ORAL PATHOLOGY IN

PEDIATRIC DENTISTRY
 Teething problems
 Teething has been used as a diagnosis to
explain vague childhood illness for over 5000
years.

 Manifestations of primary tooth eruption have

been reported to range from:
 Drooling, sleep disturbance or coughing
 to the more severe – convulsions or even death!

King, 1994
 Teething problems
 In 1839, the Registrar General attributed 5016
infant deaths in England and Wales to teething,
however, by 1910 this had reduced to 1600.

 The majority of these deaths occurred between

the ages of 6 months and 2 years old, the
period during which primary tooth eruption
takes place.

Dally, 1996
Teething problems
 Teething problems
 Increased biting
 Drooling
 Gum-rubbing
 Sucking
 Irritability
 Wakefulness

Macknin, 2000
 Teething problems
 Ear-rubbing
 Facial rash
 Decreased appetite for
solid foods
 Mild temperature
elevation (0.6 degrees)

Macknin, 2000
 Teething problems
 Systemic symptoms in the study, for example
diarrhea, cough, nasal congestion, nappy rash, and
vomiting were not significant.

 Such symptoms are probably due to an infection

unrelated to teething, but that the stress associated
with teething could make the child more vulnerable
to infection right before a new tooth appears.

Macknin, 2000
 Treatments for the symptoms of teething

Pressure based:
• Teething rings/rattles

(chilled): refrigerate,
not freeze

• Teething blankets

• Hard vegetables
(chilled carrots, celery)
Treatments for the symptoms of teething

Drug based:
 Systemic:

paracetamol/
Ibuprofen- (No
Aspirin)

 Topical: Local gel

(Lidocaine HCL)
 Treatments for the symptoms of teething

 The FDA has issued a warning

against using benzocaine based
teething gels because they can
cause methemoglobinemia.

Signs of methemoglobinemia:
 Cyanosis

 Dyspnea

 Pulse oximetry values that do

not respond to increased

oxygen delivery
 Anxiety
Soft tissue operculum/ Pericoronitis
 Acute inflammation of
gingival tissue
associated with partial
tooth impaction

 Most common in early

adulthood, eruption of
8s

 Can be associated with

6s or Es.
 Pericoronitis
 The infection may spread and produce
suppuration with lymphadenitis and pyrexia

 Sometimes associated with pain, loss of

appetite and a history of malaise
 Pericoronitis/ management
• Irrigation with normal saline to clean the space
between operculum and crown

• Instructions for the use of a mouth wash

• Antibiotic therapy

• Careful observation is required to assess

uncontrolled spread of infection.
 Eruption cyst
 A soft tissue variant of the
dentigerous cyst associated
with an erupting primary or
permanent tooth

 Occurs due to separation of

the dental follicle from around
the tooth crown

 A soft translucent well

demarcated swelling directly
overlying the crown of an
erupting tooth

 Colour?!
 Eruption Cyst/ Management
 Reassurance of the
patient and parents

 Observation until lesion

resolves spontaneously

 Surgical excision of the

roof of the cyst may
encourage eruption of
the tooth
Primary Herpetic Gingivostomatitis PHGS

 The most frequent acute

viral infection of the
oral mucosa

 Caused by the herpes

simplex virus 1 HSV-1
and rarely HSV-2
Primary Herpetic Gingivostomatitis PHGS

 Incidence increases after 6 months and peaks

between 2-4 years

 Transmission of the virus is by droplet

infection and the incubation period is about 1
week

 Most PHSV infections in children are

subclinical
 PHGS- presentation
 Incubation period of 2–20 days

 Non-specific symptoms such as malaise or

myalgia
 PHGS- presentation
 The tongue, lips, gums, buccal
mucosa and hard and soft palates

 1–2 mm blisters rapidly break down

and coalesce to form shallow,
painful small and usually irregular
ulcers covered by a yellowish-grey
pseudomembrane,and surrounded
by an erythematous halo

 Perioral lesions may occasionally

occur
 PHGS- presentation
 Pain, inability to swallow,
drooling and dehydration
are common.

 Associated fever, cervical

lymphadenopathy,
halitosis, lethargy, loss of
appetite and irritability

 The ulcers gradually heal

over 7-10 days without
scarring
 PHGS- Diagnosis
 Usually based on clinical criteria
 Viral culture
 Cytology smears
 Serological test (antibody titer)
 PHGS- management
 Herpetic gingivostomatitis does not respond
well to active treatment

 Bed rest and a soft diet

 The child should be kept well hydrated

 Pyrexia is reduced using a paracetamol

suspension
 PHGS- management
 Secondary infection of ulcers may be prevented
using chlorhexidine

 A chlorhexidine mouthwash may be used in

older children who are able to expectorate

 In younger children (under 6 years of age) a

chlorhexidine spray can be used or the solution
applied using a sponge swab.
 PHGS- management
 In severe cases of herpes simplex, in neonates,
and in immuno-compromised children
systemic acyclovir can be prescribed

