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1 www.aap.org/oralhealth/pact Protecting All Children’s Teeth Oral Findings.

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Presentation on theme: "1 www.aap.org/oralhealth/pact Protecting All Children’s Teeth Oral Findings."— Presentation transcript:

1 1 Protecting All Children’s Teeth Oral Findings

2 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.

3 3 Learner Objectives 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. Permission on ile from IStock

4 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 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. Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center

6 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. 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. Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

7 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 BuccarumLinea Alba Photos used with permission of Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

8 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 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.

10 10 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;

11 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. Used with permission from Rama Oskouian Herpes Labialis

12 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. Used with permission from Rocio B. Quinonez, DMD, MS, MPH; Associate Professor Department of Pediatric Dentistry, School of Dentistry University of North Carolina

13 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. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

14 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. 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 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. White plaques on undersurface of tongue Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

16 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. Used with permission from Dr. Brad W. Neville, DDS, Distinguished University Professor College of Dental Medicine, MUSC

17 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.

18 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. Used with permission from the AAP Red Book

19 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. Used with permission from Lauren Barone

20 20 Obstruction 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. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital Sialolith

21 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 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 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.

24 24 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 Epstein’s Pearls

25 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. Used with permission from Rama Oskouian Bohn’s Nodules

26 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. Natal Teeth Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

27 27 Congenital 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 Epulis

28 28 Developmental Tooth Defects Enamel hypoplasia can result from a number of environmental insults during development, including Infection Toxins (lead or mercury), Fluoride Medications Prematurity Tim Wright DDS, MS Professor and Chair Department of Pediatric Dentistry The University of North Carolina School of Dentistry Amelogenesis Imperfecta

29 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 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 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 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. Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

32 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. Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

33 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 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. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

35 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. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital

36 36 Eruption Cyst or 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. Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital Eruption hematoma

37 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.

38 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. Diastema Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center

39 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.

40 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. Used with permission from David A. Clark, MD; Chairman and Professor of Pediatrics at Albany Medical Center

41 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 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 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 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 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 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 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 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 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 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 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, 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): Messadi DV, Waibel JS, Mirowski GW. White lesions of the oral cavity. Dermatologic Clinics. 2003; 21: Witman PM, Rogers RS. Pediatric Oral Medicine. Dermatol Clin. 2003; 21: 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.


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