Oral Pathology

*www.aap.org/oralhealth/pactProtecting All Childrens TeethCommon Oral Pathology

http://www.aap.org/oralhealth/pact

Introduction

Mouth pain is a common presenting complaint in the primary careoffice.

It is imperative that pediatric health care professionals feelcomfortable in the proper diagnosis, management, and triage ofcommon oral pathology. www.aap.org/oralhealth/pact*

www.aap.org/oralhealth/pact

*Learner ObjectivesUpon completion of this presentation, participants will be able to: Recall the common causes, bacterial flora, management, and possible sequelae of dental abscesses.Describe the common clinical signs, symptoms, and management options of Temperomandibular joint (TMJ) disorders.Define and discuss the term referred pain as it relates to the mouth.Discuss the clinical presentation, causative agents, diagnosis, and management of primary gingivostomatitis, herpangina, hand-foot-mouth disease, and thrush.List the 2 common conditions that cause "strawberry tongue.

*www.aap.org/oralhealth/pactAbscess

A dental abscess is a collection of purulent fluid caused by a bacterial infection.

The most common cause of a dentalabscess is extension of the dental caries process into the pulp of the tooth.Used with permission from Miller Medical Illustration & Design


*www.aap.org/oralhealth/pactAbscess, continuedAbscesses can also be caused by trauma to the tooth that allows bacteria to enter the pulp.

An abscess limited to the tooth structure (pulpitis) will often present with tooth pain from the increased pressure on the nerve endings within the pulp. This pain is often worsened with heat or cold exposure.Used with permission from Melinda B. Clark, MD; Associate Professor of Pediatrics at Albany Medical Center


*www.aap.org/oralhealth/pactAbscess ProgressionIf the infection in the pulp extendsbeyond the tooth, a periapical abscess will develop.

The pressure caused by the expanding area of necrosis and inflammation causes visible swelling and may lead to slight extrusion of the tooth from the socket (as shown in the x-ray to the left).Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham


*www.aap.org/oralhealth/pactAbscess Progression, continued

As the abscess expands, the pus will spread to contiguous surfaces along the path of least resistance to form a fistula to the maxillary, mandibular, or palatal mucosa.

Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham


*www.aap.org/oralhealth/pactCellulitisIf the infection remains unchecked, an abscess can progress to facial, submandibular, or sublingual cellulitis.

Facial cellulitis presents clinically with swelling, warmth, and tenderness to palpation along the jaw.

A child with facial cellulitis should be referred for immediate ER evaluation or admitted to the hospital for IV antibiotics.Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham


*www.aap.org/oralhealth/pactSymptoms of an AbscessPatients with abscess may present with the following symptoms: Headache Fever Periorbital edema or pain Cranial nerve abnormalities.

This infection can be life-threatening and must be addressed emergently.


*www.aap.org/oralhealth/pactAbscess Treatment

First-line empiric antibiotic therapy for dental abscesses is penicillin oramoxicillin and clindamycin for penicillin-allergic patients.

Suspicion of a dental abscess requires urgent referral to a dentist fordefinitive care.


*www.aap.org/oralhealth/pactAbscess Treatment, continued

Efforts must be made to locate the site of infection, incise and drain the pus collection, and collect a specimen for culture and sensitivities.

An abscessed tooth often must be extracted. Antibiotic therapy is also required, especially in cases of contiguous spread of the infection.


*www.aap.org/oralhealth/pactTemporomandibular Joint DisordersThe temporomandibular joint (TMJ) is the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet.

Temporomandibular joint disorders include a range of problems related to this joint.


*www.aap.org/oralhealth/pactSigns of TMJSigns of TMJ disorders include:

Bruxism Wear of the occlusal surfaces of the teeth due to tooth grinding Joint sounds (clicking and crepitus) Limited mandibular opening

Pain, including TMJ pain or headache, may occur but is not always present.


*www.aap.org/oralhealth/pactTMJ Treatment

Referral to a dentist or other professional knowledgeable in treating TMJ disorders is appropriate.

Treatment is usually initiated when pain is present. Options include:Non steroidal anti-inflammatory medicationSoft diet Warm compresses Occlusal bite guards Counseling Physical therapy


*www.aap.org/oralhealth/pactReferred Pain

Referred pain is felt in an area innervated by a nerve different from that which innervates the primary site of pain.

