Pediatric Oral Pathology

Kavita Kohli, DDS

Associate Professor of Clinical Dentistry

Topics

Newborn lesions

Infections

Ulcerative and vesiculobullous lesions

Pigmented, vascular and red lesions

Exophytic lesions

Gingival Enlargements

Lesions in Newborns

D/D

Keratin Cysts

Congenital Epulis

Natal/Neonatal Teeth

Keratin Cysts of the Newborn

Epstein’s pearls

Bohn’s nodules

Dental Lamina cyst

Epstein’s Pearls

Hard, raised small nodules

Arise from epithelial remnants trapped along lines of fusion of embryological processes.

Appear in the midline of the hard palate, mainly in the posterior section.

Tx - no treatment.

Bohn’s Nodules

Ectopic mucous glands.

Small keratinizing cysts.

Usually seen on the labial aspects of the maxillary alveolar ridges.

Tx - no treatment.

Dental Lamina Cyst

Usually seen on the crest of the alveolus

Remnants of the dental lamina.

Tx - no treatment.

Congenital Epulis of the Newborn

Relatively rare, seen in neonates(at birth), of unknown origin, with proliferation of mesenchymal cells.

Equal distribution between mx and md.

Females > males.

Usually firm, pedunculated,pink, smooth, solitary.

Tx - often regress with time, but may need to be excised, recurrence is uncommon.

Natal/Neonatal Teeth

Natal - seen present at birth.

Neonatal - seen within 30 days of birth.

In almost all cases it is the early eruption of a primary incisor.

Usually only 5/6th of the crown is formed and the mobility arises from no root development.

Tx - nursing issues, firms up as root develops, may be extracted if aspiration a possibility.

Oral Infections

D/D -

Bacterial

Viral

Fungal

Bacterial Infections

Odontogenic

Scarlet fever

Tuberculosis

Atypical mycobacterial infection

Actinomycosis

Syphillis

Impetigo

Osteomyelitis

Odontogenic Infections

Acute - sick child, raised temp., red swollen face.

Chronic - sinus tract present, mobile and/or discolored tooth, halitosis.

Tx -

remove the cause and local drainage and debridement,

May admit if spikes in temp. seen, facial space involvement suspected or seen &/or dehydrated.

Antibiotics - only if systemic involvement seen, or if child is immunocompromised. Pen family first drug of choice.

Osteomyelitis

Some times an odontogenic infection can lead to osteomyelitis in the mandible.

Radiographically - moth eaten appearance.

Tx - curettage to remove bony sequestra, antibiotics (after culture and sensitivity test) for at least 6 weeks.

Viral Infections

Primary herpetic gingivostomatitis

Herpes labialis

Herpangina

Hand, foot and mouth disease

Infectious mononucleosis

Varicella

Primary Herpetic Gingivostomatitis

Most common cause of severe oral ulcerations in children over the age of 6 mos (peaks at 14 mos).

Caused by Herpes Simplex Type 1.

Incubation period of 3-5 days with a prodromal 48 hour h/o irritability, lymphadenopathy, pyrexia and malaise.

Stomatitis seen, with gingival tissues become red and edematous.

Vesicles seen any where on oral mucosa and rapidly break down to form very painful ulcers. Solitary ulcers (<3mm) seen and some times larger ulcers with irregular margins are seen when there is coalescence of individual lesions.

Self limiting and ulcers heal spontaneously without scarring within 10-14 days.

Primary Herpetic Stomatitis

Exfoliative cytology, direct immuno-fluorescence, viral culture can be done to aid diagnosis.

Tx - symptomatic care, encourage hydration, pain management, chlorhexidine rinse or swabs on lesion, topical anesthetics , antiviral therapy and may require hospitalization.

Herpangina and Hand, foot and mouth disease

Caused by the Coxsackie grp A viruses, usually seen in the summer months in young children.

Prodromal phase that lasts for several days before appearance for vesicles (Herpangina - 4-5 vesicles, HFM - up to 10 vesicles).

