2 - Oral Medicine and Oral-Facial Pathology

Question 1

For a pt with a facial swelling, what questions do you ask in the history?

Answer 1

1. How long has the swelling been present?
   - -The speed of progression of the swelling indicates the acute nature of the pathology or perhaps an acute exacerbation of a previous chronic condition.
   - -The size and extent of the swelling is also important.
2. What is the fluid balance for the child? Has the child been able to take oral fluids or food?
   - -Serious conditions in children may rapidly deteriorate when fluid balance is upset.
   - -Children may become dehydrated quickly.
   - -The ability to swallow may also indicate the extent to which the swelling involves the airway and the oral cavity.
3. Has the swelling arisen in spite of the prescription of antibiotics?
   - -This may aid your diagnosis in that a highly virulent infection may be present, or it may indicate that the swelling is not a result of a bacterial organism.
   - -Furthermore, the antibiotics may not be addressing the cause of an infection or the dose and administration of these drugs may be inappropriate.
4. Is the pain waking the child at night?
   - -The severity of any discomfort can be easily measured by assessing whether it is sufficient to wake the pt from sleep. Children (and most adults) are often unable to fall asleep with severe pain or discomfort and if they wake from sleep, then this is a good indicator of pain.

Question 2

When should antibiotics be prescribed for facial swellings?

Answer 2

While the removal of the cause of the infection may suffice in many circumstances, a large facial infection requires administration of antibiotics.

Question 3

What kind of antibiotic should be prescribed for facial swellings?

Answer 3

An antibiotic of sufficiently broad spectrum should be used initially when the exact nature of an infective organism is unknown or has yet to be determined.
–Microbiological laboratory culture and sensitivity take at least several days to weeks (in the case of anaerobic infections) to yield results and so prescription of antibiotics is usually empirical.

Question 4

What antibiotic can the child tolerate in the oral form?

Answer 4

1. Amoxicillin may be given 3 times a day with food.

2. Penicillin VK may only be given on an empty somach 4 times a day.

Question 5

Discuss drainage in facial swellings?

Answer 5

1. Removal of the cause of the infection must be the mainstay of any treatment plan. The difficulties in treating children arise due to problems with behavior management. It is impossible to drain an infection through the apices of a primary molar tooth.
2. Is there a collection of sub or supraperiosteal pus that needs to be drained? Most odontogenic infections in children of this age present as a cellulitis rather than an abscess, in which case there is little or no point in an incision and drainage.
   - -Fluctuant swellings usually indicate the presence of pus.
   - -Large submandibular swellings involving the first permanent molar may also require incision and drainage.
3. If there is a large volume of pus to drain, is an extra-oral incision necessary? Pus will not drain up. Large swellings in the mandible require an extraoral approach.
4. Consider what the child can cope with.

Question 6

When should a child with a facial abscess be admitted?

Answer 6

1. Any serious infection in the head and neck will probably require admission to a hospital. Hospital admission allows post-operative observation of the pt, allows for the administration of IV antibiotics and fluids, and allows monitoring of any complications.
2. Children should only be discharged when fluid intake is adequate and the signs of infection are resolving.
   - -Following surgery to the mouth, it is important not to over-hydrate children bc they will not feel like taking anything orally, delaying discharge.
   - -Maintenance fluids should be kept overnight but then reduced as the child improves to encourage oral intake.

Question 7

What complications can happen in infections in the head and neck?

Answer 7

1. Risk of posterior and/or inferior spread of infection along tissue planes, i.e., cavernous sinus thrombosis and possible brain abscess
2. Spread into the tonsillar fossa
3. Spread into the neck with respiratory obstruction and/or mediastinal involvement

Question 8

What surgical approach would you consider for a facial swelling?

Answer 8

1. If there is a significant accumulation of pus subperiosteally, then the elevation of a buccal flap with copious irrigation should be considered.
   - -Unlike adults, children typically present initially with a cellulitis rather than a collection of pus. Most of the swelling is associated with collateral edema.
   - -Administration of antibiotics alone may localize and wall-off the infection, resulting in the formation of an abscess cavity and further tissue destruction.

Question 9

What alternative antibiotics to penicillin are available for a facial swelling?