Dental pain can refer to other teeth, the head, ear, eye, periorbital region, or jaw.


*www.aap.org/oralhealth/pactReferred Pain, continuedThe following non-oral conditions can cause pain felt in the teeth or mouth:

Acute maxillary bacterial sinusitis or acute otitis mediaTemporomandibular Joint Atypical facial painTrigeminal neuralgiaMigraine headachesPsychogenicNeoplasia, such as leukemia


*www.aap.org/oralhealth/pactPrimary Herpetic Gingivostomatitis

Primary Herpetic Gingivostomatitis iscaused primarily by herpes simplex virus type 1.

The primary infection is most severe and usually seen in children younger than 6.Used with permission from Rama Oskouian


*www.aap.org/oralhealth/pactPrimary Herpetic GingivostomatitisThe clinical syndrome of HSV gingivostomatitis lasts 10-14 days.

Diagnosis is usually based on clinical history and exam findings.

Clinical presentation includes: Fever and malaise (precede the anorexia, oral findings, and cervical lymphadenopathy) Significant lip and gum swelling, erythema, and bleeding Vesicles on the lips, tongue, and cheeks, which then ulcerate


*www.aap.org/oralhealth/pactTreatment for Primary Herpetic GingivostomatitisTreatment is mainly supportive with hydration maintenance and pain control.The acyclovir family of antiviral medications may be used for immunosuppressed patients.

The infection is life-long, and recurrences occur as cold sores (herpes labialis), usually at times of stress or infection.Used with permission from Rama OskouianHerpes Labialis


*www.aap.org/oralhealth/pactCoxsackie Viral Infections

Coxsackie viral infections include Herpangina and Hand-Foot-Mouth Disease.

Fever, malaise, sore throat, and anorexia precede appearance of the vesicles. Cervical lymphadenopathy is also present.

Symptoms last 7-10 days.

Treatment is supportive care.HerpanginaUsed with permission from the AAP Red Book


*www.aap.org/oralhealth/pactOral CandidiasisWhite plaques or pseudomembranes are noted on the surface of the tongue and/or the buccal, labial, and gingival mucosa. Removal of the plaques shows underlying raw, red, bleeding mucosa. Oral surfaces may become painful, which can interfere with feeding.Oral Candidiasis is common in infants, but triggers for all age groups include systemic antibiotic use, inhaled steroids, diabetes, xerostomia, and poor oral hygiene.Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry, University of Alabama at Birmingham


*www.aap.org/oralhealth/pactOral Candidiasis, continuedOral Candidiasis can be treated with topical antifungal agents, such asNystatin or Clotrimazole.

If symptoms persist or recur shortly after discontinuation of the antifungal agent, consider re-infection from bottles, pacifiers, or breastfeeding (with maternal breast colonization) or resistance to antifungal medication.

Used with permission from ANZ Photography


*www.aap.org/oralhealth/pactStrawberry Tongue

Strawberry Tongue refers to an inflamed tongue.

It presents as either a diffusely erythematous tongue with prominent fungiform papillae or a tongue covered by a white membrane except for the fungiform papillae that appear red.

Used with permission from the AAP Red Book


*www.aap.org/oralhealth/pactStrawberry Tongue, continuedStrawberry Tongue is associated with Group A Beta Hemolytic Strep and Kawasaki syndrome.

Group A Beta Hemolytic Strep causes erythematous and enlarged tonsils with white exudates, anterior cervical lymphadenopathy, and fever.

Clinical presentation of Kawasaki syndrome is 5 days of fever associated with other clinical criteria, including oral mucosal findings such as a strawberry tongue.


*www.aap.org/oralhealth/pactQuestion #1Which of the following signs is not expected to be seen in aTemporomandibular Joint (TMJ) disorder? A. Swelling and erythema over the jointB. Clicking of the jointC. Wearing of the occlusal surfaces of the teethD. Limited jaw openingE. Crepitus over the joint


*www.aap.org/oralhealth/pactAnswerWhich of the following signs is not expected to be seen in aTemporomandibular Joint (TMJ) disorder? A. Swelling and erythema over the jointB. Clicking of the jointC. Wearing of the occlusal surfaces of the teethD. Limited jaw opening E. Crepitus over the joint


