Oral pathology in paediatrics part 2

Question 1

Describe ankyloglossia, its potential side effects and management

Answer 1

• Lingual frenum attached to the floor of the mouth or lingual gingiva instead of the genial tubercles. Results in a short lingual frenum, reducing mobility of the tongue
• Limited ability of tongue to be retracted or protruded, difficulty breastfeeding, persistent messy eating in later childhood(due to inability to clear food from buccal cavities and lips), difficulty in oral clearance, higher caries risk, speech problems, periodontal problems
• If a child’s speech or feeding appears to be affected, a comprehensive assessment involving a paediatric dentist and a speech pathologist is necessary to decide whether or not use surgical intervention
• Treatment is indicated only if there is an associated problem
• Treatment involves a frenectomy which involves complete removal of the frenum

Question 2

Describe large maxillary labial frenums, including management

Answer 2

• Abnormally large frenums of the upper lip are frequently seen in children and may be associated with a median diastema between the central incisors
• Frenectomy may be indicated if the frenum is thought to cause a diastema (and patient does not want a diastema)
• Assessment for frenectomy should only be considered after the permanent dentition is fully erupted. Note: often, following the eruption of the maxillary canines the diastema partially or completely closes

Question 3

List the 3 types of ulcers that occur with mechanical trauma

List the types of ulcers from chemical trauma

Answer 3

Mechanical trauma:
• Post anaesthetic trauma
• Around erupting tooth
• Quad helix

Chemical trauma:
• Aspirin burn
• Hydrogen peroxide burn

Question 4

Describe recurrent aphthous ulceration

Answer 4

• Recurrent aphthae are the most common disease of the oral mucosa
• Lesions are classified according to size, duration and severity
• Most sufferers are otherwise healthy, with the onset frequently in childhood, peaking in adolescence or early adulthood

Question 5

Describe minor aphthous ulcerations

Answer 5

• Account for majority of the cases-
• 2 to 5 shallow ulcers typical about 4-5mm (less than 10mm) on non-keratinized mucosa
• Typical central yellow slough with an erythematous halo-
• Heal within 10-14 days without scarring
• Intermittent attacks are usually at irregular intervals

Question 6

Describe major aphthous ulceration, including places of occurence, healing time

Answer 6

• This is an uncommon type
• Tend to occur in older children
• Is very painful. Greater than 10 mm in diameter with deep bases-
• Occur as a solitary ulcer or there may be several
• Keratinised mucosa may be involved
• Common on soft palate, tonsillar area and oropharynx
• 4-6 weeks is the usual healing time and scarring typically results
• Often new ulcers appear before previous ones have healed

Question 7

List 6 potential causes of recurrent aphthous ulcerations

Answer 7

• Genetics- Thought to be an influence as up to 50% of individuals report other family members with a similar condition
• Trauma- Emotional stress, unlikely to be a significant factor, anecdotal reports
• Sodium lauryl sulphate- (SLS), a detergent in some oral healthcare products may produce oral ulceration
• Food allergies- cow’s milk, chocolate, gluten, wheat, various fruits (tomatoes), preservatives and additives
• Hormones- Endocrine factors in some women are related to the fall in progestogen level in the luteal phase of their menstrual cycle

Question 8

Describe the management of recurrent aphthous ulcers

Answer 8

Refer to Dentist/ Oral Pathologist:
• For large ulcers with unknown cause
• Ulcers that do not heal within 2week/ no improvement after 2 weeks
• Persistent painful oral ulcer which fails to respond to treatment
• Ulcers which have caused scarring

The Dentist may:
• Perform a biopsy
• Refer to haematologist for haematological investigations
• Full blood count
• Blood folate level
• VitaminB12
• Ferritin (or serum iron/total binding capacity ratio)

Question 9

List the products that can be used to treat recurrent aphthous ulcers based on order of preference

