Paediatric Oral Medicine Flashcards
What are viruses that cause oro-facial soft tissue infections
primary herpes herpangina hand food and mouth varicella zoster EBV mumps measles rubella
What are bacterial ore facial soft tissue infections
staphylococcal streptococcal symphilis TB cat scratch disease
What is primary herpetic gingivostomatitis
acute infectious disease
What are fungal causes of facial soft tissue infections
candida
What is the cause of primary herpetic gingivostomatitis
herpes simplex virus I
What is the transmission of herpex simplex virus I (PHG)
droplet formation with 7 day incubation
Why is PHG uncommon in children in their first year of life
as they have a degree of immunity from circulating maternal antibodies
What is the treatment of PHG
bed rest soft diet/hydration paracetamol antimicrobial gel or mouthwash acyclovir for immune compromised children
Describe the fluid filled vesicles seen in PHG
rupture to painful ragged ulcers on the gingiva, tongue, lips, buccal and palatal mucosa
What is the most common complication of PHG
dehydration
How long does PHG last for
14 days
How does PHG heal
with no scarring
What is the recurrent disease of PHG
it remains dormant in epithelial cells
recurrent disease is is herpes labials (cold sores)
What is recurrent infection of herpes simplex I triggered by
sunlight
stress
other causes of ill health
How are cold sores managed
with topical acyclovir cream
What two infections can coxsackie A virus cause
herpangina
hand foot and mouth
What is the difference between herpangina and PHG
the vesicles in the tonsillar pharyngeal region i.e further back
How does hand foot and mouth present
presents with store throat and high temp initially
then see ulceration on the gingiva/tongue/cheeks and palate
a maculopapular rash is seen on the hands and feet
How long does herpangina last for
lasts 7-10 days
How does hand foot and mouth last for
7-10 days
What is oral ulceration defined as
a localized defect in the surface oral mucosa where covering epithelium is destroyed leaving an inflamed area of exposed connective tissue
What are the 10 key facts to ask about when taking a history on an ulcer
OFN SS DELAT
onset frequency number site size duration exacerbating dietary factors lesions in other areas associated medical problems treatment so far and if it was helpful or unhelpful
What are the causes of oral ulceration
infection immune mediated disorders vesiculobullous disorders inherited or acquired immunodeficiency disorders neoplastic/haematological trauma vitamin deficiencies recurrent apthous stomatitis
What are viral infections that can cause oral ulceration
HFM coxsackie virus herpes simplex herpes zoster CMV EBV HIV
What are bacterial infections that cause oral ulceration
TB
symphilis
What are immune mediated disorders that cause oral ulceration
crohns behcets SLE coeliac periodic fever syndromes
Vesiculobullous disorders
bullous or mucous membrane pemphigoid
pemphigus vulgaris
linear IgA disease erythema multiform
What are neoplastic/haematological conditions that cause oral ulceration
anaemia
leukamia
agranulocytosis
cyclic neutropenia
What is the most common cause of ulceration in children
recurrent apthous ulceration
What are the different types of trauma that can cause ulceration
physical
chemical
thermal
What is recurrent apthous stomatitis
it is this when there is no underlying cause identified
What are the typical apthous ulcer
round / ovoid in shape
grey or yellow base
have varying degree of perilesional erythema
What are the 3 patterns of RAU
minor
major
herpetiform
What are minor apthous ulcers
<10mm
What are major apthous ulcers
> 10mm
What are herpetiform ulcers
1-2mm
can be up to 100 at a time
What are the aetilogical factors of recurrent ulceration
unclear hereditary predisposition haematological and deficiency disorders (iron deficiency) GI disease (coeliac) minor trauma in susceptible individuals stress allergic disorders (toothpaste containing SLS/foods containing benzoate or sorbete preservatives) hormonal disturbance: menstruation
What are initial investigations for recurrent oral ulceration
diet diary
full blood count
haematinics (folate/b12/ferritin)
coeliac screen - anti transglutaminase antibodies
