2IntroductionA 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 thispresentation and are divided into acquired and congenitalor developmental categories.Notes: Additional information on oral pathology is available online at
3Learner ObjectivesPermission on ile from IStockUpon 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.
5Benign Migratory Glossitis AKA “Geographic Tongue”,Benign migratory glossitis includesloss of filiform papillae on certainareas of the tongue, making itappear smooth, red, and shiny.Usually noted on the dorsum of thetongue, 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
6Morsicatio BuccarumChronic, 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 mouthUsed with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSCDiagnosis 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.
7Linea AlbaIn contrast to Morsicatio Buccarum, linea alba is a single white line across the buccal mucosaResults from irritation of the teeth against the buccal mucosa along the plane of occlusion. No need for treatment if asymptomatic.Moriscatio BuccarumLinea AlbaPhotos used with permission of Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC
8Pyogenic GranulomaPyogenic 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
9Ulcers 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.
10Primary Herpetic Gingivostomatitis Primary Herpetic GingivostomatitisPrimary Herpetic Gingivostomatitis iscaused primarily by herpes simplexvirus type 1. The primary infection ismost severe and usually seen inchildren under age 6.Gingiva is friable and bleedsUsed with permission from Rama OskouianDue 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
11Primary 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 LabialisFor more informationUsed with permission from Rama Oskouian11
12Aphthous Ulcers Divided into 3 categories: 1. Aphthous Minor Ulcers: Characterizedby 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 diseasesUsed with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina
13Aphthous Ulcers, continued The etiology of aphthous ulcers isunknown, but they may beinfectious, autoimmune, allergic,nutritional, or traumatic in nature.Treatment includes supportivecare, bland diet (avoid spicy andcitrus), and topical anestheticcreams 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 neutrophilsUsed with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital
14Angular 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 BirminghamTreatment includes topical yeast treatment (Nystatin), topicalantibiotic agents (Mupirocin), or low-dose topical steroids.
15Leukoplakia 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 mouthWhite plaques on undersurface of tongueUsed with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC
16Oral 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
17ParotitisParotitis 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.
18Viral Causes of Parotitis Mumps is the classic virusknown to cause parotitis.Mumps parotitis is bilateralin 70% of cases and usuallyfollows a 1-2 day prodromeof 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
19Bacterial Causes of Parotitis Called “purulent parotitis”, bacterialinfection of the parotid gland istypically unilateral and extremelypainful with visible pus drainingfrom Stenson’s duct.The patient often appears ill andshould be empirically treated withantibiotics 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
20Obstruction Sialolith Parotitis from obstruction is typically the result of a salivarystone or sialolith, which isexpected to be unilateral.If the patient is not ill,expectant management forpassage of the sialolith isappropriate.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
21Other Conditions Other conditions that can result in parotid gland enlargement (with or without inflammation) include:Bulimia or other causes of chronic emesisDiabetesCollagen vascular diseasesLocal radiation treatment
22Congenital and Other Oral Findings 1. Inclusion Cysts2. Natal and Neonatal Teeth3. Congenital Epulis4. Ankyloglossia5. Cleft Lip/Palate6. Bifid Uvula7. Ranula/Mucocele8. Eruption Cyst/Hematoma9. Bony Tori (“TorusPalatinus or Mandibularis”)10. Diastema11. Macroglossia12. Micrognathia
23Inclusion CystsSmall, 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 cystsNo treatment is necessary.Notes:Inclusion cysts are present in 75% of newborns.
24Used with permission from Rama Oskouian Epstein’s PearlsEpstein’s PearlsEpstein’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
25Bohn’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 NodulesUsed with permission from Rama Oskouian
26Natal 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
27Congenital EpulisEpulisPedunculated, 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
28Developmental Tooth Defects Amelogenesis ImperfectaEnamel hypoplasia can result from a number of environmental insults during development, including• Infection• Toxins (lead or mercury),• Fluoride• Medications• PrematurityNotes: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 stateAmelogenesis Imperfecta: Faulty development of tooth enamel that is genetically determinedTim Wright DDS, MSProfessor and Chair Department of Pediatric DentistryThe University of North Carolina School of Dentistry
29Developmental 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, MSProfessor and Chair Department of Pediatric DentistryThe University of North Carolina School of Dentistry
30Developmental 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 ImperfectaNotes: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 pulpTim Wright DDS, MSProfessor and Chair Department of Pediatric DentistryThe University of North Carolina School of DentistryTeeth appear blue-gray or yellow-brown because the abnormal dentin shines through the enamel. Teeth have increased susceptibility to fracture and spontaneous abscess.