Answer 9

1. First generation cephalosporin
2. Clindamycin
3. Metronidazole

Question 10

If a pt has a history of oral inflammation and fever, what questions do you ask in the medical history?

Answer 10

1. How long has it been since the child was initially unwell?
2. Are any other unwell children in the family or has the child come into contact with any other children, relatives, or caregivers who are also unwell or have similar lesions?
3. When was the last time the child had something to eat or drink?
4. When was the last time the child urinated?
5. Is the child able to sleep at night?
6. Does anything relieve the pain or discomfort?

Question 11

What is the presentation of herpetic lesions?

Answer 11

1. Young child with a prodrome of one to two days of febrile illness followed by the development of an acute somatitis.
2. Typically, vesicles are not seen bc they form rapidly and break down to form coalesced areas of ulceration, however, the primary signs are those of acute gingival inflammation.
3. Commonly, the child will present to their local medical practitioner and antibiotics are frequently prescribed, inappropriately, in the absence of a definitive diagnosis. It is not until the appearance of the ulcers that the true diagnosis is apparent.

Question 12

What is the management of herpetic lesions?

Answer 12

1. Symptomatic care bc the disease is self-limiting (except in severe cases or children with immune suppression)
   - -Maintenance of fluid balance is essential with a soft bland diet as tolerated.
   - -Pain should be controlled with analgesics and there is evidence that the use of topical antiseptics may be beneficial.
   - -Nonalcoholic chlorhexidine mouthwash may be used to swab the mouth to debride areas of slough that may be secondarily infected with oral bacteria causing more discomfort. It is advisable to use an aqueous solution of chlorhexidine bc some formulations may contain up to 10% ethanol, which is particularly painful when applied to open ulcers.
2. Acyclovir has been shown to be effective in control of infection if administered within the first 72 hours of exposure.
   - -The usual dose is 25-100 mg/kg/day given 5 times per day as an oral suspension.
3. Paracetamol is the most appropriate analgesic to prescribe in the range of 15 mg/kg up to a maximum of 90 mg/kg/day.

Question 13

What is the prognosis of herpetic lesions?

Answer 13

1. The condition is self-limiting and should resolve within 10 to 14 days. If there is no resolution within this time, then a biopsy is indicated to exclude other conditions.
2. The pt will be prone to recurrent episodes of herpes labialis in times of stress or immune compromise or when the lips are exposed to UV radiation.

Question 14

What can help relieve pain with herpetic lesions?

Answer 14

1. Topical anesthetics and coating agents help relieve pain and facilitate food intake.
   - -However, they should be used with extreme caution in children who cannot expectorate bc of the potential for traumatic biting and numbness of the gag reflex, if swallowed, which may lead to aspiration.
2. Eating ice cream or popsicles may help relieve oral discomfort and increase the fluid intake.

Question 15

What precautions should you tell the parents about herpetic lesions?

Answer 15

1. Maintenance of oral hygiene is essential and it is important to warn the parents/caregivers to use separate utensils, change the child’s toothbrush and pacifiers, etc., and avoid contact with other children.
2. Parents should be warned that the child should not touch his eyes. The child must be hospitalized if ocular involvement occurs.

Question 16

How does the oral herpes infection start?

Answer 16

The causative agent is herpes simplex virus. Initial infection comes from direct contact with another infected individual and the virus then infects the nerve and remains latent in the trigeminal ganglion. Reactivation of the virus results in herpes labialis.

Question 17

When should a child with primary herpes be admitted to the hospital?

Answer 17

Hospital admission is only necessary if there is a risk of dehydration due to an inability to maintain an adequate intake of fluids.

• -This is an uncommon event; however, the clinician must be aware of the dangers of inadequate fluid balance and should stress to the parents or caregivers that it is essential to encourage the child to drink as much as possible.
• -Intake of solid food is not as important as fluids, but bland soft foods should also be encouraged. Young children will be hesitant to take anything orally in the acute phase.

Question 18

Should an antiviral medication be prescribed for a pt with herpes?