What are management of exacerbating factors of RAU
nutritional deficiencies
traumatic factors
avoid sharp or spicy foods
allergic factors
What are allergic factors management for RAU
dietary exclusion
SLS free toothpaste
What are pharmacological management of recurrent oral ulcers
prevention of superinfection
protecting healing ulcers
symptomatic relief
What do we use to prevent superinfection of RAU
corsodyl 0.2% moutwash
What do we use to protect healing ulcers
gengigel topical gel (hyaluronate) geclair mouthwash (hyaluronate)
What do we use for symptomatic relief
difflam (0.15% benzydamina hydrochloride)
LA spray
What is orofacial granulomatosis
uncommon chronic inflammatory disorder
What is the cause of OFG
idiopathic or associated with systemic granulomatous conditions (crohns or sarcoidosis)
What gender is OFG more common in
males
What is the characteristic pathology of OFG
non caveating giant cell granulomas which then result in lymphatic obstruction
What may OFG be a predictor of
future crohn’s disease
What are the clinical features of OFG/oral crohns
lip swelling - most common full thickness gingival swelling swelling of the non labial facial tissues peri-oral erythema cobblestone appearance of the buccal mucosa linear oral ulceration mucosal tags lip/tongue fissuring angular cheilitis
What is the etiology of OFG
largely unknown
limited evidence of genetic factors
numerous associated allergens are reported
What are the associated allergens with OFG
cinnamon compounds
benzoates
much higher IgE mediated atopy rates compared to the general population
How is OFG diagnosed
clinical
lip biopsy not essential
What are the investigations of OFG
measure growth FBC haematinics patch testing - identify triggers dietary diary - identify triggers faecal calprotectin endoscopy risky in childhood serum angiotensin converting enzyme (raised in sarcoidosis)
What is the management of OFG
can be difficult
OH support
symptomatic relief as per oral ulceration
dietary exclusion (does not cure but reduces inflammation)
manage nutritional deficiencies which may contribute to oral ulceration
topical steroids
topical tacrolimus
short courses of oral steroids (severe or unresponsive to topical)
intralesional corticosteroids
surgical intervention - unresponsive long standing disfigurement
What is geographic tongue
idiopathic and non contageous
shiny red areas on the tongue with loss of filiform papillae are surrounded by white margins
Why can geographic tongue cause intense discomfort in children
as they have thinner mucosa and a more intense sense of taste
they may feel discomfort with spicy food, tomato or citrus fruit / juice
need to have a bland diet during flareups
should become less troublesome with age
What are the different types of solid swellings
fibroepithelial polyp epulides congenital epulis HPV- associated mucous swellings neurofibromas
What is fibro-epithelial polyp
common
firm pink lump (pedunculate or sessile)
once established remains constant in size
Where are fibroepithelial polyps mostly seen
in the cheeks along the occlusal line, lips and tongue
What is the cause fibroepithelial polyps
minor trauma
What is the tx of the fibroepithelial polyp
surgical excision
curative
may need to wait until child is cooperative as hard to justify GA when benign
What are epulides
common solid swellings of oral mucosa
benign hyperplastic lesions
What are the 3 main types of epulides
fibrous epulis
pyogenic granuloma
peripheral giant cells granuloma
What are fibrous epulis
pedunculate or sessile mass
firm consistency
similar color to surrounding ginviae
inflammatory cell infiltrate and fibrous tissue
What are pyogenic granuloma/pregnancy epulis
they are soft, deep red/purple swellings
often uclerated
can haemorrhage spontaneously or with mild trauma
vascular proliferation supported by a delicate fibrous storm
probably a reaction to chronic trauma such as calculus
tend to recur
When should pregnancy epulis treated
regresses spontaneously after child is born
excision should be delayed until this time
What are peripheral giant cell granulomas
pedunculate or sessile swellings
typically dark, red and ulcerated
usually arises inter proximally and has an hour glass shape
radiographs may reveal superficial erosion of interdental bone
