12. Oral pathology and soft tissue lesions in children Flashcards
What do you look at extra-orally?
– General appearance, do they look well?
– Skull (symmetry), hair, ears, eyes, face
– Lymphadenopathy
- look at growth chart and see what percentile they are in
What do you look at intra-orally?
Soft tissues: – mucosa
– inflammation
– red patches, white patches
– swelling
– ulcers
– spontaneous bleeding
– recession
– fraenal attachment
Periodontal tissues Teeth, occlusion Salivary flow rate
How do you describe the lesion?
- Type of lesion
If they had an ulcer ask was it as small as 5 pence coin, 2 pence, tip of pen lid? - Size
– Measure with a ruler in two dimensions - Shape and symmetry
- Colour and pigmentation of lesion – E.g. red, white, purple, brown, grey
- Surface features
– E.g. Smooth, rough - Distribution over the tissue
– Location; diffuse or demarcated - Findings of palpation
– Superficial, deep, movable, fixed, tender
What is a macule?
Flat, discoloured spot on skin with sharp borders
What is a papule?
Solid elevations without fluid with sharp borders
What is a nodule, tumour?
Palpable, solid, elevated mass.
Nodules have distinct borders.
Tumours extend deep into the dermis.
Wart is a nodule.
Large lipoma is a tumour.
What is a pustule?
Vesicle or bulla filled with purulent fluid
What is a wheal?
Localised area of oedema, often irregular and of variable size and colour
What are the 8 primary lesions?
Macule
Papule
Nodule, tumour
Vesicle
Bulla
Pustule
Wheal
Plaque
What are the 4 secondary lesions?
Originate from a primary lesion
Scale, crust, fissure, ulcer
What is a scale?
Thin or thick flake of skin varying in colour, usually secondary to desquamated, dead epithelium, eg. dandruff
What is a crust?
Dried residue of exudates, eg. residue of impetigo
What is a fissure?
Linear crack in the skin, eg. athlete’s foot
What is an ulcer?
Opening in the skin caused by sloughing of necrotic tissue, extending pass the epidermis.
What is erythema?
Redness due to increased blood flow to blood vessels (vasodilatation) in that area
What is purpura?
Red/purple discolouration due to extravasation of blood into the skin from a blood vessel
What colour is melanin and lipid deposition?
Brown and yellow
How should you document a lesion?
With written description, photograph, measurement
What are 3 examples of lesions in the newborn?
Keratin cysts
Congenital epulis
Natal/neonatal teeth
What are 2 examples of keratin cysts?
Epstein pearls
Bohn’s nodules
What are epstein’s pearls?
Hard, raised small nodules
- arise from epithelial remnants trapped along lines of fusion of embryological processes
- appear in midline of hard palate
What are Bohn’s nodules?
- Odontogenic cyst arising from the dental lamina filled with keratin.
- occur in 80% of infants
- normally disappear spontaneously
Describe a congenital epulis?
Usually firm, pedunculated, pink, smooth, solitary
Present at birth
Where are congenital epulis mostly found?
Arise from the crest of the alveolus in the incisor region
What is the cause of congenital epulis?
Unknown origin
With proliferation of mesenchymal cells
Affects females more than males
What should you do for congenital epulis?
Normally do nothing, unless it is impacting on feeding
When are natal/neonatal teeth seen?
Natal teeth are seen at birth
- neonatal teeth are seen within 30 days of birth
What teeth are normally natal/neonatal teeth?
- In almost all cases it is the early eruption of a primary incisor
- they are mobile due to incomplete root formation
What is the tx for natal/neonatal teeth?
- Smooth sharp edges
- Extraction
– If extracting warn likely to have a missing primary tooth
– Often done with topical LA and gauze – Or if firm LA and forceps - No treatment required if no problems experienced.
What 3 syndromes is natal/neonatal teeth associated with?
- pachyonchia congenita
- ellis van creveld syndrome
- halermann- strieff syndrome
What are local factors that may cause delayed eruption?
- supernumerary teeth, odontomes
- thickened overlying mucosa, gingival fibromatosis
- failure of root to resorb, dilacerated permanent roots
- ectopic crypt position
What are systemic factors that may cause delayed eruption?
