Paediatric Oral Medicine Flashcards
what are the 3 causes of oro-facial soft tissue infections
- viral
- bacterial
- fungal
what are examples of viral oro-facial soft tissue infections
○ Primary herpes ○ Herpangina ○ Hand foot and mouth ○ Varicella Zoster ○ Epstein Barr Virus ○ Mumps ○ Measles ○ Rubella
what are examples of bacterial oro-facial soft tissue infections
○ Staphylococcal ○ Streptococcal ○ Syphilis ○ TB ○ Cat Scratch Disease
what are examples of fungal oro-facial soft tissue infections
○ Candida
what is primary herpetic gingivostomatitis
Acute Infectious disease caused by Herpes Simplex Virus I
how is primary herpetic gingivostomatitis transmitted
Transmission by droplet formation with 7 day incubation period
why are children in their first year of life rarely infected with primary herpetic gingivostomatitis
Degree of immunity from circulating maternal ABs therefore infection rare in 1st 12/12
ie Children in their first year of life are rarely infected because they tend to be protected due to circulating maternal antibodies
what are the signs and symptoms of primary herpetic gingivostomatitis
○ Fluid filled vesicles – rupture to painful ragged ulcers on the gingivae, tongue, lips, buccal and palatal mucosa
§ Therefore ulceration is more commonly seen on presentation
○ Severe oedematous marginal gingivitis
○ Fever
○ Headache
○ Malaise
○ Cervical lymphadenopathy
These lesions are extremely painful and the child may be reluctant to eat or drink leading to a risk of dehydration
what is the treatment for primary herpetic gingivostomatitis
○ Bed rest ○ Soft diet/hydration ○ Paracetamol ○ Antimicrobial gel or mouthwash ○ Aciclovir for immunocompromised children [Not normally helpful but may be indicated for immunocompromised children]
what is the most common complication of primary herpetic gingivostomatitis
Most common complication = dehydration
If there is a concern that the child is unable to eat or drink whilst these lesions are present then medical advice should be sought
how long does it take for primary herpetic gingivostomatitis to heal
Lasts 14 days
Heals with no scarring
what does the virus that causes primary herpetic gingivostomatitis do after the primary infection
• Remains dormant in epithelial cells
○ Following the primary infection, herpes simplex virus 1 remains dormant then presents as a secondary infection as herpes labialis
○ Recurrent disease in 50-75% = herpes labialis (cold sores)
what triggers the secondary infection of herpes labialise
Triggered by:
○ Sunlight
○ Stress
○ Other causes of ill health
how is herpes labialis managed
Management of herpes labialis is with topical acyclovir cream
what 2 herpes like viral infections does coxsackie A virus cause
- Herpangina
- Hand, foot and Mouth
what is herpangia
Mild condition presenting like primary herpetic gingivostomatitis with vesicles rupturing to ulceration
In contrast however these vesicles present further back in the mouth in the tonsillar / pharyngeal region
how long does herpangia last
Lasts 7-10 days
what is hand, foot and mouth
Ulceration on the gingivae/tongue/cheeks and palate
Maculopapular rash on the hands and feet
how long does hand foot and mouth last
Lasts 7-10 days
how does the patient present if they have hand, foot and mouth
○ Presents initially with a sore throat, high temperature and a reluctance to eat
§ Mouth ulcers and a maculopapular rash appears on the hand and feet a few days later
○ Painful condition which makes eating and drinking uncomfortable
what is oral ulceration
“a localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue”
what are the 10 key facts that needs to be asked about the history of the oral ulceration
• Onset
○ When did the ulceration first begin?
• Frequency
○ How often do the ulcers appear?
• Number
○ How many ulcers are there at any one time?
• Site
○ Where do the ulcers occur?
• Size
○ What size are the ulcers?
○ Are they always the same size?
• Duration
○ How long does each episode of ulceration normally last?
• Exacerbating dietary factors
○ Has the patient / parent noticed any diet factors which exacerbate the ulceration?
• Lesions in other areas
○ Does the patient ever experience ulceration elsewhere?
• Associated medical problems
○ What is the patient’s medical history?
○ Could this be associated?
○ What medications does the patient take?
• Treatment so far (helpful/unhelpful)
○ What treatment has the patient tried so far?
