Oral Pathology: Of the infant and toddler | Oral Manifestations of Sytemic Disease

Oral Pathology: Of the infant and toddler

Objectives: Participants will...

Be able to recognize common soft tissue pathology of the infant and toddler.
Become familiar with some developmental aberrations which occur in the infant and toddler.

Hard and soft tissue assessment of the pediatric dental patient involves a thorough knowledge of the size, shape, color, and texture of normal oral structures. More common pathology can be detected by other health care professionals as part of a thorough physical examination which includes the oral cavity. Referral to a pediatric dentist would ensure a definitive diagnosis and corresponding management.

Newborn Oral Pathology

1. Inclusion cysts appear as small white or gray lesions on the mucosa, alveolar ridge and hard palate, and are present in 75% of newborns. All three types – Epstein’s pearls, Bohn’s nodules and dental lamina cysts are asymptomatic and are usually shed within the first three months of life.

Epstein’s pearls may be found on the mid-palatal raphe of the hard palate.
Bohn’s nodules, remnants of salivary glands, are located on the buccal or lingual mucosa, or on the hard palate, away from the raphe.
Dental lamina cysts are located on the crests of the alveolar ridges.


*Epstein's Pearls*	*Bohn's Nodules*	*Dental Lamina Cysts*
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2. Congenital Epulis of the newborn is similar in appearance to a dental lamina cyst, but is usually located in the maxillary anterior region. Although some recede spontaneously, an usually large congenital epulis may cause feeding problems and require excision. Recurrence is unlikely.

3. Melanotic Neurectodermal Tumor of infancy is a benign tumor of neurectodermal origin. The clinical appearance can be similar to congenital epulis of the newborn; an exophytic non-ulcerated mass on the maxillary alveolar mucosa. The tissue may appear to be brown in color (pigmented). Radiographic examination reveals “floating teeth.”

4. Partial Ankyloglossia. The lingual frenum which has a short attachment to the floor of the mouth is often called “tongue-tie.” In a newborn, it may be present, but usually resolves over time with tongue use. Unless it is severe, it usually does not present a problem for speech or eating and does not need to be surgically corrected. In the case of ankyloglossia where movement is restricted, such that the child cannot clean the food off their teeth, a lingual frenectomy may need to be performed. An early evaluation for this is necessary to assure proper speech and placement of teeth.

Partial Ankyloglossia

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5. Natal/Neonatal teeth. Usually lower incisors, natal teeth are present at birth; neonatal teeth erupt within the first 30 days of life. As many as 85% of these are a part of the normal primary dentition and are not supernumerary. Efforts should be made to retain these teeth unless they are hypermobile and there is concern of aspiration. These teeth may be associated with Riga-Fede (see Problem with Eruption). Natal teeth may be the first sign of some syndromes including Ellis-van Creveld and Hallermann-Streiff.

Common Oral Pathology

1. Traumatic Ulcer, frequently seen on the buccal mucosa, lips and palate, is usually associated with a mechanical or thermal injury. Its potential for presentation in child abuse cases requires further investigation. A torn maxillary or lingual frenum is pathonomonic for abuse.

Aphthous Ulcer
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2. Aphthous Ulcer, usually present on mucous membranes, this lesion appears similar to a traumatic ulcer but has a recurrent pattern. It may appear singly or as multiple lesions. Lesions persist for 4 to 12 days and heal uneventfully. Symptoms are treated palliatively.

Odontogenic Infection
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3. Odontogenic Infection is an acute or chronic infection resulting from tooth related pathology which often manifests as a fluctuant nodule or vesicle, normal in color, above or adjacent to the affected tooth. It may burst and drain, resulting in a draining tract. Treatment requires intervention to eliminate the etiology of the infection.

Mucocoele
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4. Mucocoele is a salivary gland lesion of traumatic origin most commonly located on the lower lip. It forms when the main duct of a minor salivary gland is torn, resulting in a build-up of mucous into the fibrous connective tissue forming a cystlike cavity. Color may be translucent or blue. There may be cyclical drainage and swelling, as the mucous saliva continues to form at the site of the torn duct. Surgical excision of the involved accessory mucous gland is essential to prevent recurrence.

Benign Migratory Glossitis
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5. Benign Migratory Glossitis (Geographic Tongue) is fairly common in young children with unknown etiology. The condition exhibits red, smooth areas devoid of filiform papillae on the dorsum of the tongue. Involved areas enlarge and migrate by extension of the desquamated papillae at one margin and regeneration at the other. The condition may be irritated by acidity foods. It is self-limiting; no treatment is necessary.

Candidiasis: white, curdy
plaques coating the tongue Click image to enlarge.