- prematurity/low birth weight- especially if around 28 week mark
- down syndrome/turner syndrome
- cleidocranial dysplasia
- endocrine disorders- hypothyroidism or hypopituitarism
What should you follow if you have delayed eruption?
- know eruption dates
- wait at least 6 months after the contra lateral side has erupted
- if still no eruption- take radiograph
- no obstructions and tooth palpable and present consider excising the gingival margin
- remove any obstructions like supernumeraries- consider space mainainer
- refer, address any systemic conditions
What is the differential diagnoses for an eruption cyst?
- amalgam tattoo
- malignant melanoma
- freckle
Where does an eruption cyst normally occur?
6’s and central incisors
What is the treatment for eruption cyst?
- reassure- often resolve as the tooth erupts
- sometimes excision required to release pressure and allow the tooth to erupt
What is an extravasation mucocele?
Leakage of fluid from the ducts or acini into surrounding tissue
What is a retention mucocele due to?
Narrowed ductal opening
What is a mucocele often due to?
Trauma to minor salivary glands or ducts often on the lower lip.
- history of going up and down
- if on the upper lip with no clear evidence of trauma, refer
What is a ranula?
Fluid collection or cyst that forms in the floor of mouth. Filled with fluid that has leaked out of damaged salivary gland.
Where is ranula often found and what does it look like?
Floor of mouth
- blue dome shaped swelling
- lateral to midline
- associated with major salivary glands
What is a plunging ranula?
Plunging ranula (PR) otherwise known as cervical ranula is a nonepithelial‐lined salivary gland cyst that forms following mucus escape from sublingual gland and its subsequent herniation via the mylohyoid muscle into submandibular space and beyond.
What are 7 examples of bacterial infections?
- scarlet fever
- actinomycosis
- turberculosis
- atypical mycobacterial infection
- syphilis
- impetigo
- osteomyeleitis
What can TB cause?
Lymphadenopathy
What is congenital syphilis and how can it affect teeth?
- infected mother to fetus
- hutchinsons incisors and mulberry molars
What is impetigo caused by?
Bacteria- staphylococcal and streptococcal
What can impetigo cause?
Crusting lesions
It is highly contagious
Self limiting
What is acute pseudomembranous candida?
– in infants seen as Thrush
– White scrapable plaques that reveal an erythematous base.
– In older children, seen in immunocompromised
What is median rhomboid glossitis?
- seen on dorsal surface of the tongue
- usually anterior to the vallate papillae
- normally unpapillated
What viral infections are caused by herpesviridae?
- primary herpetic gingivostomatitis HSV1/2
- chickenpox VZV HHV3
What viral infections are caused by coxsackie A virus?
- herpangina
- hand foot and mouth disease
What viral infections are caused by epstein barr virus?
infectious mononucleosis
What is primary herpetic gingivostomatitis caused by?
Herpes simplex virus 1 and 2
What age does primary herpetic gingivostomatitis commonly affect?
6 months- 5 years
What is the incubation period for primary herpetic gingivostomatitis and how long does it last?
IP- 3-5 days
- Self limiting- 10-14 days
What is the main mode of transmission of primary herpetic gingivostomatitis?
saliva
What are the features in prodromal phase of primary herpetic gingivostomatitis?
- irritability, cervical lymphadenopathy, pyrexia, malaise, headache, hypersalivation, vesicles rupture to form shallow ulcers
What is the tx for primary herpetic gingivostomatitis?
- reassurance, fluids, no hard foods, bed rest, topical anaesthesia like paediatric bonjela
What can you prescribe for primary herpetic gingivostomatitis?
- alcohol free CHX
- systemic aciclovir
– Child 1–23 months -100 mg 5 times a day usually for 5 days – - Child 2–17 years- 200 mg 5 times a day usually for 5 days
What are complications of primary herpetic gingivostomatitis?
- ocular transmission
- herpetic whitlow
What is herpes labialis?
- reactivation of HSV in trigeminal ganglion
- preciptated by UV sun exposure, stress, weather change, immunosuppression
- prodrome- tingling, burning sensation, itching, mild pain and/or fever
Wha is chicken pox caused by and what are the symptoms?