Commonly seen on palate, pillars of the fauces and pharynx and other sites (hand and foot), malaise, fever.

Milder than herpes , healing in 10 days.

Tx - symptomatic care.

Infectious Mononucleosis

Caused by EBV and usually seen in late adolescents and young adults.

Highly infective.

Malaise, fever and acute pharyngitis.

In children, ulcers and petechia often seen in the posterior pharynx and soft palate.

Tx - self limiting.

Varicella

Highly contagious virus.

Seen as chicken pox in children and as shingles in adults.

Prodromal phase of malaise and fever for 24 hours, followed by crops of pruritic vesicles.

50% of children have oral lesions.

Tx - self limiting, resolves in 7-10 days, supportive and palliative.

Fungal Infections

Candidiasis

Common oral organism, but usually does not cause infection unless host is immunocompromised.

Acute pseudomembranous - in infants seen as Thrush. White scrapable plaques that reveal an erythematous base. In older children, seen in immunocompromised ones who are under active treatment - like CT, RT, broad spectrum ab.’s and steroids.

Median rhomboid glossitis - seen on dorsal surface of the tongue (usually anterior to the vallate papillae). Can be a response to broad spectrum ab.’s.

Tx - antifungal for 4 weeks (Nystatin, Ampho B, Fluconazole or Ketoconazole.

Ulcerative and Vesiculobullous Lesions

D/D -

Traumatic

Infective (already discussed)

Others

Traumatic lesions

Self induced post-anesthetic trauma

Riga-Fed`e ulceration

Self induced post-anesthetic trauma

Most common cause of traumatic ulcers.

Usually seen in children who have received their first local anesthetic injection.

Parents should be warned and children must be reminded not to bite their lips, cheeks etc.

Riga Fed`e ulceration

Ulceration of the ventral surface of the tongue of an infant or child.

Can be seen in children with natal/neonatal teeth and those with CP or comatosed.

Tx - smoothen sharp incisal edges or place domes of composite over the teeth, rarely may need to extract teeth.

Others

Recurrent aphthous ulceration

Erythema multiforme

Stevens-Johnson syndrome

Behcets syndrome

Epidermolysis bullosa

Lupus erythematosus

Neutropenic ulceration

Recurrent aphthous ulceration

Estimated to affect up to 20% of the population.

Seems to have a genetic predisposition, cause unknown

3 types -

Minor aphthae - majority of cases, crops of shallow ulcers up to 5mm, non-keratinized mucosa, typical yellow pseudomebranous slough with an erythematous border.

Major aphthae - involves the kertinized mucosa, larger ulcers, last longer.

Herpetiform ulceration

Recurrent aphthous ulceration

Tx - symptomatic care w/ mouth rinses (chlorhexidine, tetracycline,benzydamine hydrochloride, benadryl, xylocaine), heals within 10-14 days without scarring for minor, but with scarring in major.

Pigmented, Vascular and Red lesions

D/D -

Vascular

Pigmented

Others

Vascular Lesions

Hemangioma

Other vascular malformations

Hematoma

Petechiae and purpura

Hereditary haemorrhagic telangiectasia

Sturge-Weber syndrome

Maffuci’s syndrome

Hemangioma

Endothelial hamartomas,

Typically present at birth, may grow with the infant, but then regress with time and may even completely disappear

Tx - none required other than observation, may be a cosmetic concern.

Petechiae and Purpura

Petechiae - small pinpoint submucosal or subcutaneous hemorrhages.

Purpura or ecchymoses present as larger collections of blood.

Usually seen in patients with severe bleeding disorders or coagulopathies, leukemia etc.

Initially bright red in color, change to a bluish-brown hue with time as the extravasated blood is metabolized.

