Oral Lesions in Children and Adolescents

Oral Lesions in Children and Adolescents

• Oral lesions may affect hard and soft tissue in the oral maxillofacial region.
• The majority of oral lesions are mucosal conditions, developmental anomalies or reactive/inflammatory lesions.
• A thorough patient history, risk assessment, and clinical documentation are crucial in effectively diagnosing oral lesions.

Diagnosing Oral Lesions

• Rank order lesions with similar characteristics from most to least likely diagnosis
• Initial management should be guided by the most likely working diagnosis.
• Definitive diagnosis commonly involves a biopsy, the gold standard for diagnosing oral lesions.
• A soft tissue biopsy is recommended if a lesion persists for over two weeks despite treatment or if the differential diagnosis includes significant disease/neoplasm.

Excisional Biopsy

• The complete removal of small lesions.
• Indicated mainly for lesions smaller than 3cm in diameter.

Incisional Biopsy

• A portion of the suspected malignancy is removed.
• Helps determine the nature of the lesion when a full excision is not indicated or possible.

White Sponge Nevus

• Characterized by symmetrical, white, irregular, thickened and velvety plaques.
• The plaques are sponge-like and can be found on the buccal mucosa, ventral tongue, and other areas like the nose and esophagus.
• White sponge nevus is an autosomal dominant condition, caused by mutations in the KRT4 or KRT13 genes.
• It does not disappear when tissue is stretched and often persists into adulthood.
• It is important to maintain good oral hygiene, as the folds of extra tissue can promote bacteria growth and infection.

Oral Lymphoepithelial Cyst

• This is a rare, well-circumscribed, white or yellow developmental cyst.
• It is commonly found on the ventral surface and lateral borders of the tongue, as well as on the floor of the mouth.
• Typically asymptomatic, it can mimic an abscess or sialolithiasis.
• Treatment may involve conservative surgical excision if the diagnosis is uncertain or if the cyst is symptomatic.
• Small, characteristic lesions can be monitored without surgical intervention.

Sialolithiasis

• Hard, white-pinkish solitary lesions composed of calcium salt deposits in a salivary duct.
• Commonly observed in the submandibular duct (Wharton's duct), leading to ductal blockage.
• Presents with episodic pain and swelling especially during or after eating.
• Can be observed on panoramic or occlusal radiographs.
• Treatment involves salivary stimulants or surgical removal. Recurrence is possible.

Oral Burns

• Over 90% of oral burns are thermal burns.
• Chemical burns are also common and can cause painful lesions.
• Tissue may appear necrotic and irregular.
• Treatment depends on the severity, and is palliative in most cases.

Median Rhomboid Glossitis

• This benign condition presents as a smooth, red, flat or raised nodular area on the posterior dorsal midline of the tongue, about 2-3 centimeters long.
• The affected area lacks the normal coating of filiform papillae.
• It is thought to represent a chronic candidiasis in the affected area of the tongue.
• Treatment includes antifungal agents and good oral hygiene.

Erythema Migrans

• This condition is also known as geographic tongue or benign migratory glossitis.
• It presents as red areas of varying sizes on the tongue, surrounded by an irregular white border.
• The appearance is due to the loss of papilla in certain areas.
• The exact cause is unknown, but proposed factors include stress, allergies, diabetes, and hormonal disturbances.
• It affects 1-2.5% of individuals and can occur at any age.
• The lesions vary in color, shape, and size, and may disappear for a time and then reappear.
• It is often associated with a fissured tongue.
• Treatment is not necessary if the condition is asymptomatic. If symptomatic, topical steroids may be prescribed.
• Patients should avoid spicy and acidic food.

Eruption Cyst

• Also known as eruption hematoma, this is a soft tissue cyst resulting from the separation of the dental follicle from the crown of an erupting tooth.
• Fluid accumulates in the follicular space created by this separation.
• The cyst can vary in color from normal to blue-black or brown, depending on the amount of blood in the cystic fluid.
• Treatment is not usually required as the tooth erupts through the lesion.
• If the cyst does not rupture spontaneously or becomes infected, surgical opening may be required.

Oral Melanotic Macule

• This is a benign pigmented condition of the mouth that appears as a flat, brown to black patch, less than a third of an inch in size.
• It resembles a large "freckle" inside the mouth, but unlike freckles, sun exposure does not darken oral melanotic macules.
• They are commonly located on the lips, but can also appear on the gums, roof of the mouth and inside cheeks.
• Diagnosis is usually based on appearance but a biopsy may be required in certain situations.
• Multiple macules may indicate more serious conditions such as Addison's disease or Peutz-Jeghers syndrome.
• No treatment is necessary, however lesions on the lip may be removed for cosmetic purposes.