Answer 18

1. The prescription of antivirals is contentious and common practice dictates that acyclovir is only effective if administered within the first 72 hours of the appearance of the prodrome. In reality, few children will present to the dentist within this time period and have commonly visited their medical practitioner prior to the dentist.
2. Acyclovir should always be used when managing children who are immunosuppressed.

Question 19

Will a pt with primary herpes have another episode of this type of infection?

Answer 19

No, pts will not have another episode of this form of acute infection; however, they will be subject to recurrent cold sores appearing along the terminal distribution of the nerve pathways that have been involved (i.e., the particular division of the trigeminal nerve).

Question 20

What questions do you ask about the history for a pt who has a history for intra-oral lesions?

Answer 20

1. How long has the swelling been present? When did you first notice it?
2. Has it changed in appearance (size, shape, color) recently?
3. Has there been any spontaneous bleeding from this swelling or only on brushing?
4. Is the lesion painful? Does it hurt spontaneously or only when stimulated?
5. Is there anything that makes it better or worse?

Question 21

What is the general rule for a pathology with a diagnosis that cannot be determined?

Answer 21

As a general rule, if the diagnosis of a lesion cannot be determined and there is no resolution within two weeks, then further investigation is required.

Question 22

What kind of biopsies should be performed?

Answer 22

1. Smaller lesions should be completely excised with a border of normal tissue (excisional biopsy).
2. Larger lesions may require a representative portion of tissue to be removed (incisional biopsy).

Question 23

What is the etiology of a peripheral giant cell granuloma?

Answer 23

The peripheral giant cell lesion is regarded as inflammatory in origin with an unknown etiology, although some authors have associated the overgrowth with mild irritation.

Question 24

Where is the location of a peripheral giant cell granuloma?

Answer 24

The location is generally confined to the gingiva in the region of the primary dentition.

Question 25

What is the characteristic color of a peripheral giant cell granuloma?

Answer 25

The color is characteristic and may range from dark red to purple. It is generally darker than the pyogenic granuloma and it is not as vascular.

Question 26

What does the radiograph show for a peripheral giant cell granuloma?

Answer 26

Radiographically, there may be a characteristic cupping of the alveolar ridge with bone resorption.

Question 27

What is in the differential diagnosis of a peripheral giant cell granuloma?

Answer 27

1. Hyperparathyroidism must be considered in the differential diagnosis when a giant cell lesion is found. Central involvement would necessitate further investigation with blood tests for calcium and phosphate, and CT to assess the full extent of the lesion.
2. The presence of a vascular lesion must be excluded in the provisional diagnosis. Biopsy of such a lesion may result in profound hemorrhage and blood loss that may be life threatening, especially in the case of a vascular malformation.

Question 28

What is the prognosis of a peripheral giant cell granuloma?

Answer 28

There is an increased rate of regrowth if such giant cell lesions are not completely excised. However, this is not an indication for radical resection. Careful curettage of the bone will ensure complete removal.

Question 29

What complications can occur with a peripheral giant cell granuloma?

Answer 29

1. Regrowth of lesion.

2. Misdiagnosis with the possibility of a vascular lesion and massive hemorrhage when performing a biopsy.

Question 30

What investigations should be performed if hyperparathyroidism is suspected?

Answer 30

• Blood tests to determine levels of:
  1. Parathyroid hormone
  2. Calcium
  3. Phosphate
  4. Alkaline phosphatase

-CT is indicated to assess the full bony extent of any central lesion.

Question 31

What is the difference between a pyogenic granuloma and the peripheral giant cell granuloma?

Answer 31

The pyogenic granuloma arises from mild irritation from plaque, calculus or other foreign bodies and may occur anywhere in the oral cavity.

• -Some regard this lesion as a variant of the fibrous epulis with an increased vascular component.
• -They are usually found interproximally and are commonly pedunculated with no osseous involvement.

Question 32

How much tissue should be removed in a biopsy?

Answer 32

1. Biopsies must always include a border of normal tissue so that the pathologist can observe the interface between the lesion and the healthy tissue.
2. As a general rule, the clinician who will manage the case to conclusion should perform the biopsy (i.e., the surgeon who will ultimately manage a condition should be responsible for the biopsy).
3. The size of the lesion determines the extent of the biopsy. Small lesions should be excised completely. If a large tissue deficit or functional disability may result following an excisional biopsy, then an incisional biopsy may be required. There must be adequate tissue to allow for histopathological examination and any tissue taken for an incisional biopsy must be representative of the lesion in its entirety.

