Paediatric Oral Pathology and Medicine

Paediatric Oral Pathology and Medicine

• A 30-year analysis in children showed approximately 10% were under 16 years of age, with the majority being benign (less than 1% malignant), requiring minimal intervention.
• Odontogenic tumors are rare in this age group, but certain lesions like adenomatoid odontogenic tumors and ameloblastic fibromas occur predominantly in children, hence important diagnostic considerations.
• Mucous extravasation cysts are the most frequently diagnosed (over 16%).
• Periapical pathology, in the form of radicular cysts, residual cysts, or chronic periapical granulomas, accounts for 13% of cases.
• Tooth pathology accounts for 22.1%, salivary gland disease 19.1%, and mucosal pathology 12.1%

Newborn Lesions

Gingival Cysts of Infancy

• Small white or grey lesions occur on the mucosa, alveolar ridge, and hard palate
• Present in 75% of newborns
• Asymptomatic
• They usually rupture or involute within the first three months
• Examples include Bohn’s nodules, gingival cysts of newborns, and Epstein’s pearls

Bohn's Nodules - Alveolar Ridge Cysts

• The earliest epithelium to grow into ectomesenchyme is the dental lamina
• Remnants persist as rests (glands) of Serres
• Located at the crest of maxillary and alveolar ridges within connective tissue between the crown of developing teeth and oral mucosa
• Some undergo cystic degeneration, forming small swellings

Epstein's Pearls - Midline Raphe Cysts

• Inclusions occur in the line of fusion of the palatine processes
• Undergo cystic change
• Located at the mid-palatal raphe of the hard palate

Congenital Epulis

• Alveolar ridge of newborns, usually on the upper ridge
• Soft, round exophytic (sticks out) swelling
• Sometimes very large
• Occurs in 80% of females

Management of Newborn Lesions

• Large lesions may warrant conservative excision if they interfere with breathing, eating, or diagnosis
• Small lesions typically require monitoring as they tend to resolve

Melanotic Neuroectodermal Tumour of Infancy

• A biphasic neoplasm of neuroblastic and melanin-producing epithelioid cells originating from the neural crest.
• 80% are detected before 6 months of age
• 60% are located in the anterior maxilla
• Present with a slight male predilection
• Rapidly growing mass that is locally aggressive
• Rare, but can be destructive

Partial Ankyloglossia

• A lingual frenum with a short attachment to the floor of the mouth, commonly known as "tongue-tie"
• Typically does not cause problems with speech or eating and surgical correction is not necessary

Infective/Ulcerative Conditions

Pseudomembranous Candidiasis (Thrush)

• Caused by Candida albicans
• Characterized by large white plaques on the buccal, labial, or gingival mucosa, and tongue.
• A classic feature is raw, bleeding mucosa when white plaques are removed
• Swallowing can be uncomfortable
• Occurs in newborns, immunocompromised patients, and individuals on long-term antibiotics due to altered oral flora
• Most common opportunistic infection in children with paediatric HIV
• Treatment:* Antifungal agents

Acute Odontogenic Infection (Related to Tooth)

• Important to diagnose early as the child can deteriorate quickly
• Presents with a sick, upset child
• Pyrexia (raised body temperature) is present
• Manifests as a red, swollen face
• Anxious and distressed parents
• Treatment:*
• Maintain hydration
• Antibiotics for pyrexia and spreading infection, but, the cause of the infection must be eliminated by extraction or extirpation

Chronic Odontogenic Infection

• Less pressing as the child has had it for a longer time
• Sinus may be present
• Mobile tooth
• Halitosis
• Discoloured tooth
• Treatment:*
• Antibiotics are not always indicated
• Remove the cause by extraction of primary teeth
• Consider prevention and acclimatisation first

Principles of Managing a Child with Toothache (Acute or Chronic)

• Identify urgency
• Take a history and make a diagnosis
• Be aware of both parental and child anxiety
• Relieve the pain (without extraction if possible)