may recur after surgical excision
What makes peripheral giant cell granuloma different from other epulis
it is a focal collection of multinucleate giant cells in a rich vascular and cell stroke
What are congenital epulis
rare occur in neonates most common in anterior maxilla more common in fmelaes granular cells covered with epithelium benign simple excision is curative
What are HPV associated swellings for
verruca vulgaris
squamous cell papilloma
What is verruca vulgarizes
solitary or multiple intra oral lesions
may be associated with skin warts
most resolve spotnanesouly
can be removed surgically
What is the cause of verruca valgarizes
caused by HPV 2 and 4
What is verruca vulgarisms most commonly seen
most commonly on keratinsed tissue - gingiva and palate
What is squamous cell papilloma
small pedunculate cauliflower like growths
benign
vary in color from pink to white
usually solitary
treatment is surgical excision
What are the causes of squamous cell papilloma
HPV 6 & 11
What are the fluid swellings
mucoceles ranula Johns nodules epstein perals haemangiomas vesiculobullous lesions
What are the vesiculobullous lesions
primary herpes
epidermolysis bullosa
erythema multiform
What are the 2 variants of mucocele
mucous extravasion cyst
mucous retention cyst
What is a mucous extraversion cyst
normal secretions rupture into adjacent tissue
What is a mucous retention cyst
secretions retained in an expanded duct
What are mucoceles
bluish soft transparent cystic swelling
can affect minor or major salivary glands
most common is minor glands of lower lip
peak incidence is second decade
most will rupture spontaneously
surgery only if lesion is fixed in size as will likely damage the adjacent glands leading to recurrence
surgical excision involves removal of cyst and adjacent damaged minor glands
What is a ranula
it is a mucocele in the floor of the mouth
What can ranulas arise from
minor salivary glands or ducts of sublingual / submandibular glands
Why is a MRI or ultrasound needed for a ranula
excludes purging ranulas
extend through the FOM into sub mental or mandibular space
What can ranulas occasionally be found to be
lymphangioma - benign tumor of lymphatics
What are Bohn’s nodules
gingival cysts remnants of dental lamina filled with keratin occur on the alveolar rdige found in neonates usually disappear
What are Epstein pearls
small cystic lesions found along palatal midline thought to be trapped epithelium in palatal raphe common disappears in first few weeks
What is TMJ dysfunction syndrome characterized by
pain
masticatory muscle spasm
limited jaw opening
What questions should be asked in a TMJDS history
description of presenting symptoms when did discomfort begin is pain worse at any time during day what are exacerbating factors habits stress
What should an extra oral exam for TMJDS include
palpation of muscles of mastication both at rest and when teeth are clenched to assess tenderness and / or hypertrophy
palpation of the TMJ at rest and when opening and closing to assess tenderness and click/creptius
assessment of opening
When assessing opening what are we looking at
check for deviation of jaw
assess extent of opening (normal 40-50mm)
What does an intra oral examination of TMJDS include
assessment of any dental wear facets
signs of clenching and grinding
What are signs of clenching and grinding
scalloped lateral tongue surface
buccal mucosa ridges
What is the management of TMJDS
explain the condition reduction of exacerbating factors allow the over worked muscles to rest symptomatic relief if these measures are unsuccessful then referral for specialist care is indicated
How can we reduce exacerbating factors of TMJDS
management of stress - mindfulness or yoga
avoid habits such as clenching, grinding, chewing gum, nail biting or leaning on the jaw
a bit raising appliance may be considered if there is nocturnal grinding/clenching
How can we allow the over worked muscles in TMJDS to rest
avoid wide opening - stifle yawns with a closed fist
soft diet which requires little chewing
What is the symptomatic relief for TMJDS
use of ibuprofen which has anti-inflammatory action
alternate use of hot and cold packs
if these measure are unsuccessful then referral for specialist care is indicated
