Paeds Oral Medicine Flashcards
3 categories of oro-facial soft tissue infection
viral
bacterial
fungal
viral orofacial soft tissue infections (8, 3 key)
- Primary herpes
- Herpangina
- Hand foot and mouth
- Varicella Zoster
- Epstein Barr Virus
- Mumps
- Measles
- Rubella
5 types of bacterial orofacial soft tissue infection
- Staphylococcal
- Streptococcal
- Syphilis
- TB
- Cat Scratch Disease
fungal orofacial soft tissue infection
candida
primary herpetic gingivostomatitis
Acute Infectious disease
Herpes Simplex Virus I
Primary infection common in children
- Degree of immunity from circulating maternal ABs so infection rare in 1st year
Transmission by droplet formation with 7 day incubation period
- Almost 100% of the adult population are carriers
herpes simplex virus I
primary infection
recurrent infection
primary herpetic gingivostomatitis
herpes labialis (coldsores)
primary herpetic gingivostomatitis affects
children (common)
but rare is 1st year of life due to immunity from circulating maternal ABs
transmission of primary herpetic gingivostomatitis
droplet formation with 7 day incubation period
almost 100% of the adult populatin are carriers
signs and symptoms of primary herpetic gingivostomatitis
- fluid filled vesibles - rupture to painful ragged ulcers
- gingivae, tongue, lips, buccal and palatal mucosa
- severe oedematous marginal gingivitis
- fever
- headache
- malaise
- cervical lymphadenopathy
knock on effect of primary herpetic gingivostomatitis
the fluid filled vesicles rupture into ragged ulcers
extermely painful
child may be reluctant to eat/drink - risk dehydration
tx for primary herpetic gingivostomatitis
- bed rest
- soft diet/hydration
- paracetamol
- antimicrobial gel or mouthwash
- acyclovir (not normally indicated but can be helpful in immunocompromised children)
nature of primary herpetic gingivostomatitis
usually self limiting - lasts 14 days
so will resolve by itself so need to manage symptoms (rest, paracetamol, soft food and fluids)
most common complication of primary herpetic gingivostomatitis
dehydration
resolution of primary herpetic gingivostomatitis
lasts 14 days
heals with no scarring
remains dormant in epithelial cells
- recurrent disease in 50-75% = herpes labialis (cold sores)
- triggered by: sunlight, stress, other causes of illl health
- mananaged with topical acyclovir cream
prevalence of recurrence of herpes simplex I (primary herpetic gingivostomatitis)
herpes labialis in 50-75%
triggers of herpes labialis
sunlight
stress
other causes of ill health
management of herpes labialis
topical acyclovir cream
similarity between primary herpetic gingivostomatitis and coxsackie A virus
coxsackie A virus is a mild condition which presents with vesibles rupturing to ulceration (like primary herpetic gingivostomatitis) but presents further back in the mouth
coxsackie A virus
2 subtypes
herpangina
hand, foot and mouth
herpangina
coxsackie A virus
vesicles in the tonsillar/pharyngeal region
lasts 7-10 days
hand, foot and mouth
cozsackie A virus
ulceration on the gingivae/tongue/cheeks and palate
maculopapular rash on hands and feet
lasts 7-10 days
oral ulceration
a localised defect in the surface oral mucosa where the covering epithelium is destroyed leaving an inflamed area of exposed connective tissue
painful - hard to eat/drink
management like herpes simplex virus type 1
oral ulceration
history - 10 keys
- Onset
- Frequency
- Number (how many at any one time)
- Site
- Size (what size? Are the all the same?)