Question 33

What is a natal vs a neonatal tooth?

Answer 33

1. Natal tooth is present at birth.

2. Neonatal tooth erupts within a month of delivery.

Question 34

What is the treatment of the natal/neonatal tooth?

Answer 34

1. If the tooth is excessively mobile or there are feeding difficulties, then it may be extracted.
   - -Only 5/6 of the crown of a primary incisor has formed at birth; hence, the mobility of the tooth.
   - -Despite the theoretical risk, there has never been a reported case of aspiration of natal or neonatal teeth.

Question 35

What do you need to know about the extraction of natal/neonatal teeth?

Answer 35

1. It is essential to remove the dental papilla (pulp). If this is left behind, hard tissue or even a root may form.
2. Local anesthesia is usually not required bc the tooth is only indicated for extraction in cases where there is extreme mobility.
3. The airway must always be protected. Place a piece of gauze behind the teeth at the back of the mouth to avoid accidental swallowing or aspiration of the tooth.
4. It is usually convenient to use the knee to knee position with the child’s head in the operator’s lap. Young babies are best managed by wrapping them with a blanket to keep them secure, which also minimizes movement.

Question 36

What is the prognosis of an eruption cyst?

Answer 36

1. The cyst will resolve with the eruption of the new tooth and there is usually little need to surgically drain these lesions unless it is infected.
   - -If this is the case, the pt will be systemically ill bc this represents an acute infection.
   - -Chronically infected eruption cysts cannot exist bc drainage would allow for eruption of the tooth and resolution of any infection.

Question 37

What is an eruption cyst?

Answer 37

1. It is an extremely common variation of normal eruption and not considered to be pathological unless the lesion is infected.
2. The cyst represents an enlargement of the follicle around a newly erupting tooth.
3. An eruption cyst must not be confused with a vascular lesion. To test this, apply pressure to the lesion to determine whether the area changes in color due to any blood emptying. Lesions that are bilateral and symmetrical are almost invariably benign and histopathology is not required.

Question 38

What may mimic eruption cysts in a newborn?

Answer 38

1. Vascular anomalies (hemangiomas or lymphangiomas)
2. Neuroectodermal tumors of infancy
3. Other odontogenic cystic lesions

Question 39

What are your concerns for a natal/neonatal tooth?

Answer 39

1. The premature emergence of a primary tooth is of little cause for concern except that root development will not be accelerated and so the tooth is likely to show increased mobility.
2. The major concern is to ensure that the mother can adequately feed the infant without pain or trauma to the nipples.
   - -This is usually not a problem if the tooth is in the lower arch as the tongue will protect the nipple during feeding. However, if there is ulceration of the ventral surface of the tongue or the tooth is excessively mobile, then consideration should be given to its removal.

Question 40

What happens if a neonatal tooth is lost soon after birth?

Answer 40

There are few complications associated with the early loss of a primary incisor soon after birth. There is always a theoretical risk that a natal tooth or neonatal tooth may be inhaled or swallowed. Invariably, the permanent tooth erupts normally and space loss does not present a problem bc the inter-canine width is preserved. if the hard tissue of a natal tooth is removed, leaving some of the pulpal remnants behind, then a root may form from the dental papilla. If such a tooth is extracted, it is important to remove (curette) all associated tissues.

Question 41

What are the treatment options for drug induced gingival enlargement?

Answer 41

Prevention:

1. Phenytoin - depends on oral hygiene
2. Cyclosporine - has a threshold dose for some individuals

Treatment:

1. Changing the medication - done in consultation with physician.
   - -Cyclosporine - tacrolimus is often used as a substitute.
   - -Phenytoin - sodium valproate (Epilim) or carbamazepine (Tegretol).
2. Surgical resection of gingival overgrowth. The choice of surgical procedure depends on the degree of overgrowth in each pt. No one procedure is better than another.
   - -The use of diathermy or soft tissue lasers (diode, ND:YAG or CO2) are useful when only minor work is required.
   - -The classical gingivectomy may be indicated when a major resection of the gingiva is required. The disadvantage of this technique (using a bevel incision) is the large amount of open tissue that is left, making the post-operative period extremely uncomfortable for the pt and increasing the risk of infection.
   - -Flap surgery with apically repositioned flaps ensures primary closure of the wounds, less bleeding, a better post-operative recovery period, better gingival contour.