31Ankyloglossia Ankyloglossia refers to a congenitally short lingual frenulum that ties the tongueto 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 withfrenectomy 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 frenulumMartha Ann Keels, DDS, PhD; Division Head of DukePediatric Dentistry, Duke Children's Hospital
32Cleft Lip/PalateCleft 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
33Bifid UvulaBifid 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.
34Mucocele A mucocele is a bluish or translucent cyst resulting from accumulation ofmucous from trauma to a minorsalivary gland.Mucoceles generally require notreatment and many resolvespontaneously. Fluctuations in size arecommon.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
35RanulaA 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
36Eruption Cyst or Hematoma Eruption hematomaEruption 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
37Bony 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.
38Diastema Diastema refers to the space between the central incisors associated with a prominentmaxillary frenum.Diastema is normal in childhood,but a diastema greater than 3mm after eruption of thepermanent upper canines (ages10 to 13) should be evaluatedfor 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
39Macroglossia 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).
40MicrognathiaMicrognathia 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
41Question #1 A small jaw from hypoplasia of the mandible is known as A. MacroglossiaB. Micrognathia C. Bony Tori D. Diastema E. Angular Cheilitis
42Answer A small jaw from hypoplasia of the mandible is known as A. MacroglossiaB. Micrognathia C. Bony Tori D. Diastema E. Angular Cheilitis
43Question #2Which of the following is indicative of a geographic tongue? A. Chronic cheek bitingB. Erosions at the corner of the mouthC. Loss of filiform papillae on areas of the tongue that appear smooth, red, and shinyD. White lesions on the tongue E. Yellowish-grey cysts
44Answer Which of the following is indicative of a geographic tongue? A. Chronic cheek biting B. Erosions at the corner of the mouthC. Loss of filiform papillae on areas of the tongue that appear smooth, red, and shinyD. White lesions on the tongueE. Yellowish-grey cysts
45Question #3In deciding whether to intervene when a newborn is diagnosed with ankyloglossia, the most important factor is: A. The input of a professional lactation consultantB. How far the baby can extend his or her tongueC. Breastfeeding success and maternal pain with latchingD. Parental input. This is an elective procedure and should be done only if the parents request itE. None of the above because intervention is rare for newborns and recommended only in severe cases
46AnswerIn deciding whether to intervene when a newborn is diagnosed with ankyloglossia, the most important factor is: A. The input of a professional lactation consultantB. How far the baby can extend his or her tongue C. Breastfeeding success and maternal pain with latchingD. Parental input. This is an elective procedure and should be done only if the parents request itE. None of the above because intervention is rare for newborns and recommended only in severe cases
47Question #4Which of the following statements about aphthous ulcers is correct? A. Aphthous ulcers can be divided into 3 categoriesB. Aphthous ulcers etiology is unknownC. Aphthous ulcers are more common in individuals with inflammatory bowel diseaseD. All of the aboveE. None of the above
48AnswerWhich of the following statements about aphthous ulcers is correct? A. Aphthous ulcers can be divided into 3 categories B. Aphthous ulcers etiology is unknownC. Aphthous ulcers are more common in individuals with inflammatory bowel diseaseD. All of the aboveE. None of the above
49Question #5What is the most appropriate course of action when a ranula is diagnosed? A. Incise and drain the lesionB. Refer for excisionC. Observe for spontaneous resolutionD. Prescribe a 10-day course of oral antibiotics E. None of the above
50Question #5What is the most appropriate course of action when a ranula is diagnosed? A. Incise and drain the lesion B. Refer for excisionC. Observe for spontaneous resolutionD. Prescribe a 10-day course of oral antibioticsE. None of the above
51References1. 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.