- varicella zoster virus
- vesicles over face and oral mucosa
- cutaneous lesions
- droplet infection from nasopharynx
What is the reactivation of varicella zoster?
- lies latent on sensory ganglia
- reactivation causes shingles (herpes zoster)
- causes unilateral, distinctive painful rash over a dermatome
What are the oral manifestations of shingles?
affects opthlamic, maxillary and mandibular nerve distribution
When is chicken pox infectious?
As soon as they get a temperature.
Stops becoming infectious at around day 15 when lesions start to crust over
What is hand foot and mouth disease caused by?
Coxsackie strain A16
What are the symptoms of hand, foot and mouth disease?
- mild prodrome phase
- followed by sparse distribution of vesicles with erythematous halo
- self limiting 5 to 7 days
Where do ulcers of hand, foot and mouth disease mostly affect?
hard palate, tongue, and buccal mucosa
What is the treatment for hand, foot and mouth disease?
Self-limiting- 5 to 7 days
- reassure parent, usr topical agents to help child eat or drink, refer if child is really unwell and dehydrate
What is the incubation period for herpangina?
4 days
What is the general symptoms of herpangina?
Abrupt onset of fever with malaise, headache, neck or back pain
Describe the ulcers in herpangina?
1-2mm grey-white papulo-vesicular lesions that progress to ulcers surrounded by erythematous halo
Where does the herpangina affect?
- anterior tonsillar pillars
- soft palate
- uvula
- tonsils
- oropharynx may appear diffusely hyperaemic
What is the duration of herpangina?
7 days
What is infectious mononucleosis caused by?
- epstein barr virus
Who does infectious mononucleosis commonly affect?
teenagers
What is the general symptoms of infectious mononucleosis?
- lymph node enlargement
- fever, malaise and acute pharyngitis
What are the oral symptoms of infective mononucleosis?
Oral ulceration and pethecial haemorrhage at junction of hard and soft palate
What is the treatment for infectious mononucleosis?
Analgesia and fluids
Where is HPV most commonly seen?
On the lips
What is the treatment for human papilloma virus?
- excision
- cryosurgery
- laser
- biopsy- HPV 16 and 18 (both strains have been linked to OSCC)
What virus causes MMR?
Myxovirus
When is MMR vaccine given?
- dose at 12 months then 40 months
What are the symptoms of mumps?
Painful enlargement of parotid glands
- usually bilateral
- causes headache, vomiting, and fever
What is the incubation period for mumps and how long does it last?
- contagious
- incubation period is 2 to 3 weeks
- lasts about 7 days
What are the symptoms of measles?
- affects buccal mucosa
- is white speckling surrounded by red margin (Koplick spots)
- followed by red maculopapular rash
- fever
- contagious
What is an ulcer?
Break in the skin extending through all the layers, discontinuation of the epithelial lining
What are 4 related diseases to recurrent oral ulceration?
- Behcet’s disease
- Sweet’s syndrome
- MAGIC syndrome
- HIV
What does Behcet’s disease affect?
Oral, ocular, genital
What does sweets syndrome cause?
Acute febrile neutrophilic dermatosis
What does MAGIC syndrome cause?
mouth and genital ulcers, inflamed cartilage
What should you do if someone has RAS?
- ulcer diary
- do routine full blood count, ferritin, folate and B12 levels
What is the preventative treatment for RAS?
- give iron supplements
- advise benzoate/cinnamon/sls free exclusion, eg. kingfisher or proenamel toothpaste
What is the symptomatic relief for RAS?
CHX, benzydamine hydrochloride
What topical steroids can you give for RAS?
Beclomethasone
What are the symptoms of orofacial granulomatosis?
- Lip Swelling
- Linear ulceration
- Cobble stoning of mucosa
- Gingivalenlargement
- Mucosal tags
- Facial nerve palsy
- Cervical lymphadenopathy
What do you need to exclude if someone has orofacial granulomatosis?
- Crohn’s, sarcoidosis, TB
- however, 85% of patients with oral crohn like features have no gut problems
What allergens is orofacial granulomatosis associated with?