Answer 9

• Covering agents: Orabase Protective Paste provides physical protection for ulcers
• Mouth rinses: Chlorhexidine gluconate 0.2%, 10 ml three times daily OR Benzydamine hydrochloride 0.15% and chlorhexidine 0.12% (DifflamC)
• Salicylate containing ointments: Bonjela has an analgesic effect if applied every few hours (only in adults)
• Low potency corticosteroids (hydrocortisone): Anti-inflammatory effect (Kenalog in Orabase, prescribed by dentist or GP)
• Topical anaesthetic pastes or sprays: Have a numbing effect: SM-33 contains salicylates and lidocaine (to be used in adults only)

Question 10

Describe orabase protective gel in terms of age of recommendation

Answer 10

• Gelatine, pectin and sodium carboxymethylcellulose in plastibase (plasticised hydrocarbongel)
• Contains benzocaine to provide topical anaesthesia
• Not approved for use in children under 2 years of age

Question 11

Describe bonjela in terms of age of recommendation

Answer 11

• Ointment containing choline salicylate, cetalkonium chloride, alcohol glycerol, menthol, hypromellose 4500, anise oil, sodium saccharin and water
• Recommended to be used only for 16 years old and over (salicylate)
• Analgesic effect and may be anti-inflammatory
• Can be used every few hours

Question 12

Describe Difflam C in terms of age of recommendation

Answer 12

• Each 15 mls contain: Benzydamine Hydrochloride 22.5mg, Chlorhexidine Gluconate18mg
• Anti-inflammatory and antiseptic
• Benzydamine also possess local anaesthetic activity
• Rinse 1.5 -3 hours for 30secs
• Not recommended under 12years of age (for both topical treatment and spray)
• Use cotton bud to dab on ulcer/s for young children

Question 13

List 9 medical conditions that cause severe ulcerations

Answer 13

• Erythema multiforme
• Stevens-Johnson syndrome
• Toxic Epidermal Necrolysis
• Behcet’s syndrome
• Epidermolysis bullosa
• Lupus erythematosus
• Orofacial granulomatosis / Crohn disease
• Ulcerative colitis
• Coeliac disease

Question 14

Describe erythema multiforme in terms of gender affected, potential causes, symptoms

Answer 14

• This is a skin and mucosal disease of abrupt onset, self limiting but recurrent
• Young male adults are typically the group affected, and is seen less commonly in females and younger children
• Unknown although many precipitating factors have been implicated: Some antibiotics, especially sulphonamides, allergy
• Often initiated by herpes simplex virus
• Prodromal phase with upper respiratory infection, headache, malaise, nausea and arthralgia occurs

Question 15

List clinical features of erythema multiforme

Answer 15

• Skin of the hands and feet may have rash-like or ‘target’ lesions
• Ulcers with ragged margins, mainly in the anterior parts of the mouth, limited to lips and gingiva
• Oral lesions are cracked, bleeding, crusted, swollen lips

Management by GP includes use of systemic corticosteroids or immunosuppressive drugs

Question 16

Describe stevens- Johnson syndrome in terms of who is most affected, precipitating factors and symptoms

Answer 16

• A severe form of erythema multiforme

• Affects: children and young adults
• Precipitating factor: Mycoplasma pneumoniae respiratory infection or drug reaction

Signs:
• Cutaneous and stomatologic  structures involvement
• Fever
• Malaise
• Headache
• Chest pain
• Diarrhoea
• Vomiting
• Arthralgia
• Eye lesions
• Genital lesions
• Stomatitis

Oral signs:
• Extensive ulcerative and haemorrhagic lesions of the lips and denudated areas of the oral mucosa are painful, preventing patients from eating and swallowing
• Dehydration and debilitation are common sequalae that necessitate hospitalization
• Healing takes about 6 weeks

Question 17

Describe toxic epidermal necrolysis and its management

Answer 17

• Similar to Stevens-Johnson Syndrome
• Severe, can be fatal
• Bullous drug-induced eruption where sheets of skin are lost
• Large areas of skin form bullae, that slough, leaving huge areas of denudated skin
• Management is similar to that of a burn patient
• Intravenous fluid, nutrition therapy, antiseptic rinses, antibiotics (avoiding secondary infections)
• It takes months to heal and permanent eye damage is frequent