○ Was it 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 Aphthous Stomatitis (RAU)
○ Ulceration can have no clear underlying cause
what infections can cause oral ulceration
○ Viral: § Hand foot and mouth § Coxsackie Virus § Herpes Simplex § Herpes Zoster § CMV § EBV § HIV
○ Bacterial:
§ TB
§ syphilis
what immune mediated disorders cause oral ulceration
○ Crohns, ○ behcets, ○ SLE, ○ Coeliac, ○ Periodic fever syndromes
what vesiculobullous disorders cause oral ulceration
○ Bullous or mucous membrane pemphigoid,
○ pemphigus vulgaris,
○ linear IgA disease,
○ erythema multiforme
what neoplastic / haematological problems can cause oral ulceration
○ Anaemia
○ Leukaemia
○ Agranulocytosis
○ cyclic neutropenia
what happens if ulcers do not heal as expected
Where ulcers do not heal as expected then the ulcer cannot be dismissed as benign, a biopsy or referral to the local oral cancer unit should be actioned
how can trauma cause oral ulceration
○ Can be physical, thermal or chemical trauma
○ Usually a local factor in these instances can be identified
○ The ulcer presents where the trauma has occurred and will resolve approximately 2 weeks after the causative factor (eg a sharp tooth) has been managed
what vitamin deficiencies cause oral ulceration
○ Iron
§ An iron deficiency can often present in a growing child given that iron demands in this period increases
○ B12,
○ Folate
what is the most common cause of ulceration in children
RAU is the most common cause of ulceration in children
what do aphthous ulcers present like
Typically, aphthous ulcers are round or ovoid in shape with a grey or yellow base and have a varying degree of perilesional erythema.
what are the 3 sub-groups of RAU
○ Minor - <10mm
§ These are always found on the non-keratinised mucosa
§ Tend to heal within a 10-14 day period
○ Major - >10mm
§ These ulcers can also affect the keratinised tissues
§ Healing of larger ulcers may take several weeks and these may heal with residual scarring
○ Herpetiform – 1-2mm
§ Normally present with multiple ulcers [up to 100 at a time]
§ This can appear similar to primary herpetic gingivostomatitis
§ However, unlike the viral infection, RAU will not normally be accompanied by a fever and can be recurrent
what is the aetiology of RAU
The aetiology is unclear ~ no single causative factor identified
Aetiological factors:
• Hereditary predisposition (FH in 45%)
○ Holds the strongest risk for a child developing ulcers
○ There may be times however in a child with genetic predisposition to oral ulceration where the pattern of ulceration changes (eg becomes more frequent)
§ This may indicate other factors at play during this time such as haematological deficiency
• Haematological and deficiency disorders (iron Def in 20%)
○ Iron demands increase with a growing child and therefore low iron levels and subsequent oral ulceration may be seen during periods of growth
○ Deficiencies of vitamin B12 and folate are more uncommon in children but may be suggestive of coeliac disease
§ Lower levels of vitamin B12 or folate therefore warrant referral to a paediatrician for further investigation
- Gastrointestinal disease (Coeliac in 2-4%)
- Minor trauma in a susceptible individual
• Stress
○ Including anxiety
• Allergic disorders ○ toothpaste containing SLS ○ Foods containing benzoate or sorbate preservatives ~ Benzoic acid ○ Chocolate ○ Tomatoes
• Hormonal disturbance: Menstruation
what initial investigations should be done for a patient with RAU
○ Diet diary
○ Full Blood Count
○ Haematinics (Folate/B12/Ferritin)
○ Coeliac Screen: Anti-transglutaminase antibodies
How should RAU be managed
○ Diet analysis may suggest exacerbating food groups
○ Low Ferritin = 3 months of iron supplementation
○ Low Folate/B12 or positive Anti-transglutaminase antibodies = referral to paediatrician for further investigation
○ Worth noting that tea can inhibit the absorption of iron so it is important that this is not taken with meals
how can the exacerbating factors of RAU be managed
• Nutritional deficiencies
○ Correction of nutritional deficiencies
○ Removal of any predisposing factors
• Traumatic factors
• Avoid sharp or spicy food
○ These can be uncomfortable and exacerbate the ulceration
• Allergic factors:
○ Dietary exclusion
○ SLS free toothpaste
what is the pharmacological management of RAU
Management in GDP:
• Prevention of Superinfection:
○ Corsodyl 0.2% Mouthwash
• Protect healing ulcers
○ Gengigel topical gel (hyaluronate)
○ Gelclair mouthwash (hyaluronate)
• Symptomatic relief
○ Difflam (0.15% benzydamine hydrochloride)
○ Local anaesthetic Spray
• Other pharmacological interventions such as the use of steroid medication can be useful however should be considered in liaison with oral medicine
What is the main aim of pharmacological intervention
The main aim of pharmacological intervention is to prevent superinfection, protect healing ulcers and provide relief of symptoms