6. Pseudomembranous Candidiasis (Thrush) is caused by the fungus, candida albicans, and appears as large white plaques or as milk curds on the buccal, labial or gingival mucosa and on the tongue. Removal of the white plaque results in raw, bleeding, underlying mucosa. This condition may occur in newborns, immunocompromised patients and individuals on long term antibiotics, where the normal oral flora have been altered. Successful treatment can be accomplished by use of an antifungal agent. Candidasis is the most common opportunistic infection in children infected with pediatric human immunodeficiency virus (HIV).

Heck’s disease

7. Heck's Disease (Focal Epithelial Hyperplasia) is common in children and is seen as small multiple bumps on the oral mucosa. No treatment is necessary as it does not have any symptoms and disappears on its own.

Several large painful ulcers are evident on the tongue, lips and face of a pre-school child with acute herpetic gingivostomatitis
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8. Primary Herpetic Gingivostomatitis. Aside from the most common cold and influenza, herpetic infections are probably the most common human diseases. This results from the initial exposure to the Herpes Simplex virus – HSVI. Clinical presentation includes small vesicles on the lips, tongue, and cheeks which coalesce and rupture forming painful ulcerations and may be accompanied by malaise, anorexia and a low-grade fever. Primary herpes simplex occurs most frequently in infants and children below the age of 6. In the acute febrile state, parent may consult the physician first. Maintaining adequate fluid and nutritional intake is the main focus of treatment. A very young child can quickly dehydrate and require hospitalization. The acute phase generally lasts 10-14 days.

Condyloma Acuminatum
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9. Condyloma Acuminatum presents as small lesions that occur on the oral mucosa, but may also be present on the tongue and palate. The lesions have small pink projections, and may look like an oral wart. Since this is associated with a papillomavirus that is sexually transmitted, removal and histologic examination are required, as it is considered a sign of sexual abuse.

Problems with eruption

1. Eruption cyst/eruption hematoma is a fluctuant, fluid cyst which may appear 2-3 weeks prior to the eruption of a tooth. As the tooth emerges, the cyst may be blood filled and appear blue to purple in color (eruption hematoma). Eruption cysts and eruption hematomas are usually asymptomatic and resolve with eruption of the tooth. The lesions should not be incised as this may increase the potential for infection.

2. Riga-Fede Ulceration. A traumatic ulcer on the ventral surface of the tongue caused by rubbing of the tongue on the newly erupted sharp incisal edges of mandibular anterior teeth. Usually, treatment requires only smoothing the incisal edges. If the baby has decreased feeding and losing weight, the tooth might have to be polished down or even removed. There is a high incidence of the condition in children with congenital indifference to pain, familial dysautonomia, and cerebral palsy.


*Eruption Hematoma*	*Riga-Fedé ulcer*
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3. Delayed Eruption. The primary dentition usually begins to erupt by one year and is completed by three years of age. A significant delay in eruption may signify an underlying metabolic disease or genetic syndrome, including cleidocranial dysplasia, hypothyroidism and dwarfism.

4. Early Exfoliation. As a rule, primary teeth begin to exfoliate around 5-6 years of age. Premature loss may be due to localized trauma, periodontal disease, a benign and malignant tumor or a sign of metabolic disease. Pappillon Lefevre, which includes hyperkeratosis of the palms and soles, includes periodontal disease and loss of multiple and often all primary teeth. Cyclic neutropenia can present as periodontal disease with early loss of teeth. AIDS and diabetes mellitus also may present with early exfoliation. Hypophosphatasia and some childhood leukemias may be diagnosed first due to early exfoliation of primary teeth.

Developmental Aberrations

Disturbances during the embryonic development of the dentition may produce a variety of anomalies in number, shape and size of teeth. Tooth development is affected by environmental factors such as nutrition, exanthematous disease and premature birth. Atypically appearing teeth may also be a sign of an underlying syndrome.

Enamel Hypoplasia
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1. Enamel Hypoplasia. Defective enamel development may be caused by systemic or local effects. Deficiency in Vitamins A, C and D may cause generalized defects in the developing enamel. A high number of dental anomalies due to nutritional deficiencies, low birth weight and periods of hypoxia may be associated with premature birth. Hypoplasia of the primary incisors and palatal groove malformation has been attributed to laryngoscopy or extended oral intubation. Generalized enamel hypoplasia of the primary teeth, often occurring in gingival areas, is more susceptible to decay.