- Duration (how long does each episode normally last)
- Exacerbating dietary factors
- Lesions in other areas
- Associated medical problems (medical history and medicines)
- Treatment so far (helpful/unhelpful)
what to do if oral ulcers do not heal as expected
cannot be dismissed as benign
need referral to local oral cancer unit
causes of oral ulceration (8)
- infection
- immune mediated disorders
- vesiculobullous disorders
- inherited or acquired immunodeficieny disorders
- neoplaste/heamatological
- trauma
- vitamin deficiencies (iron, B12, folate)
- recurrent apthous stomatitis (no clear cause)
infections which can cause oral ulceration
Viral: Hand foot and mouth/ Coxsackie Virus/ Herpes Simplex/ Herpes Zoster, CMV, EBV, HIV
Bacterial: TB, syphilis
immune mediated disorders which can cause oral ulceration
crohns,
bechets
SLE
coeliac
periodic fever syndromes
vestibullous disorders which can cause oral ulceration
bullous or mucous membrane pemphigoid
pemphigus vulgaris
linear IgA disease
erythema multiforme
neoplastic/heamatological causes of oral ulceration
anaemia
leukaemia
agranulocytosis
cyclic neutropenia
trauma causes of oral ulceration
physical, thermal, chemical
usually a local factor can be identified
usually resolve 2 weeks after causative factor has been managed (e.g. sharp tooth)
most common cause of oral ulceration in children
recurrent apthous ulceration (RAU)
typical appearance of RAU
round or ovoid in shape
grey or yellow base
varying degree of perilesional erythema
RAU cause
no clear underlying cause
3 patterns of RAU
minor
major
herpetiform
minor RAU
<10mm
always on non-keratined mucosa
heal 10-14 days
major RAU
>10mm
non-keratinised and keratinised mucosa
can take weeks to heal, scarring possible
herpetiform RAU
1-2mm
normally present with multiple ulcers
up to 100 at a time
RAU and primary herpetic gingivostomatitis similarity and difference
similar appearance
but no clear cause, can be recurrnet and no fever
factors for RAU
- hereditary predisposition (FH in 45%)
- haematological and deficiency disorders
- gastrointestinal disease (coeliac in 2-4%)
- minor trauma in susceptible individual
- stress or anxiety
- allergic disorders
- hormonal disturbance: mestruation
what indicates RAU not just a heriditary disorder
can change in pattern from genetic predisposition e.g. become more frequent
indicates other factors at play
iron deficiency in children
iron demands increase in growing child, so can be seen during periods of growth
linked to oral ulceration
vitamin B12 and folate deficiency in child may indicate
coeliac disease - refer
allergic disorder which could be factors for RAU
toothpaste containing SLE
foods with benzoate or sorbate perservatives
benzoic acid
chocolate
tomatoes
initial investigation for RAU consists of (4)
- Diet diary
- Full blood count
- Haematinics (folate/B12/ferritin)
- Coaeliac screen: anti-transglutaminase antibodies
low ferritin management
- 3 months iron supplementation
- Diet advice of iron rich food
- tea can inhibit absorption of iron so do not take with meals
Low folate/B12 or positive Anti-transglutaminase antibodies
managment
referral to paediatrician for further investigation
diet analysis for RAU may
suggest exacerbating food groups
management of exacerbating factors in RAU (4)
- Nutritional deficiencies
- Traumatic factors
- Avoid sharp or spicy food – uncomfortable, exacerbate ulceration
- Allergic factors
- Dietary exclusion
- SLS free toothpaste
pharmacological management of RAU in GDP
3 prong
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
Potential to use steroid medication but should be considered in liaison with oral medicine
orofacial granulomatosis
uncommon chronic inflammatory disorder
OFG
cause of OFG
idiopathic or associated with systemic granulomatous conditions (Crohn’s disease or Sarcoidosis)
average age of onset of OFG
11 years
sex prevalence of OFG
male>female
characteristic pathology of OFG
due to a combination of an allergic component resulting in lymphoedema and swelling or the oral tissues and presence of non caseating giant cell granulomas which then result in lymphatic obstruction.
- Biopsy of infected tissue has histology of non-caseating granulomas and lymphoedema
May be a predictor of future Crohn’s disease
clinical features of OFG
- 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
similarities between OFG and oral crohns
have the same clinical features, but these features vary between pts
OFG aetiology
Largely unknown
- Limited evidence of genetic factors
- Numerous associated allergens reported:
- Cinnamon Compounds
- Benzoates
- Much higher IgE mediated atopy rates compared to the general popn
OFG diagnosis
clinical (oft made solely on - lip biopsy can be uncomfortable and distressing, may cause additional post-operative swelling)
investigations for OFG
considered to rule out any underlying conditions
- Measure growth – paediatric growth charts growth failure/delay is seen in Crohn’s
- Full Blood Count
- Haematinics
- iron deficiencies can cause oral ulceration over and above OFG
- Patch testing – ID triggers
- Diet diary to ID any triggers
- Faecal Calprotectin
- Endoscopy risky in childhood
- Serum Angiotensin Converting Enzyme (raised in sarcoidosis)
OFG management
- Can be difficult and sore
- Oral hygiene support
- Symptomatic relief as per oral ulceration
- Dietary exclusion (does not cure just reduces orofacial inflammation)
- Manage nutritional deficiencies which may contribute to oral ulceration
medicaments can be considered with careful consideration with specialist
- Topical steroids
- Topical tacrolimus
- Short courses of oral steroids (severe or unresponsive to topical)
- Intralesional corticosteroids
- Surgical intervention – unresponsive long standing disfiguremen
t
most common mucosal lesion of tongue in children
georgraphic tongue
geographic tongue presentation
Idiopathic and non contagious, benign
- May be seen at a young age
Shiny red areas on the tongue with loss of filiform papillae are surrounded by white margins
appearance of geographic tongue
Shiny red areas on the tongue with loss of filiform papillae are surrounded by white margins
impact of geographic tongue in children
