
Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

16. Oral Hairy Leukoplakia
Oral hairy leukoplakia present as white lesions on any surface of the tongue (most often along the sides of the tongue) or on the buccal mucosa.
The lesions are not painful and may be smooth and flat, irregular, and “hairy” or “feathery” in appearance. 
Benign and self-limited finding.
No treatment is usually required.
Notes:
Oral hairy leukoplakia is caused by the Epstein-Barr virus (EBV) and usually seen in immunocompromised patients, especially immunocompromise from HIV.
Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

17. Parotitis
Parotitis is the clinical term for inflammation and swelling of the parotid gland.
With parotitis, the parotid gland is tender to palpation and the opening to Stenson’s duct appears inflamed and swollen.
Notes:
If the clinician is unclear if the swelling noted is actually the parotid gland and not another structure, an elevated serum amylase can be confirmatory.
Etiologies of parotitis include infectious causes, obstruction, and other conditions.

18. Viral Causes of Parotitis
Mumps is the classic virus
known to cause parotitis.
Mumps parotitis is bilateral
in 70% of cases and usually
follows a 1-2 day prodrome
of fever, headache, emesis,
and myalgias. 
Notes:
Although mumps is less common in this age of universal immunization with MMR vaccine, there have been many well-documented outbreaks in the United States in the recent past.
Other viruses that may cause parotitis include parainfluenza, influenza, CMV, EBV, enteroviruses, and HIV.
Used with permission from the AAP Red Book

19. Bacterial Causes of Parotitis
Called “purulent parotitis”, bacterial
infection of the parotid gland is
typically unilateral and extremely
painful with visible pus draining
from Stenson’s duct.
The patient often appears ill and
should be empirically treated with
antibiotics after culture obtained.
Notes:
Purulent parotitis is most commonly caused by S aureus, either as a primary infection or super infection of parotitis of another cause (most commonly a duct obstruction). 
Used with permission from Lauren Barone

20. Obstruction Sialolith Parotitis from obstruction is
typically the result of a salivary
stone or sialolith, which is
expected to be unilateral.
If the patient is not ill,
expectant management for
passage of the sialolith is
appropriate.
Notes:
Rarely, parotid duct obstruction can result from a tumor, which is usually benign.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

21. Other Conditions Other conditions that can result in parotid gland
enlargement (with or without inflammation) include:
Bulimia or other causes of chronic emesis
Diabetes
Collagen vascular diseases
Local radiation treatment

22. Congenital and Other Oral Findings
1. Inclusion Cysts
2. Natal and Neonatal Teeth
3. Congenital Epulis
4. Ankyloglossia
5. Cleft Lip/Palate
6. Bifid Uvula
7. Ranula/Mucocele
8. Eruption Cyst/Hematoma
9. Bony Tori (“Torus
Palatinus or Mandibularis”)
10. Diastema
11. Macroglossia
12. Micrognathia

23. Inclusion Cysts
Small, white or translucent papules or cysts seen in newborns. Usually asymptomatic and resolve spontaneously by 3 months of age. There are 3 types of inclusion cysts found in newborns:  
1. Epstein’s Pearls 
2. Bohn’s Nodules 
3. Dental lamina cysts
No treatment is necessary.
Notes:
Inclusion cysts are present in 75% of newborns.

24. Used with permission from Rama Oskouian
Epstein’s Pearls
Epstein’s Pearls
Epstein’s Pearls are epithelial remnants of palatal fusion located along the mid-palatal raphe of the hard palate.
Resolve spontaneously with no need for evaluation or intervention.
Used with permission from Rama Oskouian

25. Bohn’s Nodules and Dental Lamina Cysts
Bohn’s Nodules are heterotopic salivary gland remnants located on the buccal or lingual surface of the alveolar ridge (not the crest), or on the hard palate, away from the raphe. 
Dental lamina cysts are located on the crest of the alveolar ridge.
Bohn’s Nodules
Used with permission from Rama Oskouian

26. Natal and Neonatal Teeth
Some infants erupt teeth, usually lower incisors, before birth (natal teeth) or shortly thereafter (neonatal teeth).
Most often primary (not extra) teeth.
No treatment is generally indicated. Extraction may be considered only if teeth are mobile, interfere with breastfeeding, or lead to Riga-Fede ulceration. Avoid wiggling as not to loosen the tooth.
Notes:
Refer to (Dental Development: Tooth eruption) for more information about natal and neonatal teeth.
Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

27. Congenital Epulis
Epulis
Pedunculated, non-tender, spongy mass is usually located on the anterior maxillary alveolar ridge.
Congenital Epulis is benign in nature and may regress spontaneously. If it is large and interferes with feeding, excision may be required.
Recurrence is unlikely.
Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

28. Developmental Tooth Defects
Amelogenesis Imperfecta
Enamel hypoplasia can result from a number of environmental insults during development, including
• Infection
• Toxins (lead or mercury),
• Fluoride
• Medications
• Prematurity
Notes:
Refer to and for more information about enamel hypolpasia. 
Glossary:
Enamel: Intensely hard calcareous substance that forms a thin layer partly covering the teeth; the hardest substance of the animal body; consists of minute prisms arranged at right angles to the surface and bound together by a cement substance Hypoplasia: A condition of arrested development in which an organ or part of an organ remains below the normal size or in an immature state
Amelogenesis Imperfecta: Faulty development of tooth enamel that is genetically determined
Tim Wright DDS, MS
Professor and Chair Department of Pediatric Dentistry
The University of North Carolina School of Dentistry