*www.aap.org/oralhealth/pactQuestion #2What is the most common cause of a dental abscess? A. Trauma to the toothB. Ludwig's anginaC. Extension of the dental caries process into the pulp of the toothD. BruxismE. Facial cellulitis


*www.aap.org/oralhealth/pactAnswerWhat is the most common cause of a dental abscess? A. Trauma to the toothB. Ludwig's anginaC. Extension of the dental caries process into the pulp of the toothD. BruxismE. Facial cellulitis


*www.aap.org/oralhealth/pactQuestion #3Which of the following conditions can cause pain in the teeth or mouth? A. Migraine headachesB. Acute maxillary bacterial sinusitisC. LeukemiaD. Acute otitis mediaE. All of the above


*www.aap.org/oralhealth/pactAnswerWhich of the following conditions can cause pain in the teeth or mouth? A. Migraine headachesB. Acute maxillary bacterial sinusitisC. LeukemiaD. Acute otitis mediaE. All of the above


*www.aap.org/oralhealth/pactQuestion #4Which of the following statements about Oral Candidiasis is not true? A. The same fungus causes angular cheilitisB. It should be treated with antiviral medicationC. Re-infection from bottles or pacifiers is possibleD. It can be triggered by antibiotic useE. It is common in infants


*www.aap.org/oralhealth/pactAnswerWhich of the following statements about Oral Candidiasis is not true? A. The same fungus causes angular cheilitisB. It should be treated with antiviral medicationC. Re-infection from bottles or pacifiers is possibleD. It can be triggered by antibiotic useE. It is common in infants


*www.aap.org/oralhealth/pactQuestion #5Which of the following statements is true when treating anabscess? A. The first step is to locate the site of infectionB. In severe cases, intravenous antibiotics are necessary and hospitalization may be requiredC. An abscessed tooth often must be extractedD. In cases limited to pulpitis, a root canal may be performed to salvage the toothE. All of the above


*www.aap.org/oralhealth/pactAnswerWhich of the following statements is true when treating anabscess? A. The first step is to locate the site of infectionB. In severe cases, intravenous antibiotics are necessary and hospitalization may be requiredC. An abscessed tooth often must be extractedD. In cases limited to pulpitis, a root canal may be performed to salvage the toothE. All of the above


*www.aap.org/oralhealth/pactReferences1. Avcu N, Gorduysus M, Omer Gorduysus M. Referred dental pain. The Pain Clinic. 2003; 15(2): 173-178. 2. Ferretti GA, Cecil JC. Kids Smile: Oral Health Training Program Lecture Series. Sponsored by the Kentucky Department for Public Health and the University of Kentucky College of Dentistry. 3. Handbook of Pediatric Dentistry. 2nd ed. Cameron AC, Widmer RP (Eds). Mosby; 2003. 4. Krol DM, Keels, MA. Oral Conditions. Pediatr Rev. 2007; 28(1): 15-22. 5. Okeson JP, Falace DA. Nonodontogenic toothache. Dental Clinics of North America. 1997; 41(2): 367-83. 6. Oral Pathology: Clinical Pathologic Correlations. 4th ed. Regezi JA, Sciubba JJ, Jordan RCK (Eds) WB Saunders, St Louis Mo. 2003. 7. Pediatric Dentistry: Infancy through Adolescence. 4th ed. Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak AJ (Eds). WB Saunders, St Louis, Mo. 2005.


Common pediatric oral findings are discussed in course 11 (Oral findings) includingBenign Migratory Glossitis, Morsicatio Buccarum, Pyogenic Granuloma, Oral Ulcers, Angular Cheilitis (Perleche), Leukoplakia (White Patch), Oral Hairy Leukoplakia, Parotitis, Inclusion Cysts, Natal and Neonatal Teeth, Congenital Epulis, Ankyloglossia, Cleft Lip/Palate, Bifid Uvula, Ranula/Mucocele, Eruption Cyst or Hematoma, Bony Tori (Torus Palatinus or Mandibularis, Diastema, Macroglossia, and Micrognathia.

Course 11 can be downloaded and used in conjunction with this presentation.

*Notes:The collection of pus from an abscess is located in the pulp of the tooth but can spread to the periapical structures of the jaw and beyond if not adequately and appropriately treated. Glossary:Abscess: A localized collection of pus surrounded by inflamed tissuePulp: The highly vascular sensitive tissue occupying the central cavity of a tooth * ***Notes:Cellulitis of the submandibular and sublingual spaces is called Ludwigs angina and is of significant concern as the swelling can compromise the airway. Although rare in children, pediatricians should consider Ludwigs angina in a child with redness and swelling of the upper neck, under the chin, or a swollen or displaced tongue.