intense discomfort (spicy food/ tomato or citrus fruit/juice)
more sensitive than adult presenation as have a thinner oral mucosa and more sensitive to taste
management of geographic tongue in children
bland diet during flare ups
if tongue sensitivity present - rule out haematinic deficiencies of iron, folic acid and vitamin B12
- Likely to become less troublesome with age
- So dietary restrictions can gradually decrease
solid swellings in children oral cavity (5)
- fibroepithelial polyp
- epulides
- congential epulis
- HPV associated mucosal swelling
- neurofibromas
fibroepithelial polyp
common, benign
firm pink lump (pedunculated or sessile)
sites of fibroepithelial polyp
mainly
- cheeks (along occlusal line)
- lips
- gingiva
- tongue
size of fibroepithelial polyps
once established remains constant in size
cause and effect of fibroepithelial polyp
thought to be intiated by minor trauma - accidental biting or sharp tooth edges
generally cause no discomfor unless subject to repeated trauma
tx of fibroepithelial polyp
surgical excision is curative
may need to be delayed untile the child can co-operate for it - as since benign difficult to justify GA
epulides
common solid swelling on oral mucosa
bening, hyperplatic lesion
epulides presentation and common cause
localised gingival enlargements, most arise from interproximal dental tissues
related to chronic irritation - particularly presence of plaque or calculus
3 main types of epulides
fibrous epulis
pyogenic granuloma
peripheral giant cell granuloma
common clinical features of 3 types of epulides
- Majority occurring anterior to the molar teeth and being more common in the maxilla
- interproximal areas of gingival enlargements
- Management is surgical removal and identification and management of exacerbating factors
- plaque, calculus
Have tendency to recur
similarlity between fibroepithelial polyp and epulides
similar in appearance but epulides on gingiva only
whereas FEP - cheeks, lips, tongue, gingiva
fibrous epulis
- Pedunculated or sessile mass
- Firm consistency
- Similar color to surrounding gingivae
- inflammatory cell infiltrate and fibrous tissue
pyogenic gramuloma
- Soft, deep red/purple swelling
- Often ulcerated
- haemorrhage spontaneousl or with mild trauma
- vascular proliferation supported by delicate fibrous stroma
- probably reaction to chronic trauam (calculus)
- tend to recur after removal
pyogenic epulis and preganncy epulis
Both types of vascular epulis
Clinically and histologically identical with distinction purely based on whether they are found on a pt who is pregnant or not
- In pregnancy tend to regress spontaneously or decrease in size and assume features of a fibrous epulis after a child is born*
- delay excision until this time
peripheral giant cell granuloma appearance
Pedunculated or sessile swelling
- Typically dark red and ulcerated
Usually arises inter-proximally and has an hour-glass shape
- Buccal and lingual swellings with narrow middle section joined between the teeth
May recur after surgical excision
peripheral giant cell granuloma radiographic change
Radiographs may reveal superficial erosion of the interdental bone
- Need to rule out central giant cell lesion – perforate the cortex and presented similarly as peripheral swelling
peripheral giant cell granuloma histology
Multinucleate giant cells in a vascular stroma (so histological distinct from other epulis)
congenital epulis (congential gingival granular cell tumour)
Rare lesion
Occurs in neonates
- Most commonly affect the anterior maxilla (incisor region)
- F>M
Granular cells covered with epithelium (histological)
- Benign
- Simple excision is curative
congenital epulis effects
Occurs in neonates (rare)
Most commonly affect the anterior maxilla (incisor region)
F>M
congenital epulis
histological
granular cells covered with epithelium
2 types of HPV associated swellings
both benign
- verruca vulgaris
- squamous cell papilloma
associated with different types of HPV but are clinically similar - pedunculated cauliflower like growths
verruca vulgaris
appearance
- Solitary or multiple intra-oral lesions
- Most commonly on keratinized tissue – gingivae and palate
pedunculated cauliflower like growths
verruca vulgrais
association
caused by HPV 2 and 4
May be associated with skin warts
- May transfer to mouth by autoinoculation from lesions on the finger
verucca vulgaris resolution
most resolve spontaneously
can be removed surgically - if required
squamous cell papilloma
cause
HPV 6 and 11
squamous cell papilloma
appearance
- Small pedunculated cauliflower like growths
- Benign
- vary in colour - pink to white
- usually solitary
tx of squamous cell papilloma
surgical excision
6 types of fluid swellings
- Mucoceles
- Ranula
- Bohn’s nodules
- Epstein pearls
- Haemangioma’s
- Vesiculobullous lesions
- Primary herpes
- Epidermolysis bullosa
- Erythema multiforme
mucoceles
cyst arising in connection with minor salivary gland
2 variants of mucoceles
mucous extravastation cycst
mucous retention cyst
mucous extravastation cyst
normal secretions rupture into adjacent tissue
mucous retention cysts
- secretions retained in an expanded duct
mucocele appearance
- Bluish, soft, transparent cystic swelling, with a history of rupture, collapse and reswelling
mucoceles occur
Can affect minor or major salivary glands
- Most = minor glands of the lower lip, extravasation cysts
- Related to minor trauma e.g. biting lip
Peak incidence = 2nd decade
mucoceles peak incidence
2nd decade
resolution of mucoceles
Most will rupture spontaneously
- Surgery only if lesion fixed in size as will likely damage adjacent glands leading to recurrence or causing distress to the child or inhibiting daily function
Surgical excision involves removal of the cyst and the adjacent damaged minor salivary gland
- GA not indicated – benign, tendency to recur
rannula
appearance
Mucocele in the FOM resembles a frog’s belly (most are extravasation cysts)
rannula arise from
minor salivary glands or ducts of sublingual/submandibular gland
assessment of rannula
Ultrasound or MRI needed asses the extent of lesion
- exclude plunging ranula (extend through the FOM into the submental or submandibular space – need specialist management).
