Protecting All Children

1
Protecting All Childrens 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.

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. 

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. 

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.

10
Primary Herpetic Gingivostomatitis
www.aap.org/oralhealth/pact

• 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
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
Used with permission from Rama Oskouian
www.aap.org/oralhealth/pact
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
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
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
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
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
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 Stensons duct
  appears inflamed and swollen.

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
Bacterial Causes of Parotitis

• Called purulent parotitis, bacterial
• infection of the parotid gland is
• typically unilateral and extremely
• painful with visible pus draining
• from Stensons duct.
• The patient often appears ill and
• should be empirically treated with
• antibiotics after culture obtained.

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.

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. Epsteins Pearls 
• 2. Bohns Nodules 
• 3. Dental lamina cysts
• No treatment is necessary.

24
Epsteins Pearls
Epsteins Pearls

• Epsteins 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
Bohns Nodules and Dental Lamina Cysts

• Bohns 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.

Bohns Nodules
Used with permission from Rama Oskouian
26
Natal and Neonatal Teeth
Natal 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.

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

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
www.aap.org/oralhealth/pact
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
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
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
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.

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.

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 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.

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.

38
Diastema
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.

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.

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
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) 15-22.
• 4. Messadi DV, Waibel JS, Mirowski GW. White
  lesions of the oral cavity. Dermatologic Clinics.
  2003 21 63-78.
• 5. Witman PM, Rogers RS. Pediatric Oral Medicine.
  Dermatol Clin. 2003 21157-170.
• 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.