Ectodermal Dysplasia Intraoral View
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2. Congenital absence (aplasis) of teeth may occur as a mutation (an isolated instance), or associated with genetic factors. A single missing primary tooth is rare, whereas multiple missing primary teeth may be associated with syndromes including Down’s and Ectodermal Dysplasia. The dentition, in which multiple teeth may be missing or have atypical anatomy (conical shaped teeth), may provide an early clue in the diagnosis of Ectodermal Dysplasia, which affects the skin, hair and nails as well as the teeth.

Mesiodens Click image to enlarge.

3. Hyperdontia. (Supernumerary teeth) An excessive number of teeth may be due to an overdevelopment of the dental lamina. In the primary dentition, this may present as a single conically shaped tooth in the maxillary midline (Mesiodens). Multiple extra teeth may be associated with Cleidocranial Dysplasia, Orofacial Digital Syndrome and Gardner’s Syndrome.

Oral Manifestations of Systemic Disease

Objectives: Participants will...

Recognize the close relationship between oral health and general health.
See advantages to paying close attention to the oral cavity in routine physical examination.
Be able to identify specific systemic diseases from their known oral manifestations.

Some of the earliest manifestations of systemic disease can be seen in and around the oral cavity. Changes in the appearance of the mucosa and the structural integrity of the teeth are often warning signals. It is vital to identify the underlying cause of these changes, which may signify one of numerous systemic diseases, whether hereditary or acquired, with either known etiology or idiopathic.

1. Measles (rubeola) is a common infectious disease produced by a virus. Several characteristic and diagnostic oral lesions appear during the prodromal phase of measles. Koplik spots, as they are called, are a distinct eruption on the buccal mucous membrane and the inside of the lips, not on the hard palate. They usually appear in about 48 hours, but it may be as long as 6 or 7 days before the skin rash. They consist of small, irregular spots of bright red color with a minute bluish white speck in the center, which can be seen with a bright light. The mild fever which accompanies the early symptoms, resembling an upper respiratory infection, may bring the child to the physician before the rash erupts.

Courtesy of Dr. Phelan

2. Varicella-Zoster (Chicken Pox). Typically, the patient presents with hundreds of small, 3 – 4 mm. fluid filled vesicles on both the skin and mucous membranes. The vesicles are very itchy and will heal with scarring if they are forcibly ruptured, and/or infected. The duration of the primary infection is approximately 21 days.

3. Herpangina and Hand, Foot and Mouth Disease. Both of these infections are caused by the Coxsackie A Virus and are common in young children. Herpangina is more common in summer, with small ulcers on the soft palate and tonsillar pillars. It looks similar to strep throat. Hand, Foot and Mouth Disease presents with oral ulcers on the buccal mucosa and hard palate, and vesicles on palms of the hands and soles of the feet. The symptoms include a low grade fever, malaise and lymphadenopathy. The treatment is palliative including antipyretics and increased fluids. Symptoms resolve in 7-14 days.

4. Scarlet Fever, caused by beta hemolytic streptococci, is characterized by erythematous or prominent papillae (strawberry tongue). The white coating on the tongue is soon lost, leaving an erythematous glistening surface with the tonsils and faucial pillars covered with a grayish white exudate.

5. Diabetes Mellitus Type 1, or insulin dependent diabetes mellitus, is the most common form in children. Periodontal disease is a constant oral finding; xerostomia and recurrent intraoral abscesses may be present.

6. Hematologic Disorders:

Anemias: the anemias are the most common blood disorders in children. In many cases, oral changes have been known to be the earliest discernible indication of a hematalogic disturbance.
Sickle Cell Anemia is a homozygous hereditary disorder affecting African-Americans almost exclusively. Manifestations may appear as early as three or four months, but the majority manifest symptoms late in the first year or later in childhood. Clinically there is enamel hypomineralization and increased prevalence of periodontal disease. Radiographically, the reduced number of trabeculae and their stepladder appearance between the teeth are definitive symptoms.
Acute Lymphoblastic Leukemia is the most common malignancy in children occurring in approximately 4 in 100,000. Oral ulceration, pharyngitis, gingival infection unresponsive to conventional treatment, gingival oozing, hematoma, petechiae or ecchymosis formation are among the oral lesions noted.
Hemophilia A is an x-linked recessive deficiency of factor VIII observed almost exclusively in a male. It involves a history of mild to moderate persistent bleeding often involving the maxillary lip, lingual frenum and tongue. Generally, the onset of the bleeding episodes in this condition does not occur until the toddler stage.

This small sampling of abbreviated oral manifestations of systemic disease underscores the urgency of forming a medical/dental partnership toward pediatric oral health. It reinforces the adage “you are not healthy without good oral health.” and it challenges medical and dental professionals to assume a reciprocal role in reaching the national health objectives for the Year 2010 and beyond.