*Notes:Although rare, dental abscesses can spread in a retrograde fashion via the vasculature to the cavernous sinus. This can lead to the formation of a blood clot or cavernous sinus thrombosis.*Notes:The flora of a dental abscess is usually a mix of bacteria. Anaerobic gram negative rods and gram positive cocci (eg, Bacteroides, Fusobacterium, Peptococcus, Peptostreptococcus, Streptococcus viridans) play a significant pathogenic role.Many practitioners use amoxicillin-clavulanate as first-line therapy to provide coverage for B-lactamase producing anaerobes*Notes:In cases limited to pulpitis, a root canal may be performed to salvage the tooth.For more severe infections, intravenous delivery of the antibiotics is necessary and patients may require hospitalization.*Notes:The prevalence of TMJ disorders in children is less than in adults, but the prevalence increases with age, with 33% of adults experiencing at least one TMJ symptom.

Glossary:Temporomandibular Joint: The diarthrosis between the temporal bone and mandible that includes the condyloid process below separated by an articular disk from the glenoid fossa above and that allows for the opening, closing, protrusion, retraction, and lateral movement of the mandibleTemporomandibular Joint Disorder: A group of symptoms that may include pain or tenderness in the temporomandibular joint or surrounding muscles, headache, earache, neck, back, or shoulder pain, limited jaw movement, or a clicking or popping sound in the jaw and that are caused either by dysfunction of the temporomandibular joint (as derangement of the articular disk) or another problem (as spasm or tension of the masticatory muscles) affecting the region of the temporomandibular joint*Glossary:Bruxism: The habit of unconsciously gritting or grinding the teeth especially in situations of stress or during sleep *Notes:The evidence for TMJ disorder treatment in children is controversial.Simple lifestyle changes such as avoiding opening the mouth too wide, not resting the jaw on a propped-up arm, decreasing gum chewing, and rotating ears during cell phone use can reduce TMJ discomfort.

*Notes:Dental disease should be considered in the differential diagnosis of otalgia, eye pain, facial pain, headache, jaw pain, and pain localized to the temple.

*Notes:With acute maxillary bacterial sinusitis or acute otitis media, pain may be felt in the upper back teeth.With atypical facial pain, a facial nerve disorder often presents as a toothache.Neoplasia can cause jaw plain, which can refer to the mouth.**Notes:The ulcers are painful and cause children to refuse to drink, which can result in hospitalization for dehydration.*Notes:Cultures, antigen testing, or PCR can be performed in unclear cases.Varicella can also present with oral vesicles and ulcers on multiple areas of the oral mucosa. The concurrent cutaneous lesions of varicella should help to distinguish the 2 viruses.

*Notes:Multiple small ulcers (2-4 mm) on the soft palate and tonsils caused by Coxsackie A (less commonly B) are symptoms of Herpangina.With Hand-Foot-Mouth disease, ulcers are present on pharynx, other mucosa, and hard palate, with vesicles on the palms and soles caused by Coxsackie A (usually serotype A16).*Notes:Oral Candidiasis is also known as pseudomembranous candidiasis or thrush.Oral Candidiasis is caused by a fungal infection from C albicans.

Glossary:Xerostomia: Abnormal dryness of the mouth due to insufficient saliva production *Notes:Ensure caregivers are cleaning and sterilizing bottles, nipples and pacifiers to prevent re-inoculation.Consider immunocompromise (eg, HIV or primary immunodeficiency) in children older than 6 months who have persistent or frequently recurring candidal infections in the absence of antibiotic therapy, especially if this pattern persists into the second year of life.Candida also causes angular cheilitis (see http://aap.org/oralhealth/pact/ch11_sect1c.cfm for more information), median rhomboid glossitis, and atrophic candidiasis (erythematous patches without a pseudomembrane).

*Notes:Often the white membrane is seen first and peels off, leaving the erythematous base.

Glossary:Fungiform Papilla: Any of numerous papillae on the upper surface of the tongue that are flat-topped and noticeably red from the richly vascular stroma and usually contain taste buds **

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Oral Pathology

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