- benzoates, sorbate, cinnamon
What is the management for orofacial granulomatosis?
- 3 month empirical exclusion diet
- topical treatment to angular cheilitis fissures such as hydrocortisone or miconazole
What is the topic treatment to lip swellings or facial erythema for orofacial granulomatosis?
- tacrolimus ointments
- intralesional steroids to lip
What do you need to do in crohn’s screening?
- make the parent aware of importance of altered bowel habits or abdominal pain
- growth monitoring
What can you test for in Crohn’s?
- faecal calprotectin assay
- however, unreliable in younger children
- screening test for endoscopy
- good predictor of Crohn’s disease activity
What is epiderymolysis bullosa?
Rare vesiculobullous lesion
- digits often fuse together
- difficult to treat oral lesions
What is the treatment ofr erythema multiforme?
- Minor- symptomatic treatment, possibly aciclovir
- Major- systemic corticosteroids, immunomodulatory drugs, antiseptic and analgesia
What are examples of benign tumours?
– Squamous cell papilloma/verruca
– Fibroepithelial polyp
– Fibrous epulis
– Pyogenic granuloma
– Peripheral giant cell granuloma
– haemangiomas
What are examples of malignant tumours?
– Epithelial tumours eg squamous cell carcinoma
– Lymphomas (Hodgkins, non hodgkins)
– Rhabdomyosarcomas, muscle tumour most common tongue
– Leukaemia- blood cancer often presenting in the oral tissues with gingival bleeding
What are differential diagnosis for fibrous lumps in the mouth?
– Fibroepithelial polyp
– Fibrous epulis
– Pregnancy epulis
– Pyogenic granuloma
– Denture irritation granuloma and papillary hyperplasia
What are neoplastic lesions that present as fibrous lumps?
Fibroma, giant cell fibroma, fibrosarcoma, fibrous histiocytoma, malignant fibrous histiocytoma
Where is a fibroepithelial polyp found?
- firm pink lump on gingivae
- usually buccal
- often same colour as gingivae
- caused by trauma
- contains avascular fibrous tissue, scar like
What is the tx for fibroepithelial polyp?
- remove trauma/irritation and review
- excision biopsy
- can recur
What is a cavernous haemangioma?
A cavernous hemangioma happens when capillaries – small blood vessels that connect arteries and veins – swell and form a noncancerous mass called an angioma.
What is the treatment for cavernous haemangioma?
- establish extent of lesion
- hazardous in surgery
- if unsure, refer prior to dental surgery
- excision, cryotherapy, embolisation, laser therapy
What is a capillary haemangioma?
- common
- benign tumour of vascular origin
- often presents as facial birth marks that appear in first 6 months of life
- varies in shape and presentation
- blanch on pressure
- can reduce in size as child gets older
What is geographic tongue?
Common 1-2% population
* Associated with psoriasis
* Usually asymptomatic, occasionally sore with spicy foods/acidic
* Red areas (depapillated areas) change in size and migrate around
* Red areas sometimes surrounded by yellow raised margins
What is median rhomboid glossitis and what factors affect it?
Candida infection
* Factors – Smoke
– Xerostomia
– Denture wearers – Steroids
– Anaemia
What is a fissured tongue?
Common
* Often hereditary
* Found in the general population
* Often present in Down syndrome
* Multiple fissures
* Often of no consequence
What is ankyloglossia?
Tongue tie
* Lingual fraenum anchors the tongue
* Restricts protrusion and lateral movements
* Can make it difficult for oral cleansing
* Differingo pinions on its effect on speech, should always involve speech therapy
What are red flags?
If the child is systemically unwell
* Lesion rapidly increasing in size
* Spontaneously bleeding gums of no obvious cause
What is the age acute lymphoblastic leukaemia affects most?
4-5 years
What is the cure rate of acute lymphoblastic leukaemia?
60% cure rate with chemotherapy in children
What may you see in acute lymphoblastic leukaemia?
- infections
- purpura
- gingival bleeding
- lymphadenopathy
- facial nerve palsy
- orofacial paraesthesia/anaesthesia