Melanocytic Nevus

• This is a rare lesion derived from nevus cells in the oral mucosa and causes focal hyperpigmentation.
• The most common locations are the hard palate, buccal mucosa, and gingiva.
• They usually present as small, well-circumscribed macules, but can occasionally appear as slightly raised papules.
• Treatment involves excisional biopsy due to the risk of malignant transformation.

Soft Tissue Enlargements

Mucocele

• Commonly encountered in children and adolescents.
• Forms due to a ruptured minor salivary gland excretory duct, leading to the leakage of mucin into adjacent connective tissues and potentially forming a fibrous capsule.
• Characterized as a well-circumscribed, bluish, translucent fluctuant swelling that is firm to palpation.
• Deeper or long-standing mucoceles may range from normal color to a whitish keratinized surface.
• Most commonly seen on the lower lip, usually lateral to the midline, but also can be found on the buccal mucosa, ventral surface of the tongue, retromolar region, and floor of the mouth (ranula).
• Most mucoceles require treatment to minimize the risk of recurrence.
• Superficial mucoceles may burst spontaneously, leaving shallow ulcers that heal within a few days.

Ranula

• A fluid-filled cyst (mucocele) that forms under the tongue, resulting from saliva leakage from a damaged salivary gland.
• It appears as a smooth, translucent red/blue swelling.
• The size fluctuates and the ranula may be mildly tender.
• May cause periodic drainage and can elevate the tongue.
• It is caused by trauma to the sublingual or submandibular salivary glands, or mucous retention.
• There are two types: Simple Ranula (stays under the tongue) and Plunging Ranula (extends into the neck).
• Treatment usually involves surgical excision or marsupialization (which may recur).

Irritation Fibroma

• This is a benign reactive lesion that forms in response to chronic trauma or irritation to the mucosa.
• It is a firm, pink nodule that is composed of fibrous connective tissue.
• Common locations include the buccal mucosa, tongue, and attached gingiva.
• Treatment involves excisional biopsy. It is important to remove the source of irritation to prevent recurrence.

Parulis

• Also known as soft tissue abscess, this is an acute inflammatory lesion caused by odontogenic infection.
• It is a pinkish-white or red solitary nodule, with erythema (redness) and fluctuates in size.
• Often tender or painful, and may have pus drainage.
• Can progress to cellulitis if untreated.
• Treatment involves eliminating the source of infection.

Squamous Papilloma

• This is a benign lesion caused by HPV types 1 and 6.
• It presents as soft, painless, pink to white, pedunculated lesions with multiple finger-like projections on the surface, resembling a cauliflower.
• While mostly occurring in adulthood, 20% of cases occur before the age of 20.
• Vertical transmission is common in children, while horizontal transmission is more common in adults.
• Treatment involves thorough patient history, surgical excision, and recurrence is uncommon.

Verruca Vulgaris (Common Wart)

• Caused by HPV types 2, 4, 6.
• Primarily observed on the skin of the hand but can develop intraoral lesions due to autoinoculation through finger or thumb sucking.
• Malignant transformation is rare.
• Similar in appearance to squamous papilloma, it can be sessile (broad based) or pedunculated.
• It has a rough, bumpy surface.
• Common sites in the oral cavity include the lips, tip of the tongue and labial mucosa.
• Treatment involves surgical excision with a low recurrence rate.

Pyogenic Granuloma

• Reactive inflammatory lesion arising from fibrous connective tissue in response to irritation or hormonal changes.
• It can be smooth to irregular, ulcerated, soft to firm and display a pedunculated or sessile nodule.
• Usually ulcerated and bleeds easily.
• Observed more commonly in females and can occur at any age.
• Causes include local irritation, trauma, and hormonal changes, especially during pregnancy.
• Common locations are the attached gingiva, lips, tongue, and buccal mucosa.
• Treatment involves excisional biopsy and removal of the local irritant.
• Recurrence is a possibility.

Localized Juvenile Spongiotic Gingival Hyperplasia

• An isolated patch of sulcular/junctional epithelium affected by local factors like mouth-breathing or orthodontic appliances.
• Presents as bright red enlargement of the anterior facial gingiva.
• Bleeds easily and does not respond to oral hygiene measures.
• More common in females with most lesions occurring under age 20; median age of diagnosis is 12 years.
• Treatment involves excision, with some lesions (up to 16%) recurring.

Peripheral Ossifying Fibroma

• A reactive gingival lesion common in adolescents, especially females.
• Less common in children with primary dentition.
• Declines after age 30, suggesting a hormonal influence.
• Commonly found on the maxilla.

This quiz covers the identification and management of oral lesions in children and adolescents, focusing on diagnosis techniques and biopsy procedures. Understand the types of lesions, their characteristics, and the importance of thorough patient evaluation for effective treatment. Learn about the distinctions between excisional and incisional biopsies and their indications.