Question 18

Describe Behcet’s syndrome in terms of cause, symptoms, eye lesions, skin lesions and treatment

Answer 18

• Causes inflammation in blood vessels throughout body. Cause is unknown, but through to be autoimmune related. Genetic and environmental factors are implicated
• Oral ulcers may be the first sign of the disease
• May include mouth sores, eye inflammation, skin rashes and lesions, and genital sores
• Often can control signs and symptoms and reduce the risk of complications
• Eye lesions include photophobia, conjunctivitis and iritis – may lead to blindness
• Skin lesions are characterized by nodular eruptions that ulcerate
• Topical and systemic steroids are used in treatment

Question 19

Describe Behcet’s syndrome in terms of cause, symptoms, eye lesions, skin lesions and treatment

Answer 19

• Causes inflammation in blood vessels throughout body. Cause is unknown, but through to be autoimmune related. Genetic and environmental factors are implicated
• Oral ulcers may be the first sign of the disease
• May include mouth sores, eye inflammation, skin rashes and lesions, and genital sores
• Often can control signs and symptoms and reduce the risk of complications
• Eye lesions include photophobia, conjunctivitis and iritis – may lead to blindness
• Skin lesions are characterized by nodular eruptions that ulcerate
• Topical and systemic steroids are used in treatment

Question 20

Describe epidermolysis bullosa in terms of causes, appearance and oral impacts

Answer 20

• Occurs due to a genetic defect in basement membrane proteins, causing blisters in the skin and mucosal membranes
• Blisters may form from birth or appear in the first few weeks of life
• Skin blisters are due to mild trauma, leading to scaring and disfigurement
• “Butterfly Children” is a term often used to describe younger patients (because the skin is said to be as fragile as a butterfly’s wings, or “Cotton Wool Babies”)
• Caries and periodontal disease are common due to inability to maintain good OH

Question 21

Describe lupus erythematous in terms of oral lesions, places of occurrence and treatment

Answer 21

• Lip lesions are red with a white scaly margin (lower lip at vermilion border is a common site)
• Oral lesions: central red atrophic area sometimes covered by a fine stippling of white dots. Periphery is irregular, composed of alternating red and keratotic white lines
• The buccal mucosa, then tongue, palate, gingiva is the most frequent intraoral site
• Treatment of ulcerative lesions: avoid stress, cold, sunlight, topical steroids, immunosuppressive agents

Question 22

Describe orofacial granulomatosis/ crohn disease and the associated oral lesions (4)

Answer 22

• Crohn’s disease is a chronic disease of unknown aetiology causing thickening and ulceration of any part of the gastrointestinal tract, but most commonly the ileum
• Leads to folic acid and vitamin B12 deficiency (absorbed from small bowel)
• Both topical and systemic corticosteroids are used as treatments
• Oral lesions occur in individuals with established disease

There are several types of oral lesions:
• Diffuse swellings of the lips and cheeks
• Cobblestone-like thickening of the buccal mucosa with fissuring and folding
• Solitary, persistent ulcers in any part of the mouth
• Glossitis

Question 23

Describe ulcerative colitis

Answer 23

• Clinically and Histological identical to oral manifestations of Crohn’s Disease
• Probable etiology is a hypersensitivity response to certain foods and additives, such as cinnamon and benzoates
• Treatment: systemic corticosteroid
• Beginning in adolescence, this disease involves inflammatory changes in the mucosa and sub mucosa of the colon
• Oral ulcers resembling major aphthae occur in some patients

Question 24

Describe coeliac disease

Answer 24

• This is a malabsorption disease caused by gluten intolerance
• Gluten, the protein contained in wheat and rye flour damages the mucosa of the digestive tract in susceptible individuals
• Oral mucosal ulcers occasionally are seen in association with this disease