Pigmented lesions

Melanotic neuroectodermal tumor of infancy

Peutz-Jeghers Syndrome

Addision’s disease

Other Red lesions

Giant cell epulis/peripheral giant cell granuloma

Eruption cyst

Langerhans cell histiocytosis

Geographic tongue

Fissured tongue

Median rhomboid glossitis - already discussed

Heavy metal toxicity

Eruption Cyst or hematoma

Follicular enlargement appearing just before the eruption of tooth.

Blue-black in color (may contain blood).

Tx - none unless infected, reassure the child and parent, follicle will rupture, but may need to surgically opened if infected.

Geographic tongue

Also known as glossitis migrans, benign migratory glossitis, erythema migrans or wandering rash of the tongue.

Areas of depapillation and erythema with a heaped up keratinized margin on the lateral and dorsal surface of the tongue - map like area that changes.

Tx - none, may prescribe chlorhexidine mouthwash and/or topical steroids when child in pain

Fissured Tongue

Also known as plicated tongue, scrotal tongue, fissured tongue or lingua secta.

Usually see fissures that run perpendicular to the lateral borders

Commonly seen in children w/ Downs.

About 20% will also have geographic tongue or associated c/ Melkersson-Rosenthal Syndrome.

Tx - none

Exophytic Lesions

D/D -

Inflammatory

Congenital epulis of newborn

Squamous papilloma

Viral Warts

Eruption cysts/hemtomas

Inflammatory Hyperplasias

Fibrous Epulis

Giant cell epulis/peripheral giant cell granuloma

Fibrous Epulis

Most common exophytic lesion, also called fibroma and pyogenic granuloma if infected.

Usually an unusual response to plaque.

Commonly seen on interdental papillae, usually pink (red -yellow).

Can be firm or soft

Tx - improvement of oral hygiene, removal of irritant, surgical excision, can reoccur.

Giant Cell epulis/peripheral giant cell granuloma

Occur in the primary dentition, well circumscribed, sessile noduleous nodule, often ulcerated and hemorrhagic.

Color usually dark purple - “liver colored”, alveolar bone loss seen as cupping in the radiograph.

D/d - central giant cell if intra osseous lesions.

Tx -surgical excision, watch for recurrence.

Squamous papilloma

True benign tumor.

Cauliflower-like growth on the mucosa.

Color depends on degree of keratinization.

Clinically hard to distinguish from a viral wart.

Tx - surgical excision, including the stalk and normal border tissue.

Viral Warts

Viral infection of the human papilloma virus.

May be multiple or single.

Look for warts on other areas of the body, especially hands and fingers.

Surgical excision, extra-oral lesions may need to be managed by a dermatologist.

Gingival Enlargements

D/D -

Drug induced hyperplasias

Syndromes

Drug Induced Hyperplasia

Phenytoin

Cyclosporin A

Nifedipine

verapamil

Drug Induced Gingival Enlargements

Phenytoin

Interdental papillae, may be delayed eruption due the bulk of fibrous tissue, ectopic eruption, withdrawal of drug will bring about resolution in most cases.

Tx - oral hygiene key in control of overgrowth, chlorhexidine mouthwash, gingivectomy to allow for eruption and esthetics.

Cyclosporin A

H/o liver, kidney, heart and combined heart/lung transplants. most commonly used med for anti-rejection, seen in about 30-70% of these cases.

Nifedipine and verapamil

Both are calcium channel blockers, used to control cyclosporin induced hypertension after transplants in children.

Tx - oral hygiene and gingivectomy.

Syndromes with gingival enlargement

Hereditary gingival fibromatosis

May be associated with intellectual disabilities

May be sporadic in occurrence or an AD or AR trait.

Tx - gingivectomy or perio flaps to allow for eruption, maintain esthetics

Others e.g.: Leukemia.

References

Handbook of Pediatric Dentistry, 2nd ed. by Cameron and Widmer.

Dentistry for the Adolescent and child, 7th ed. by McDonald and Avery.

Oral and Maxillofacial Pathology by Neville, Damn, Allen and Bouquot.

The Handbook, 2nd ed., AAPD.


