Paediatric Oral Medicine

Question 1

What can cause oro-facial soft tissue infections?

Answer 1

• viral
  
  • primary herpes
  • herpangina
  • hand, foot and mouth
  • varicalla zoster
• bacterial
  
  • staphylococcal
  • streptococcal
  • syphilis
  • tuberculosis
• fungal
  
  • candida

Question 2

What is primary herpetic gingivostomatitis?

Answer 2

• acute infectious disease
  
  • herpes simplex virus 1
• primary infection
  
  • common in children
  • recurrence as cold sores
• transmission by droplet formation
  
  • 7 day incubation
• signs and symptoms
  
  • fluid filled vesicles
    - rupture to ulcers
  • severe oedematous marginal gingivitis
  • fever
  • headache
  • malaise
  • cervical lymphadenopathy
• treatment
  
  • usually self limiting after 14 days
  • bed rest
  • soft diet and hydration (dehydration most common cause)
  • paracetamol
  • antimicrobial gel or mouthwash
  • acyclovir for immunocomprimised children
• virus remains dormant in epithelial cells
  
  • recurrent as herpes labials in 50-75% of cases
  • triggered by sunlight, stress or other causes of ill health
  • managed by topical acyclovir cream

Question 3

What does coxsackie A virus cause?

Answer 3

• herpangina
• hand, foot and mouth disease

Question 4

What is herpangina?

Answer 4

• mild condition
• vesicles in the tonsils pharyngeal region
  
  • similar to primary herpetic gingivalvostomatitis
  • lasts 7-10 days
• management
  
  • same as that of herpes simplex 1

Question 5

What is hand foot and mouth disease?

Answer 5

• ulceration on the gingivae, tongue, palate and cheeks
• maculopapular rash on the hands and feet
  
  • a couple of days after ulceration appears in mouth
• lasts 7-10 days

Question 6

What is oral ulceration?

Answer 6

a localised defect in the surface oral mucosal where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue

Question 7

What 10 key facts must be determined about an ulcer?

Answer 7

• onset
• frequency
• number
• site
• size
• duration
• exacerbating dietary factors
• lesions in other areas
• associated medical problems
• treatment attempt so far (success?)

Question 8

What infections can cause oral ulceration?

Answer 8

• viral
  
  • hand, foot and mouth
  • herpes simplex
  • herpez zoster
• bacterial
  
  • tuberculosis
  • syphilis

Question 9

What immune mediated disorders can cause oral ulceration?

Answer 9

• Crohns
• behcets
• SLE
• coeliac

Question 10

What vesticulobullous disorders can cause oral ulceration?

Answer 10

• bulbous or mucous membrane pemphigoid
• pemphigus
• pemphigus vulgaris
• linear IgA disease

Question 11

What are the potential causes of oral ulceration?

Answer 11

• infection
• immune mediated disorders
• vesticulobullous disorders
• inherited or acquired immunodeficiency disorders
• neoplastic/haemotalogical
• trauma
• vitamin deficiencies
• recurrent apthous stomatitis

Question 12

What neoplastic/haemotalogical factors can cause oral ulceration?

Answer 12

• anaemia
• leukaemia
• agranulocytosis
• cyclic neutropenia

Question 13

What vitamin deficiencies can cause oral ulceration?

Answer 13

• iron
• B12
• folate

Question 14

What is recurrent pathos ulceration?

Answer 14

• most common cause of ulceration in children
• round or ovoid shaped ulcers
  
  • grey or yellow base
  • varying degree of perilesional erythema
• 3 patterns
  
  • minor (<10mm), 10-14 days to heal, only unkeratinised
  • major (>10mm), several weeks to heal, also keratinised
  • herpetiform (1-2mm), many ulcers at a time
• aetiological factors
  
  • hereditary predisposition
  • haemotalogical and deficiency disorders
  • GI disease
  • minor trauma in susceptible individuals
  • stress
  • allergic disorders
  • hormonal disturbance
• investigations
  
  • diet diary
  • FBC
  • haematinics
  • coeliac screen
• management
  
  • avoid exacerbating food groups
  • supplementation
  • pharmacological
    - corsodyl 0.2% mouthwash (infection prevention)
    - gengigel topical gel, gelclair mouthwash (protection)
    - difflam, LA spray (symptomatic relief)

Question 15

What is orofacial granulomatosis?

Answer 15

• uncommon chronic inflammatory disorder
  
  • associated with systemic granulomatous conditions
    - Crohns
    - sarcoidosis
  • average onset at 11 years old
• non caseating giant cell granulomas
  
  • result in lymphatic obstruction
  • can be predictor of future Crohns
• clinical features
  
  • lip swelling
  • full thickness gingival swelling
  • swelling of other facial tissues
  • peri-oral erythema
  • cobblestone appearance buccal mucosa
  • linear ulceration
  • mucosal tags
  • lip/tongue fissuring
  • angular chelitis
• aetiology
  
  • largely unknown
  • potentially genetic
  • associated allergens
    - cinnamon compounds
    - benzoates
  • higher IgE mediated atopy rates
• diagnosis
  
  • clinical, lip biopsy not essential
  • measure facial growth
  • FBC
  • haematinics
  • patch testing to identify triggers
  • diet diary to identify triggers
  • faecal calprotectin
• management
  
  • oral hygiene support
  • symptomatic relief for ulceration
  • dietary exclusion
  • management of nutritional deficiencies
  • topical steroids
  • topical tacrolimus
  • short course of oral steroids
  • intralesional steroids
  • surgical intervention

Question 16

What is geographic tongue?

