Peads Oral Medicine 1 Flashcards
What infections can affect oral tissues?
Viral
Bacterial
Fungal
What are some viral infections affecting soft tissues?
primary herpes
Herpangina
Hand foot and mouth
MMR
Epstein barr virus
Varicella Zoster
What bacterial infections affect soft tissues?
Staph
Strep
Syphillis
TB
Cat scratch disease
What is an example of an oral infection caused by fungi?
Candida
What is primary herpetic gingivostomatitis?
most common viral infection of the mouth.
its an acute infectious disease resulting from herpes simplex 1
What causes primary herpetic gingivostomatitis?
Primary herpetic gingivostomatitis is caused by an initial infection with the herpes simplex virus Type I and characterized by painful, erythematous, and swollen gingivae.
How is primary herpetic gingivostomatitis transmitted?
Droplet formation with 7 day incubation period
What can a recurrence of herpes simplex virus type 1 cause?
Herpes labialis = cold sores
Why is herpes simplex 1 infection rare in first year of life?
Due to circulating maternal antibodies
What does primary herpetic gingivostomatits initially present like?
multiple fluid filled vesicles on gums, tongue, lips, buccal and palatal mucosa which then rupture into large painful ragged ulcers
severe oedematous marginal gingivitis
fever
headache
illness
cervical lymphadenopathy
What is most common presentation of primary herpetic gingivostomatitis?
painful rugged ulceration
What other symptoms can be seen alongside oral symptoms of primary herpetic gingivostomatitis?
malaise
fever
headache
pt may be unable to eat or drink due to pain –> leads to dehydration
What is the treatment for primary herpetic gingivostomatitis?
it is a self limiting condition which must be managed with
bed rest
adequate fluid intake/soft diet
paracetamol
antimicrobial gel or mouthwash
aciclovir for immunocompromised kids
Why would we use mouthwash or antimicrobial gel in children with PHG?
To prevent super infections
When would we use aciclovir for PHG?
In immunocompromised pts - we would also want to seek medical impute for these groups of children
What is most common complication of PHG?
Dehydration - child may find eating and drinking difficult du eat pain
How long does PHG last?
14 days
How does PHG heal?
No scarring
What happens following primary infection of herpes simplex I?
it remains dominant in epithelial cells and can re present with secondary infection such as cold sores
What can trigger re occurrence of herpes simplex I?
Stress
Ill health
Sun
How can we manage herpes labialis?
Aciclovir topical cream 5% (2g applied to lesion every 4 hours 5x day for 5 days)
How can we manage herpes simplex?
Aciclovir tablets - 200mg oral tablets or oral suspension (2-17 years 5x daily) under 2 is diff dose
What can the coxsackie A virus cause?
herpangina
hand foot and mouth
both are herpes like infections
What is herpangina?
mouth blisters, is a painful mouth infection caused by coxsackieviruses. Usually, herpangina is produced by one particular strain of coxsackie virus A
What does herpangina present like?
Vesicles in the tonsillar/pharyngeal region
its a mild condition that presents like PHG with vesicles rupturing to ulceration but further back in the mouth (tonsil pharyngeal region)
What is hand foot and mouth?
caused by coxackie A virus
Hand, foot and mouth disease is a common infection that causes mouth ulcers and red spots on the hands and feet. It mainly affects children.
What does child present with in hand foot and mouth?
Ulcers on the gingival/tongue/cheeks and palate
and a maculopapular rash on hands and feet
soar throat
reluctance to eat
What appears a few days after mouth ulcers in hand foot and mouth?
Maculopapular rash on hands and feet
What is management like for hand foot and mouth?
Same as herpes simplex 1 - bed rest, stay hydrated, paracetamol if required and will heal in 7-10 days
What is an oral ulceration?
Localised defect in surface oral mucosa where covering epithelium is destroyed leaving inflamed area of exposed connective tissue
What are the 10 facts we need when taking ulcer history?
onset
freq
number
size
site
duration
exacerbating diet factors
lesions in other areas?
associated med problems
any tx so far that has helped or not helped?
What are the 8 causes of oral ulceration?
infection
immune mediated disorders
vesticulobullous disorders
inherited or acquired immunodeficiency disorders
neoplastic/haematological
trauma
vitamin deficiencies
recurrent apthous stomatitis
What infections can cause ulcers?
herpes simplex
hand foot and mouth
coxsackie virus
syphillis
What immune mediated conditions can cause ulcers?
Crohns
coeliac
What neoplastic/haemotological conditions can cause ulcers?
leukaemia
anaemia
What causes trauma ulcers?