	Newborn lesions
	Infections
	Ulcerative and vesiculobullous lesions
	Pigmented, vascular and red lesions
	Exophytic lesions
	Gingival Enlargements


	Hard, raised small nodules
	Arise from epithelial remnants trapped along lines of fusion of embryological processes.
	Appear in the midline of the hard palate, mainly in the posterior section.
	Tx - no treatment.


	Ectopic mucous glands.
	Small keratinizing cysts.
	Usually seen on the labial aspects of the maxillary alveolar ridges.
	Tx - no treatment.


	Usually seen on the crest of the alveolus
	Remnants of the dental lamina.
	Tx - no treatment.


	Relatively rare, seen in neonates(at birth), of unknown origin, with proliferation of mesenchymal cells.
	Equal distribution between mx and md.
	Females > males.
	Usually firm, pedunculated,pink, smooth, solitary.
	Tx - often regress with time, but may need to be excised, recurrence is uncommon.


	Natal - seen present at birth.
	Neonatal - seen within 30 days of birth.
	In almost all cases it is the early eruption of a primary incisor.
	Usually only 5/6th of the crown is formed and the mobility arises from no root development.
	Tx - nursing issues, firms up as root develops, may be extracted if aspiration a possibility.


	Odontogenic
	Scarlet fever
	Tuberculosis
	Atypical mycobacterial infection
	Actinomycosis
	Syphillis
	Impetigo
	Osteomyelitis


	Acute - sick child, raised temp., red swollen face.
	Chronic - sinus tract present, mobile and/or discolored tooth, halitosis.
	Tx -
		remove the cause and local drainage and debridement,
		May admit if spikes in temp. seen, facial space involvement suspected or seen &/or dehydrated.
		Antibiotics - only if systemic involvement seen, or if child is immunocompromised. Pen family first drug of choice.


	Some times an odontogenic infection can lead to osteomyelitis in the mandible.
	Radiographically - moth eaten appearance.
	Tx - curettage to remove bony sequestra, antibiotics (after culture and sensitivity test) for at least 6 weeks.


	Primary herpetic gingivostomatitis
	Herpes labialis
	Herpangina
	Hand, foot and mouth disease
	Infectious mononucleosis
	Varicella


	Most common cause of severe oral ulcerations in children over the age of 6 mos (peaks at 14 mos).
	Caused by Herpes Simplex Type 1.
	Incubation period of 3-5 days with a prodromal 48 hour h/o irritability, lymphadenopathy, pyrexia and malaise.
	Stomatitis seen, with gingival tissues become red and edematous.
	Vesicles seen any where on oral mucosa and rapidly break down to form very painful ulcers. Solitary ulcers (<3mm) seen and some times larger ulcers with irregular margins are seen when there is coalescence of individual lesions.
	Self limiting and ulcers heal spontaneously without scarring within 10-14 days.


	Exfoliative cytology, direct immuno-fluorescence, viral culture can be done to aid diagnosis.
	Tx - symptomatic care, encourage hydration, pain management, chlorhexidine rinse or swabs on lesion, topical anesthetics , antiviral therapy and may require hospitalization.


	Caused by the Coxsackie grp A viruses, usually seen in the summer months in young children.
	Prodromal phase that lasts for several days before appearance for vesicles (Herpangina - 4-5 vesicles, HFM - up to 10 vesicles).
	Commonly seen on palate, pillars of the fauces and pharynx and other sites (hand and foot), malaise, fever.
	Milder than herpes , healing in 10 days.
	Tx - symptomatic care.


	Caused by EBV and usually seen in late adolescents and young adults.
	Highly infective.
	Malaise, fever and acute pharyngitis.
	In children, ulcers and petechia often seen in the posterior pharynx and soft palate.
	Tx - self limiting.


	Highly contagious virus.
	Seen as chicken pox in children and as shingles in adults.
	Prodromal phase of malaise and fever for 24 hours, followed by crops of pruritic vesicles.
	50% of children have oral lesions.
	Tx - self limiting, resolves in 7-10 days, supportive and palliative.