29. Developmental Tooth Defects
Inherited enamel defects include Amelogenesis Imperfecta (AI, often autosomal dominant). AI results in hypoplastic and hypocalcified enamel, which appears yellow or brown and is easily worn away.
Tim Wright DDS, MS
Professor and Chair Department of Pediatric Dentistry
The University of North Carolina School of Dentistry

30. Developmental Tooth Defects
Inherited dentin defects include Dentinogenesis Imperfecta which vary in phenotypic expression and are usually inherited in an autosomal dominant manner.
DI can be a clinical feature of Osteogenesis Imperfecta
Notes:
Dentinogenesis Imperfecta Type I may be associated with Osteogenesis Imperfecta. 
Abnormal tooth development can result from many other genetic and systemic conditions.
Glossary:
Dentin: A calcareous material similar to bone but harder and denser that composes the principal mass of a tooth; consists of a matrix containing minute parallel tubules which open into the pulp cavity and during life contain processes of the cells of the pulp
Tim Wright DDS, MS
Professor and Chair Department of Pediatric Dentistry
The University of North Carolina School of Dentistry
Teeth appear blue-gray or yellow-brown because the abnormal dentin shines through the enamel. Teeth have increased susceptibility to fracture and spontaneous abscess.

31. Ankyloglossia Ankyloglossia refers to a congenitally short lingual
frenulum that ties the tongue
to the floor of the mouth,
decreasing its mobility.
The tongue appears notched or heart-shaped at the tip. 
In general, no intervention is recommended. Treat with
frenectomy if severe enough to interfere with feeding or speech.
Notes:
Ankyloglossia is noted in 4% to 5% of newborns.
Significant ankyloglossia may result in speech articulation difficulties, specifically with “s” and “t” sounds. 
May interfere with breastfeeding or bottle-feeding, but this generally only occurs if the baby cannot protrude the tongue past the front teeth ridge. 
A severity scale, called the Hazelbaker Assessment Tool for Lingual Frenulum Function, was developed but it has not received universal acceptance because it is not well-validated.
Glossary:
Frenectomy: Excision of a frenulum
Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital

32. Cleft Lip/Palate
Cleft lip and/or palate may cause feeding, swallowing, and respiratory difficulties in infancy, along with speech and cosmetic concerns. 
Surgical repair is typically approached in a step-wise fashion.
Outcomes are best with a team treatment approach. Primary care providers are encouraged to utilize an interdisciplinary team for cleft lip and palate management.
Notes:
Cleft lip, including cleft lip with palate, is the most common craniofacial anomaly at a rate of 1 to 2 cases per 1,000 births. 
A cleft may be an isolated occurrence or arise in association with a syndrome.
A cleft may result from teratogen exposure, insufficiency of an essential nutrient, or be genetic or syndromic.
Reference: Austin AA, Druschel CM, Tyler MC, et al. Interdisciplinary Craniofacial Teams Compared With Individual Providers: Is Orofacial Cleft Care More Comprehensive and Do Parents Perceive Better Outcomes? Cleft Palate–Craniofacial Journal, January 2010, Vol. 47(1): 1-8.
Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

33. Bifid Uvula
Bifid uvula can be an isolated finding but is often associated with a congenital submucosal cleft, which may be difficult to appreciate on examination. 
Children with submucosal clefts may develop hypernasal speech. Children with a bifid uvula should be referred for speech therapy and for ENT evaluation if speech concerns arise.

34. Mucocele A mucocele is a bluish or translucent
cyst resulting from accumulation of
mucous from trauma to a minor
salivary gland.
Mucoceles generally require no
treatment and many resolve
spontaneously. Fluctuations in size are
common.
If the lesion is large or uncomfortable,
excision may be warranted.
Notes:
Usually located on the lower lip, mucoceles are generally painless and can range from very small to several centimeters in size.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

35. Ranula
A ranula is a larger collection of mucous under the tongue that is unilateral.
Unlike mucoceles, ranulas require surgical excision with marsupialization of larger lesions because they are likely to recur.
Notes:
Ranulas result from blockage of a major or minor salivary duct located on the floor of the mouth.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

36. Eruption Cyst or Hematoma
Eruption hematoma
Eruption cysts develop 1 to 3 weeks prior to tooth eruption as a dome shaped soft tissue lesion overlying the erupting tooth.
When mixed with blood, it appears more bluish and is referred to as an eruption hematoma.
No treatment is recommended because the cyst will resolve spontaneously when the tooth completely erupts.
Notes:
As the tooth breaks through, the fluid becomes bloody and blue or purple in color (an eruption hematoma). 
Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

37. Bony Tori (“Torus Palatinus” or “Mandibularis”)
Bony tori refer to benign bony overgrowth (exostosis) in the midline of the hard palate (palatinus) or the lingual aspect of the mandible (mandibularis), where they are often bilateral and symmetric. 
Bony tori do not require intervention unless the lesion becomes painful, ulcerated, or interferes with speech or eating.
Notes:
Torus palatinus is quite common and often not present or noticeable until adulthood, often in the third decade.
Approximately 20% to 30% of the adult population develops a torus palatinus. Torus mandibularis is less common. 

