Orofacial Infections in Paediatric Dentistry Flashcards
handbook of paediatric dentistry
chapter 10
What should be investigated when looking at an oral lesion?
VITAMIN DIC
Vascular Inflammatory Traumatic Autoimmune Metabolic Infection Neoplastic Degenerative Idiopathic Congenital
What are the types of orofacial infections?
Viral (Primary herpetic gingiva-stomatitis, herpes labialis, herpangina, hand foot mouth disease, infectious mononucleosis, and varicella)
Bacterial (odontogenic, scarlet fever, TB, etc)
Fungal (candidosis)
What are the most common viral aetiologies for infections of the mouth?
Herpes simplex virus type 1 (Primary herpetic gingivostomatitis and herpes labialis)
Epstein Barr virus (Infectious mononucleosis)
Coxsackie A, B, enterovirus 71 (Hand foot mouth disease)
Coxsackie A (herpangina)
Varicella zoster virus (Chickenpox)
What is the most common symptom associated with herpes simplex?
Ulceration (usually occurs at 6 months of age and coincides with eruption of primary incisors)
How common is infection with herpes simplex type 1?
60% infected 1% show symptoms
What is the clinical presentation of primary herpetic gingivostomatitis?
General:
Febrile illness with raised temperature of 37.8 - 38.9 degrees celsius
Headaches, malaise, irritability
Cervical lymphadenopathy
Oral:
Oral pain, mild dysphagia
Stomatitis
Intraepithelial fluid-filled vesicles appear on tongue, lips, buccal and palatal mucosa.
Ulcers can be solitary (Usually small and painful with erythematous margins) or larger and irregular due to coalescence of individual lesions
Can secondary herpetic gingivostomatitis occur?
Secondary recurrent infection can occur and usually occurs in older kids
What is the incubation time of primary herpetic gingivostomatitits?
3 - 5 days (with a prodromal 48-h history of irritability, pyrexia, and malaise)
How is primary herpetic gingivostomatitis transmitted?
Direct contact with lesions
Contact with infected oral secretions (droplet infection)
What is the typical course of primary herpetic gingivostomatitis?
Disease is self-limiting
Ulcers heal spontaneously without scarring within 10 - 14 days
What are the histological features of primary herpetic gingivostomatitis?
Tzanck cells: Multinucleated giant cells with jig saw nucleus
How is primary herpetic gingivostomatitis diagnosed?
History, clinical features and age group of affected children
Exfoliative cytology: presence of multinucleated giant cells and viral inclusion bodies can be used for rapid diagnosis.
Viral antigen
Viral culture
Viral antibody detection in blood samples
What are the differentials for primary herpetic gingivostomatitis?
Necrotizing ulcerative gingivitis
Erythema multiforme
Herpangina
What are the complications that can arise from primary herpetic gingivostomatitis?
Very rarely, it can lead to:
Aseptic meningitis
Encephalitis
How is primary herpetic gingivostomatitis treated?
Encourage oral fluids
Bed rest + soft diet
Analgesics (paracetamol 15mg/kg, 4 - 6 hourly)
Mouthwashes (chlorhexidine can be swabbed over the affected areas in younger children and in older children mouthwash can be used 10mL 4 hourly)
Antiviral chemotherapy: Oral and intravenous acyclovir is approved for use in children (20mg/kg body weight 5 hourly or IV 10mg/kg) although evidence of efficacy is limited.
Should topical therapies be used for primary herpetic gingivostomatitis?
No recommended due to concern over systemic overdose.
Which mouthwashes can be used for primary herpetic gingivostomatitis?
Young children: Swab chlorhexidine on the ulceration.
Older children: Chlorhexidine mouthwash 0.2%, 10mL 4 hourly
Children >12 years old: Tetracycline or minocycline mouthwashes can be used.
Difflam C can be helpful in addition.
What causes herpes labialis?