Physical, thermal or chemical trauma can cause ulceration which will cause ulcer in area of trauma that will resolve approx 2 weeks after causative factor is identified and solved - ie if sharp tooth we manage it and ulcer should resolve within 14 days
What vitamin deficiencies can cause ulcers?
iron
b12
folate
What is recurrent apthous stomatitis?
This is when there is no underlying cause
What is the most common cause of ulceration in children?
recurrent apthous ulceration
How would apthous ulcers be described as?
Round or ovoid in shape with grey or yellow base and varying degree of perilesional erythema
What are the 3 subgroups of recurrent apthous ulceration?
minor
major
herpetiform
What are minor ulcers?
These are under 10mm in size and don’t affect keratinised mucosa and tend to heal within 10-14 days
Describe the mucosa in the mouth
Keratinized squamous epithelium is present in the attached gingiva and hard palate as well as areas of the dorsal surface of the tongue. Nonkeratinized squamous epithelium covers the soft palate, inner lips, inner cheeks, and the floor of the mouth, and ventral surface of the tongue.
What are major ulcers?
These are >10mm in size and can affect keratinised tissue and takes several weeks to heal and can leave residual scarring
What are heptiform ulcers?
Ulcers 1-2mm in size, normally multiple present at a time and can be up to 100 present
What can heptiform ulcers appear like?
similar to PHG however unlike viral infections they aren’t normally accompanied by a fever and can be recurrent
What are the causes of recurrent ulcers?
Aetiology unclear - no single causative factor however genetic predisposition holds strongest risk for children developing ulcers where pattern of ulceration changes
What are some other causes of recurrent ulcers?
Haematological and deficiency disorders - iron demands increase in childhood and low iron levels and subsequent ulcers can be seen during growth
GIT disease such as coeliac - low level of b12 will warrant referral
stress
allergic disorders
hormonal disturbances
What allergies can cause ulcerations?
SLS in toothpaste
foods with benzoate - chocolate, tomatoes
If following history and exam pt is considered to have recurrent apthous ulceration then what should we do?
Often useful to carry out some investigations such as:
- diet diary
- FBCs
- Haematinics - folate/b12/ferritin
- coeliac screen
If pt is expected coeliac what investigation do we do?
Anti-transglutaminase antibodies
How do we manage recurrent ulceration?
Diet analysis to see if any exacerbating food groups
low ferritin - 3 months of iron supplementation
low b12 or folate then refer to paediatrician
positive anti-ttransglutaminase then referral also
How can we manage exacerbating factors of ulcers?
we can correct nutritional deficiencies
avoid sharp or spicy foods
manage traumatic factors
allergic facets - diet exclusion, sis free toothpaste
What is the main aim of pharmacological intervention in recurrent ulcers?
To prevent superinfection, protect healing ulcers and provide relief of symptoms
What do we use to prevention superinfection?
Corsodyl 0.2% mouthwash
What do we use to protect healing ulcers?
gengigel topical gel
- 3-4 times a day
gengigel mouthwash
How do we relieve symptoms of ulcers?
benztdamine mouthwash, spray echt
(bran - difflam)
0.15%
When does OFG begin
Often begins in childhood - average onset of age is 11
What is OFG?
rofacial granulomatosis (OFG) is an uncommon condition of the mouth that causes lip swelling, and sometimes swelling of the face, inner cheeks, and the gums.
What does OFG appear like?
Identical to oral manifestation of crohns disease - can be future predictor of crohns
What causes the clinical features of OFG?
Allergic component which results in lymphoedema and swelling of oral tissues and the presence of non caveating granulomas in oral tissues which prevent normal lymphatic drainage
What is the characteristic pathology of OFG?
Non caveating giant cell granulomas which then result in lymphatic obstruction
What can OFG be a future predictor of?
Crohns disease
What are the clinical features of OFG?
Lip swelling
full thickness gingival swelling
swelling of non labial facial tissues
cobblestone appearance of buccal mucosa
mucosal tags
lip tongue fissuring
angular chelitis
deep penetrating ulcers
Whats the cause of OFG?
Unknown - limited evidence of genetic predisposition
How do we dx OFG?
Mostly by clinical basis as biopsy of lip not essential and can be uncomfy and distressing resulting in additional post op swelling
For pts who have clinical OFG dx what do we do?
Consider investigations to aid management and rule out other underlying conditions
What are some OFG investigations we can do?
Measure growth - to track weight and height - growth failure or pubertal delay can be see in crohns disease and can indicate this disease
FBC - iron deficiency may be present
Check for c reactive proteins - usually raised in crohns
faecal calcirotein
How do we manage OFG in kids?
Can be difficult - needs referral to specialist often
support needed with OHI as oral discomfort often present
can provide symptomatic relief as per oral ulceration (difflam)
manage nutritional deficiencies
topical steroids
short courses of oral steroids if severe or unresponsive to topical