38. Diastema Diastema refers to the space between the central incisors
associated with a prominent
maxillary frenum.
Diastema is normal in childhood,
but a diastema greater than 3
mm after eruption of the
permanent upper canines (ages
10 to 13) should be evaluated
for treatment.
Notes:
Treatment options for diastema include orthodontic treatment or a frenectomy.
Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center

39. Macroglossia Macroglossia refers to enlargement of the tongue.
With macroglossia, airway maintenance and feeding are paramount.
Involve appropriate specialists (ENT, genetics) to ensure timely evaluation and management.
Notes:
Macroglossia has a wide differential that includes Down syndrome, Beckwith-Wiedemann, Hurler’s syndrome, hypothyroidism, Rubenstein-Taybi, and local factors (lymphangioma, hemangioma).

40. Micrognathia
Micrognathia denotes a small jaw, commonly from hypoplasia of the mandible. 
This can be an isolated finding or can be associated with a number of syndromes.
Notes:
Syndromes with which micrognathia can be associated include Pierre Robin sequence, Treacher Collins syndrome, Goldenhar’s syndrome, or Cri du-chat (5p-syndrome).
Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

41. Question #1 A small jaw from hypoplasia of the mandible is known as
A. Macroglossia
B. Micrognathia  
C. Bony Tori  
D. Diastema 
E. Angular Cheilitis

42. Answer A small jaw from hypoplasia of the mandible is known as
A. Macroglossia
B. Micrognathia 
C. Bony Tori  
D. Diastema 
E. Angular Cheilitis

43. Question #2
Which of the following is indicative of a geographic tongue?  
A. Chronic cheek biting
B. Erosions at the corner of the mouth
C. Loss of filiform papillae on areas of the tongue that appear smooth, red, and shiny
D. White lesions on the tongue 
E. Yellowish-grey cysts

44. Answer Which of the following is indicative of a geographic tongue?
A. Chronic cheek biting 
B. Erosions at the corner of the mouth
C. Loss of filiform papillae on areas of the tongue that appear smooth, red, and shiny
D. White lesions on the tongue
E. Yellowish-grey cysts

45. Question #3
In deciding whether to intervene when a newborn is diagnosed with ankyloglossia, the most important factor is:  
A. The input of a professional lactation consultant
B. How far the baby can extend his or her tongue
C. Breastfeeding success and maternal pain with latching
D. Parental input. This is an elective procedure and should be done only if the parents request it
E. None of the above because intervention is rare for newborns and recommended only in severe cases

46. Answer
In deciding whether to intervene when a newborn is diagnosed with ankyloglossia, the most important factor is:  
A. The input of a professional lactation consultant
B. How far the baby can extend his or her tongue 
C. Breastfeeding success and maternal pain with latching
D. Parental input. This is an elective procedure and should be done only if the parents request it
E. None of the above because intervention is rare for newborns and recommended only in severe cases

47. Question #4
Which of the following statements about aphthous ulcers is correct?  
A. Aphthous ulcers can be divided into 3 categories
B. Aphthous ulcers etiology is unknown
C. Aphthous ulcers are more common in individuals with inflammatory bowel disease
D. All of the above
E. None of the above

48. Answer
Which of the following statements about aphthous ulcers is correct?  
A. Aphthous ulcers can be divided into 3 categories 
B. Aphthous ulcers etiology is unknown
C. Aphthous ulcers are more common in individuals with inflammatory bowel disease
D. All of the above
E. None of the above

49. Question #5
What is the most appropriate course of action when a ranula is diagnosed?  
A. Incise and drain the lesion
B. Refer for excision
C. Observe for spontaneous resolution
D. Prescribe a 10-day course of oral antibiotics 
E. None of the above

50. Question #5
What is the most appropriate course of action when a ranula is diagnosed?  
A. Incise and drain the lesion 
B. Refer for excision
C. Observe for spontaneous resolution
D. Prescribe a 10-day course of oral antibiotics
E. None of the above

51. References
1. Brown GC et al. Partners in Prevention- Infant Oral Health Manual for Health Professionals. New York University College of Dentistry; Department of Pediatric Dentistry. 2nd Edition, 2000.
2. Ferretti GA, Cecil JC. Kids Smile: Oral Health Training Program Lecture Series. Sponsored by the Kentucky Department for Public Health and the University of Kentucky College of Dentistry.
3. Krol DM, Keels, MA. Oral Conditions. Pediatr Rev. 2007; 28(1):
4. Messadi DV, Waibel JS, Mirowski GW. White lesions of the oral cavity. Dermatologic Clinics. 2003; 21:
5. Witman PM, Rogers RS. Pediatric Oral Medicine. Dermatol Clin. 2003; 21:
6. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.