Recurrence of herpes simplex virus type 1 on the vermilion border and adjacent skin of the lips.
What triggers herpes labialis?
UV light and trauma
What are the prodromal signs and symptoms of herpes labialis?
Symptoms most severe in the first 8 hours
Pain, burning, itching, tingling, and warmth
Erythema 6 - 24 hours before lesions develop
Multiple small, erythematous papules develop
Clusters of fluid filled vesicles
Vesicles rupture and crust within 2 days
What is the the typical course of herpes labialis?
It is self limiting and heals within 7 - 10 days
How is infectious mononucleosis transmitted?
Intimate contact usually:
Main route of transmission is by blood or saliva
Intrafamilial spread is common, once a person is exposed EBV remains in the host for life.
Children get it often from contaminated saliva on fingers, toys, or other objects.
Adults usually contract the virus directly through salivary transfer such as shared straws or kissing.
What are the symptoms of infectious mononucleosis?
Low-grade fever
Hepatosplenomegaly
Rhinitis or cough
Malaise, headache
Cervical lymphadenopathy and tenderness
Oral ulcers, palatal petechiae, and gingival ulcerations (necrotizing ulcerative gingivitis), tonsillitis with or without pharyngitis
What is the typical course of infectious mononucleosis?
The disease is self-limiting and resolves within one or two weeks
What are the histopathological features of infectious mononucleosis?
Downey cells - atypical lymphocytes
What are the differentials for infectious mononucleosis?
Trauma
Reactive gingival lesions
Haematological disorders (Thrombocytopaenia, platelet disorders, and haemorragic telengiactasia)
How is infectious mononucleosis diagnosed?
History + clinical features
Atypical lymphocytes on blood film
Positive heterophile antibody test (Monospot test and Paul-Bunnel agglutination test)
Indirect immunofluorescent assays
Real-time PCR
How is infectious mononucleosis treated?
Most cases resolve within 4 to 6 weeks
Otherwise symptomatic treatment.
What are the potential significant complications of EBV infection?
Splenic rupture
Thrombocytopaenia
Autoimmune haemolytic anaemia
Aplastic anaemia
Neurological problems
Myocarditis
Haemophagocytic lymphohistiocytosis
Patients experience fatigue lasting for several weeks to months in <10% of cases)
Increased risk for developing MS later in life
Burkitt lymphoma association with EBV
What causes herpangina?
Coxsackie group A viruses
Who is most commonly affected by herpangina?
Mainly children <10 years of age
How is herpangina transmitted?
Faecal-oral route
How long is herpangina’s incubation time?
4 - 7 days
What are the general symptoms fo herpangina?
Low-grade fever, malaise, headache
Sore throat, dysphagia, anorexia, rhinorrhea
Vomiting diarrheoa
Myalgia
Oral lesions
What do herpangina oral lesions look like?
Red macules (usually 2 - 6) which form fragile vesicles that ulcerate rapidly (2 - 4mm)
Where do herpangina oral lesions form?
Palate
Pillars of the fauces and pharynx
Herpangina lesions do not coalesce to form large areas of ulceration
What is the course of disease of herpangina?
Self-limiting healing occurs within 1 - 2 weeks
What are the histopathological features of herpangina?
Intraepithelial vesicles containing eosinophilic exudate.
Nuclear ballooning degeneration of epithelial cells
What is the differential diagnosis of herpangina?
Other viral mucosal ulcers
How is herpangina diagnosed?
Known epidemic
Viral culture from swab
Clinical appearance and history
How is herpangina managed?
Symptomatic care
Adequate hydration
Analgesisa for pain control and antipyretics
What are the potential complications of herpangina?
Pneumonia
Pulmonary oedema
Haemorrhage
Acute flaccid paralysis
Encephallitis meningitis
Carditis
What is the viral aetiology of hand foot and mouth disease?
Coxsackie A
Coxsackie B
Enterovirus 71
What age and gender commonly is affected by hand foot and mouth disease?