Question 42

What medications can cause gingival enlargement?

Answer 42

1. Immunosuppressant - cyclosporine
2. Calcium channel blocker - nifedipine
3. Antiepileptic - phenytoin

Question 43

What is the mechanism of how cyclosporine causes gingival overgrowth?

Answer 43

1. The precise mechanisms by which cyclosporine causes overgrowth of gingival tissues has yet to be fully determined.
2. Nonetheless, there is increasing risk in younger children, those who express HLA-A24 antigen and those with poor oral hygiene.
3. Cyclosporine causes an increase in fibroblast proliferation, possibly in response to elevated IL-6 and TFG-B1. There is an increase in volume of extracellular collagen and decreased collagen loss.
4. The question of dose relationship is contentious, although it appears that a threshold may exist above which enlargement may occur.

Question 44

Is orthodontic treatment in children following organ transplant possible?

Answer 44

There is no contraindication to orthodontic treatment in the post-transplant pt.

Question 45

Describe the pre-transplant dental care for organ transplant pts?

Answer 45

Pre-transplant care:

1. Excellent oral hygiene and preventive protocols (fluoride, fissure sealants, etc.)
2. Aggressive removal of any present and/or potential pathology that may compromise the child during immunosuppression.

Question 46

Describe the post-transplant dental care for organ transplant pts?

Answer 46

1. Continuation of excellent oral hygiene practices, including regular reviews and preventive monitoring.
2. Avoid elective dental treatment during immunosuppression periods. In consultation with the pt’s cardiologist, use antibiotic prophylaxis if the pt is immunosuppressed and the dental treatment cannot be postponed.
   - -Organ transplantation does not put the child at a greater risk of developing endocarditis, except if valvulopathy develops.

Question 47

For a pt with gingival overgrowth, what type of surgical excision is preferable in cases in which all of the gingival tissues are involved?

Answer 47

1. If small amounts of tissue need to be removed - the classical gingivectomy technique may be used.
2. If large amounts of tissue need to be removed - it is often better to use a flap procedure so that the primary closure may be achieved. This is usually tolerated better by the pt and a better gingival contour may be achieved.

Question 48

When should orthodontic treatment be commenced in children with drug-induced gingival enlargement?

Answer 48

It is essential to seek an early orthodontic opinion in such cases. It is important to observe the displacement of the teeth secondary to the growth of the gingival tissues and intervene where there is tooth movement.

Question 49

What orthodontic treatment can be done on pts with drug-induced gingival enlargement?

Answer 49

1. Selective gingivoplasty ranging to a full-mouth gingivectomy may be required to allow tooth eruption.
2. Orthodontics should not be attempted unless the child and caretaker can maintain an adequate level of oral hygiene.
   - -While tooth alignment will not prevent gingival overgrowth, it may facilitate better oral hygiene that complicates such cases.

Question 50

What is the antibiotic of choice when performing any gingival surgery on a child with a heart transplant?

Answer 50

1. The transplant recipient who is on anti-rejection medication requires only the routine antibiotic medication to prevent post-operative infections.
   - -Children who have received a new heart are not at risk of developing endocarditis, except if they develop valvulopathy.
2. However, perioperative and post-operative antibiotics are required to cover the immunosuppressed child from potential infection of tissues involved in the surgery.
   - -In the absence of any allergies, a broad-spectrum antibiotic such as amoxicillin, which is active against Gram-positive facultative oral organisms, is appropriate.

Question 51

What is the dental treatment for hypophosphatasia?

Answer 51

There is no specific treatment for hypophosphatasia other than maintenance of excellent oral hygiene to ensure that teeth are preserved as long as possible to remain caries-free.

Question 52

What is the importance of early tooth loss?