	Candidiasis
		Common oral organism, but usually does not cause infection unless host is immunocompromised.
		Acute pseudomembranous - in infants seen as Thrush. White scrapable plaques that reveal an erythematous base. In older children, seen in immunocompromised ones who are under active treatment - like CT, RT, broad spectrum ab.’s and steroids.
		Median rhomboid glossitis - seen on dorsal surface of the tongue (usually anterior to the vallate papillae). Can be a response to broad spectrum ab.’s.
	Tx - antifungal for 4 weeks (Nystatin, Ampho B, Fluconazole or Ketoconazole.


	Most common cause of traumatic ulcers.
	Usually seen in children who have received their first local anesthetic injection.
	Parents should be warned and children must be reminded not to bite their lips, cheeks etc.


	Ulceration of the ventral surface of the tongue of an infant or child.
	Can be seen in children with natal/neonatal teeth and those with CP or comatosed.
	Tx - smoothen sharp incisal edges or place domes of composite over the teeth, rarely may need to extract teeth.


	Recurrent aphthous ulceration
	Erythema multiforme
	Stevens-Johnson syndrome
	Behcets syndrome
	Epidermolysis bullosa
	Lupus erythematosus
	Neutropenic ulceration


	Estimated to affect up to 20% of the population.
	Seems to have a genetic predisposition, cause unknown
	3 types -
			Minor aphthae - majority of cases, crops of shallow ulcers up to 5mm, non-keratinized mucosa, typical yellow pseudomebranous slough with an erythematous border.
			Major aphthae - involves the kertinized mucosa, larger ulcers, last longer.
			Herpetiform ulceration


	Tx - symptomatic care w/ mouth rinses (chlorhexidine, tetracycline,benzydamine hydrochloride, benadryl, xylocaine), heals within 10-14 days without scarring for minor, but with scarring in major.


	Hemangioma
	Other vascular malformations
	Hematoma
	Petechiae and purpura
	Hereditary haemorrhagic telangiectasia
	Sturge-Weber syndrome
	Maffuci’s syndrome


	Endothelial hamartomas,
	Typically present at birth, may grow with the infant, but then regress with time and may even completely disappear
	Tx - none required other than observation, may be a cosmetic concern.


	Petechiae - small pinpoint submucosal or subcutaneous hemorrhages.
	Purpura or ecchymoses present as larger collections of blood.
	Usually seen in patients with severe bleeding disorders or coagulopathies, leukemia etc.
	Initially bright red in color, change to a bluish-brown hue with time as the extravasated blood is metabolized.


	Melanotic neuroectodermal tumor of infancy
	Peutz-Jeghers Syndrome
	Addision’s disease


	Giant cell epulis/peripheral giant cell granuloma
	Eruption cyst
	Langerhans cell histiocytosis
	Geographic tongue
	Fissured tongue
	Median rhomboid glossitis - already discussed
	Heavy metal toxicity


	Follicular enlargement appearing just before the eruption of tooth.
	Blue-black in color (may contain blood).
	Tx - none unless infected, reassure the child and parent, follicle will rupture, but may need to surgically opened if infected.


	Also known as glossitis migrans, benign migratory glossitis, erythema migrans or wandering rash of the tongue.
	Areas of depapillation and erythema with a heaped up keratinized margin on the lateral and dorsal surface of the tongue - map like area that changes.
	Tx - none, may prescribe chlorhexidine mouthwash and/or topical steroids when child in pain


	Also known as plicated tongue, scrotal tongue, fissured tongue or lingua secta.
	Usually see fissures that run perpendicular to the lateral borders
	Commonly seen in children w/ Downs.
	About 20% will also have geographic tongue or associated c/ Melkersson-Rosenthal Syndrome.
	Tx - none


	D/D -
		Inflammatory
		Congenital epulis of newborn
		Squamous papilloma
		Viral Warts
		Eruption cysts/hemtomas