Mainly children <10 years old
No gender predilection
What are the general features of hand foot mouth disease?
Low-grade fever
Sore throat, dysphadia
Cough, rhinorrhea, anorexia, vomiting, diarrhoea, myalgia and headache
Cutaneous lesions on the palms and soles and ventral surfaces and sides of he fingers and toes, buttocks
What do the oral lesions in hand foot mouth disease look like?
Resemble those of herpangina (more numerous and frequently involve anterior regions of the mouth)
Appearance of red macules which form fragile vesicles that rapidly ulcerate
Number of lesions ranges from 1 to 30
Where are the oral lesions usually appear in the oral mucosa?
Buccal and labial mucosa
Tongue
Palate
Pillars of the fauces and the pharynx
How do the cutaneous lesions in hand foot mouth disease form?
Cutaneous lesions begin as erythematous macules that develop central vesicles and heal without crusting
Nail loss or ridges form and may ensure after several weeks
What is the typical course of disease hand foot mouth disease?
Usually a self limiting disease
What are the histopathological features of hand foot mouth disease?
Intraepithelial vesicles: early stages with intracytoplasmic eosinophilic inclusion bodies
Later stages: Shallow ulcerations and erosions with regeneration of the amrginal epithelium
Superficial inflammatory cell infiltrate in submucosa
What are the differentials for hand foot and mouth disease?
Herpetic gingivostomatitis
Herpangina
Varicella
Aphthous stomatitis
How is hand foot and mouth disease diagnosed?
Clinical appearance and history
Known epidemic
Viral culture from swab
What are the complications of hand foot mouth disease?
Neurological complications
Viral meningitis
Encephalitis
Cerebellar ataxia
Who most commonly gets varicella?
Chicken pox in children
Shingles in older adults
How is varicella transmitted?
Spread through air droplets
Direct contact with active lesions
What is the incubation period of varicella?
10 to 21 days (avg 15 days)
How does chickenpox present in immunized children?
Maculopapular, cutaneous rash with only a small number of lesions
Oral: Few or no vesicles.
What is the typical course of varicella?
A shortened disease course of 4 - 6 days
How does chickenpox present in unimmunized children?
General:
Malaise, pharyngitis, nausea, anorexia, and vomiting.
Skin:
intensely pruritic exanthema
Vesicular stage (each vesicle is surrounded by a zone of erythema.
Lesions continue to erupt for 4 or more days and old crusted lesions intermixed with newly formed, intact vesicles
What do the oral lesions of varicella look like?
Begin as 3 to 4mm, white, opaque vesicles.
Vesicles rupture to form 1 to 3 mm ulcerations.
Which sites on the oral mucosa are mostly affected by varicella?
Vermillion border and palate most frequently
Buccal mucosa and gingival less frequently
How long do oral ulcerations last in varicella infections?
In mild cases = 1 to 3 days. (1 - 2 ulcers)
In severe cases = 5 - 10 days. (up to 30 ulcers)
When is the immunization to chickenpox provided?
at 18 months MMR, and chickenpox
What are the histopathological features of varicella?
Cytological alterations identical to HSV
Virus causes acantholysis, formatino of numerous free-floating Tzanck cells, which exhibit nuclear margination of chromatin and occasional multinucleation
How is varicella diagnosed?
Viral cytology
PCR on vesicular fluid/cells from base of lesion/scab from resolving skin lesion
Direct fluorescent antibody assay
How is varicella treated?
Symtomatic treatment: Warm baths with soap, baking soda, or colloidal oatmeal.
Application fo calamine lotion
Antihistamines
Antipyretics
Antiviral meds have been shown to reduce duration if administered with 24 hours of the rash
What are the potential complications of a varicella infection?
Encephalitis
Pneumonia
Necrotizing fasciitis
Septicemia
Toxic shock syndrome
Other life threatening conditions