Answer 52

1. All conditions that present with early loss of teeth are serious and potentially life threatening; thus, early recognition and diagnosis are essential.
2. Any unexplained tooth loss needs immediate investigation.
3. Teeth may exfoliate due to metabolic disturbances, periodontal disease, connective tissue disorders, neoplasia, loss of alveolar bone support or self-inflicted trauma. The major diagnostic criterion is the state of the gingival tissues.

Question 53

What is the cause of early tooth loss?

Answer 53

1. The majority of teeth are lost from periodontal disease.
   - -Gingivitis is common in children, but periodontal disease is extremely rare and indicates an underlying immune disorder based on quantitative or qualitative white cell disorders.
2. Hypophosphatasia - teeth exfoliate due to deficiency in cellular cementum. The root surface shows an absence of cellular cementum that may account for the exfoliation of these teeth. Permanent teeth rarely exfoliate.

Question 54

What is the main organisms involved in prepubertal periodontal disease in children?

Answer 54

1. Actinobacillus actinomycetemcomitans
2. Prevotella intermedia
3. Eikenella corrodens
4. Capnocytophaga sputigena

All are present in response to altered immune status, but only some, particularly the Actinobacilli, secrete leukotoxins.

Question 55

What is hypophosphatasia?

Answer 55

1. Hypophosphatasia is an uncommon inherited metabolic disorder in which there is a deficiency in the activity of tissue non-specific alkaline phosphatase.
2. It is characterized by a defective bone mineralization with highly variable clinical features, ranging from the premature loss of primary teeth to neonatal death.
   - -The milder cases in which there is no long-bone involvement are diagnosed due to their dental manifestations.
   - -In children with only dental involvement, the prognosis is very good.

Question 56

What biochemical and blood tests would you order if you suspect a child has hypophosphatasia?

Answer 56

1. Blood tests: Full blood test with differential white cell count; erythrocyte sedimentation rate (ESR); electrolytes, urea and creatinine; Calcium, phosphate and alkaline phosphatase.
2. Urine tests: Vitamin B6 (pyridoxyl-5-phosphate); phosphoethanolamine (requires specialized metabolic assays that are only available to certain laboratories).
3. Bone densitometry should be considered to assess the calcification of the long bones and for any rachitic changes that might be present.

Question 57

What is the cause of amelogenesis imperfecta?

Answer 57

It is caused by improper differentiation of ameloblasts in the absence of systemic involvement with the phenotypic manifestations of mutant genes influencing different levels of enamel development.

Question 58

What are the genes associated with amelogenesis imperfecta?

Answer 58

1. Amelogenin (AMELX)
2. Enamelin (ENAM)
3. Enamelysin (MMP20)
4. Kallikrein 4 (KLK4)

Question 59

What is the most frequent dental anomaly associated with amelogenesis imperfecta?

Answer 59

Taurodontism.

Question 60

What are the most commonly reported problems in the eruption of permanent teeth with amelogenesis imperfecta?

Answer 60

1. Follicular cysts
2. Delayed eruption
3. Retention or impaction of teeth

Question 61

Describe the radiologic appearance of amelogenesis imperfecta?

Answer 61

1. Smooth hypoplastic type - the enamel layer is conspicuously thin, radiodensity is greater than the adjacent dentin.
2. Hypocalcified type - the enamel layer appears absent.
3. Hypomaturation type - the radiodensity of the enamel is almost equal to that of normal dentin.

Question 62

What oral problems are seen in amelogensis imperfecta?

Answer 62

1. Tooth sensitivity
2. Poor esthetics
3. Dental caries
4. Anterior open bite
5. Advanced dental age and/or failure of dental eruption
6. Pre-eruptive tooth resorption
7. Gingival inflammation
8. Loss of occlusal vertical dimension

Question 63

What is the goal of treatment in pts with amelogensis imperfecta?

Answer 63

1. For a young child or adolescent, the long-term aim of treatment is to maintain the maximum amount of dental hard tissue possible until the pt reaches an age at which advanced restorative techniques can be employed to rehabilitate the dentition.
2. In the short-term, it is frequently necessary to intervene to improve esthetics, maintain tooth structure, maintain or increase occlusal vertical dimension and relieve the symptoms of tooth sensitivity.