 The drug is most effective when given at the

onset of the infection

 Antibiotics may also be prescribed to prevent

secondary infection
 Herpes Labialis
 After the primary infection, the herpes virus
remains dormant in the sensory ganglion

 Reactivation causes cutaneous and

mucocutaneous recurrent herpetic infection
 Herpes Labialis

 Herpes labialis, “cold

sore” on the
mucocutaneous
border of the lips
 Herpes Labialis
 Reactivation can be spontaneous, or triggered
by a number of factors

Fever Ultraviolet light

exposure
Common cold Emotional stress
Fatigue Trauma
Immunosuppression Oral and facial surgery
Viral infections Gastrointestinal upset
Menstruation
 Herpes Labialis
 Prodromal symptoms
 Vesicular eruption
 Pustular scabs and ulcers
 Healing within 1-10 days
 Acute necrotizing ulcerative gingivitis
ANUG
 Necrotizing ulcerative gingivitis (NUG) is one
of the commonest acute diseases of the gingiva.

 In developing countries, NUG is prevalent in

children as young as 1 or 2 years of age when
the infection can be very aggressive leading to
extensive destruction of soft and hard tissues.
 ANUG- Etiology
 Anaerobic Microorganisms:
• Fusiform bacilli
• Spirochetes.
 ANUG
 NUG is
characterized by
necrosis and
ulceration, which
first affect the
interdental papillae
and then spread to
the labial and
lingual marginal
gingiva
 ANUG
 The ulcers are
'punched out',
covered by a
yellowish-grey
pseudomembranous
slough, and
extremely painful to
the touch
 ANUG
 Pre-existing gingivitis; the tissues bleed
profusely on gentle probing

 The standard of oral hygiene is usually very

poor

 A distinctive halitosis is common in established

cases of NUG
 ANUG- management
 The patient is informed of the nature of NUG
and the likelihood of recurrence of the
condition if the treatment is not completed.

 Smokers should be advised to reduce the

number of cigarettes smoked.

 A soft tooth brush is recommended.

 ANUG- management
 Mouthwashes for a short-term (7-10 days)

• Chlorhexidine (0.2% for about 1 min) reduces plaque

formation, while

• Hydrogen peroxide or sodium hydroxyperborate

mouthwash oxygenates and cleanses the necrotic
tissues.
 ANUG- management
 Gentle mechanical debridement should be
undertaken at the initial visit.

 Metronidazole may be prescribed, but the

patients must be informed that they are
required to reattend for further treatment.
 Traumatic ulcer
 Is a form of acute or chronic injury that results
in removal of all epithelial layers

 Sharp or broken tooth, Orhtodontic wires…

 Lip biting following Local Anesthesia

 Traumatic ulcer- presentation
 Single
 Ill defined
 Painful
 Smooth surface
 Erythematous or whitish borders
 Usually heals with 7- 10 days
 May be asscoiated with intraoral buccal
ulceration
 Traumatic ulcer- management
 Removal of cause

 Symptomatic relief of symptoms with analgesics

(systemic or topical)

 Chlorhexidine gluconate (0.12%)

• No systemic antibiotics are indicated unless the lip

becomes secondarily infected

• No surgical intervention (e.g., incision and drainage) is

indicated
 Traumatic ulcer- management

 Hyaluronic acid
contaning gels combined
with polycarbophil
 provide:

 Pain relief

 Reduced healing time

 Recurrent aphthous ulcer (RAU)
 Also known as recurrent aphthous stomatitis
(RAS)

 The exact etiology remains unknown

 One of the most common oral lesions (10-30%)

of the general populaiton

 Usually occur after 6 years of age and recur at

intervals ranging from days to months to years
 RAU- presentation
 Occur on the non-keratinized mobile oral
mucosa (buccal mucosa, labial mucosa, tongue,
floor of the mouth, soft palate and uvula)

 Classified into minor, major and herpetiform

 Minor RAU
 The most common
 Shallow, round, 3-6 mm
painful ulcers
 Covered by a yellow
white membrane
 Surrounded by a red
halo
 Heal without scarring
within 6-12 days
 Major RAU
 Less common

 Deep larger 1-2 cm

extremely painful ulcers

 Lasts from 3 to 6 weeks

 Might leave a scar after

healing
 Herpetiform RAU
 Rare in children
 Small painful shallow
ulcers
 1-2 mm in diameter
 Occur in clusters
 Persist for 1 -2 weeks
 Heal without scarring
 RAU- Diagnosis
 Based on clinical features
 No special test
 Differantial diagnosis include:
 PHGS and other viral infections involving the oral
mucosa
 Crohn’s disease
 Behcet disease
 Traumatic ulcer
 PFAPA syndrome
 RAU- management
 Systemic analgesics
 Topical anesthetics
 Topical/ intralesional corticosteroids
 Systemic corticosteroids