rannula can sometimes be
Occasionally found to be lymphangioma – benign tumour of the lymphatics
Bohn’s nodules
- Gingival cysts, benign
- Occur on the alveolar ridge
- Found in neonates (1st 28 days)
- Remnants of the dental lamina
- Filled with keratin
- Usually disappear in the early months of life (3 months)
Epstein pearls
- Small cystic lesions
- Found along the palatal mid-line
- Thought to be trapped epithelium in the palatal raphe
In ~ 80% neonates (common)
- Disappear in the first few weeks after birth
temporomandibular joint dysfunction syndrome
TMJDS
The most common condition affecting the temporomandibular region
Characterised by:
- Pain
- Masticatory muscle spasm
- Limited jaw opening
history for TMJDS
- A description of presenting symptoms
- pain, swelling, clicking, cracking, limitation jaw opening, locked jaw, generalised facial discomfort, earache, numbness over masseter muscles (cheeks)
- When did the discomfort begin? Any predisposing factors (e.g. traumatic injury)?
- Is the pain worse at any time during the day?
- Morning – may indicate nocturnal clenching or grindinghabit
- Exacerbating factors – chewing, yawning
- Habits – chew on pens/chewing gum, lean on jaw when studying, grinding teeth at night
- Stress – sensitive – exams, traumatic life events (bereavement, divorce)
EO for TMJDS
- Palpation of the muscles of mastication both at rest and when the 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/crepitus
- Assessment of opening
- Check for any deviation of the jaw
- Assess extent of opening (normal = 40-50mm)
IO exam for TMJDS
- Assessment of any dental wear facets
- Signs of clenching/grinding:
- Scalloped lateral tongue surface
- Buccal mucosa ridges
management of TMJDS
- explain condition in way pt understands
- reduction of exacerbating factors
- allow over worked muscles to rest
- symptomatic relief
how to explain TMJDS
TMJDs and muscle discomfort is normally due to the overworking and misuse of the muscles – like completing exercise each evening on the legs would expect leg pain, may lead to alteration in how you walk to keep more comfortable
Same with jaws – if overworked (e.g. grinding overnight), muscles will be sore and not able to function correctly, this can lead to an alteration in how we use the jaw which can worsen the problem
- Needs rest and management of exacerbating
- Most resolve spontaneously over a few months but can put measures in place to help this – note and explain clearly to pt and record in notes so they have realistic expectations
reduction of exacerbating factors for TMJDS (3)
- Management of stress – mindfulness/yoga
- Avoid habits such as clenching, grinding, chewing gum, nail biting or leaning on the jaw
- A bite raising appliance may be considered if there is nocturnal grinding/clenching
how to allow overworked muscles to rest in TMJDS
- Avoid wide opening – stifle yawns with a closed fist
- Soft diet which required little chewing
- Food cut small, avoid opening wide when food consumed, eaten on both sides of mouth and avoid incising food which involves anterior movement of the mandible and stretching of muscles
- Pt must always ensure a small gap remains between the teeth and teeth only come into contact when food is being swallowed or chewed
symtomatic relief for TMJDS
- Use of ibuprofen which has anti-inflammatory action
- Alternating use of hot and cold packs
TMJDS improvement
need to be persisting with management measures for several months to see improvement
if these measures are unsuccessful referral for specialist care is indicated.
TMJDS recurrence
Pts often prone to TMJDS recurrence and exacerbation throughout life during certain periods (e.g. stress)
may need to adopt some prevention measures to avoid exacerbating this when it tends to occur