Primary Herpetic Gingivostomatitis

• Caused by Herpes Simplex Virus 1 (HSV-1).
• Presents usually between 2-4 years, but is increasingly seen in older children and young adults
• Transmitted via direct contact with skin or saliva
• 90% of cases are asymptomatic
• Clinical Presentation 1:*
• Depends on the infection's severity
• After a 6-7 day incubation, small vesicles form throughout the mouth (oral mucosa, tongue, gingivae, and lips)
• Vesicles break down and coalesce into a highly infectious fibrinous exudate, resulting in fiery red gingivae and painful stomatitis, and may include bleeding and crusting of the lips
• Clinical Presentation 2:*
• Raised temperature
• Increased salivation
• Submandibular lymphadenopathy
• May be too painful for the child to carry out oral hygiene measures and eat or swallow leading to dehydration
• Treatment:*
• Often palliative as peak activity may have occurred already
• Analgesia
• Encourage cool fluid and soft food intake
• Severe cases: Aciclovir at 200mg, 5x daily (double in immunocompromised) for 7 days

Similar Viral Infections

• Herpangina
• Hand, Foot, and Mouth disease
• Varicella Zoster (Chicken Pox)
• Herpes Zoster (Shingles)
• Erythema Multiforme
• Fungal infections like Thrush

Herpangina

• Caused by Coxsackie virus.
• Typically presents in the first few years of life.
• Child is febrile, irritable, has general malaise, and loss of appetite
• Develops vesicles with cervical lymph node enlargement
• Located primarily in the soft palate and fauces, sparing the gingivae

Hand, Foot, and Mouth Disease:

• Caused by Coxsackie virus
• Vesicular lesions mainly affect the tongue and oral mucosa
• Transmitted via the faeco-oral route
• Vesicles also appear on the lateral margins of fingers and toes

Erythema Multiforme

• Aetiology is complex, often precipitated by infections or drugs
• Oral lesions progress from macules to blisters predominantly in the anterior part of the mouth
• Bloodstained or crusted lips with target lesions
• Accompanied by target lesions on squamous epithelium

Ulcerative Lesions

• Traumatic
• Infective (already discussed)
• Others -->Self-induced post-anaesthetic trauma e.g. bite lip after LA -->Riga-Fede'e ulceration -->Recurrent aphthous ulceration
• Erythema multiforme
• Stevens-Johnson syndrome
• Bechet's syndrome Epidermolysis bullosa
• Lupus erythematosus
• Neutropenic ulceration

Riga-Fede Ulceration

• Traumatic ulcer on ventral surface of tongue due to tongue rubbing newly erupted sharp incisal edges of lower anterior teeth.
• High incidence of condition in children with congenital indifference to pain, familial dysautonomia, and cerebral palsy.
• Treatment involves smoothing the incisal edges

Pigmented, Vascular, and Red Lesions

Eruption Cyst/Eruption Haematoma

• Fluctuant fluid cyst may appear 2–3 weeks before a tooth eruption
• As the tooth emerges, it may be blood-filled to appear like a blue/purple eruption hematoma.
• Generally asymptomatic and resolves with eruption of the tooth.
• Lesions should not be incised to avoid infection and resolve spontaneously.

Haemangioma/Lymphangioma

• Typically present at birth and may grow with the infant, often regressing with time.
• Treatment involves observation or cosmetic intervention

Sturge–Weber Syndrome

• Involves haemangioma of the face and oral mucosa.
• Includes ipsilateral haemangioma and calcification of the meninges, making the individual susceptible to seizures, mental retardation, and epilepsy.

Exophytic Lesions include:

• Congenital epulis of newborn
• Eruption cysts or haematomas
• Mucocele
• Squamous papilloma
• Epuli

Extravasation Mucocele

• Occurs due to damage of minor salivary gland duct (often biting)
• Seen on the lower lip or cheek
• Duct damage results in mucous spilling into connective tissue
• Presents as a bluish swelling that may have a keratinised surface (white)
• Resolves spontaneously or requires surgical removal
• Mucous retention cysts are less common with similar appearance but lined by epithelium, caused by expansion of duct that is more common in older patients.

Gingival Enlargements - Drug-Induced Hyperplasia and Syndromes

Other common Paediatric Odontogenic Tumours:

• Ameloblastic Fibroma
• Adenomatoid Odontogenic Tumour
• Odontomes

Odontomes

• Complex type: Disorganised mass of dentine, enamel, and pulp commonly found in the posterior mandible
• Compound type: Mass of discreet denticles, each containing enamel, dentine & pulp (4x more common than complex) and prevents eruption of teeth.
• Investigations should be radiographic and clinical analysis
• Treatment includes enucleation, surgical exposure and orthodontic alignment.