Answer 16

• shiny red areas on tongue with loss of filiform papillae surrounded by white margins, migrating over tongue
• benign but can be painful

Question 17

What solid swellings can be seen in the mouth?

Answer 17

• fibroepithelial polyp
• epulides
• congenital epulis
• HPV-associated mucosal swellings
• neurofibromas

Question 18

What are fibroepithelial polyps?

Answer 18

• firm pink lumps
  
  • pedunculate or sessile
  • benign
• mostly found in commonly traumatised areas
• managed by surgical excision under LA

Question 19

What are epulides?

Answer 19

• common solid swellings over the oral mucosa
• benign hyperplastic lesions
  
  • inter proximal dental tissues most common
  • related to chronic dental irritation (calculus and plaque)
  • majority anterior to molars, mostly in maxilla
• 3 main types
  
  • fibrous epulis
    - pedunculate or sessile mass
    - firm consistency
    - similar colour to surrounding gingival
    - inflammatory cell infiltrate and fibrous tissue
  • pyogenic granuloma
    - soft, deep, red/pruple swelling
    - often ulcerated
    - haemorrhage spontaneously or with mild trauma
    - vascular proliferation supported by fibrous stroma
    - reaction to chronic trauma
    - tend to recur after removal
  • peripheral giant cell granuloma
    - pedunculate or sessile swelling
    - typically dark red and ulcerated
    - interproximally with hourglass shape
    - superficial erosion of interdental bone
    - multinucleate giant cells in vascular stroma
    - may recur after surgical excision
• managed by surgical excision and removal of exacerbating factors
  
  • commonly recur

Question 20

What are congenital epulis?

Answer 20

• rare lesion occurring in neonates
  
  • most common in anterior maxilla
• granular cells covered with epithelium
  
  • benign
• simple surgical excision
  
  • does not recur

Question 21

What are HPV associated swellings

Answer 21

• verruca vulgaris
  
  • HPV 2 and 4
  • solitary or multiple lesions
  • keratinised tissue most commonly affected
  • spontaneous resolution or surgical removal
• squamous cell papilloma
  
  • HPV 6 and 11
  • small pedunculate cauliflower like growths
  • benign
  • white-pink in colour
  • usually solitary
  • surgical excision

Question 22

What fluid filled swelling can be seen in the mouth?

Answer 22

• mucoceles
• radula
• Bohn’s nodules
• Epstein pearls
• haemangiomas
• vesiculobullous lesions
  
  • primery herpes
  • epidermolysis bulls
  • erythema multiforme

Question 23

What are mucoceles?

Answer 23

• 2 variants
  
  • mucous extravasions cyst
    - normal secretions rupture into adjacent tissues
  • mucous retention cyst
    - secretions retained in an expanded duct
• blush, soft, transparent, cystic swelling
• affect minor or major salivary glands
  
  • most affect minor glands of the lower lip
• most rupture spontaneously
• surgery only if lesion fixed in size
  
  • will likely damage adjacent gland
  • leads to recurrence
  • removal of cyst and adjacent damaged minor salivary gland

Question 24

What are ranula?

Answer 24

• mucocele in the floor of the mouth
  
  • minor salivary glands or ducts or sublingual/submandibular
• ultrasound or MRI needed to exclude plunging radula
  
  • extended into submittal or submandibular space
  • occasionally found to be lymphangioma
    - benign tumour of the lymphatics

Question 25

What are Bohn’s nodules?

Answer 25

• gingival cysts
  
  • remnants of the dental lamina
  • filled with keratin
  • occur on alveolar ridge
• found in neonates
  
  • first 28 days
  • disappear in early months of life

Question 26

What are Epstein pearls?

Answer 26

• small cystic lesions
  
  • found along palatal midline
  • trapped epithelium in palatal raphe
• in around 80% of neonates
  
  • disappear in first few weeks

Question 27

What is temporomandibular joint dysfunction syndrome?

Answer 27

• most common condition affecting the temporomandibular region
• characterised by:
  
  • pain
  • masticatory muscle spasm
  • limited jaw opening
• history
  
  • presenting symptoms
  • when discomfort started
  • exacerbating factors
  • habits
  • stress
• examination
  
  • palpation of muscles of mastication
    - at rest and on clenching
    - assess tenderness or hypertrophy
  • palpation of TMJ
    - at rest
    - when opening and closing
    - assess tenderness and click/crepitus
  • assessment of opening
    - check for deviation of jaw
    - assess extent of opening
  • intraoral
    - assessment of dental wear facets
    - signs of clenching or grinding
    - scalloped lateral tongue surface
    - buccal mucosa ridges
• symptomatic relief
  
  • ibuprofen
  • alternating use of hot and cold packs