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Home , Dens evaginatus, Dentin dysplasia, Enamel pearl, Leiomyoma, Oral allergy syndrome, Pericoronitis

A Mixed Bag of Oral Lesions in Oral Lesions in Schoolchildren Tots & Teens: Diagnostic Tips • Aphthous ulcers • Gingival hyperplasia & Treatment Options, #2 • migrans • Melanotic macule • • Mucocele • • Tumors, NOS Catherine M. Flaitz, DDS, MS • Cheek-biting/linea alba • Hemangioma/vascular malformation Professor, Division of • Traumatic Pediatric • Papilloma, verruca • Purpura The Ohio State University vulgaris College of Dentistry • , angular • Overall Prevalence: 27.5% Associate Chief of Dentistry Nationwide Children’s • Commissural pits April 2018 Hospital • Fordyce granules Fehmida, Flaitz, et al. AAPD abstract, 2014

Soft Tissue Enlargements Papillary Surface Enlargements . Papillary or stippled surface . Papillary Surface Enlargements . Spongy to firm, rough to palpation . Acute Inflammatory Enlargements . Usually pink or white in . Reactive Hyperplasias . Moderate growth rate . Benign Submucosal & . Limited growth potential . Many caused by HPV . Aggressive & Malignant . May resolve spontaneously Neoplasms . Common lesions

Squamous Papilloma Verruca Vulgaris . Type: HPV 6,11 . Cause: HPV 2, 4 . Sexual, nonsexual . Prevalence: 10-50% of children transmission . Site: Hands, face are common . Incubation: 3 wks – 2 yrs . Oral Site: Lip, labial mucosa, anterior tongue . Comprise 8% of all oral . S/S: Nodule with fingerlike projections or growths in children rough, pebbly; pink, brown or white; painless . Site: , tongue, . TX: Remission – 20% in 6 mos; 65% in 2 yr; . S/S: Solitary, pink, red, or excise, laser, cryotherapy, cimetidine, white papillary nodule salicylic acid, duct tape, imiquimod, other . Tx: Excise; not precancerous . Prognosis: Recurs, no malignant potential

1 Verruca Vulgaris What Else Is In The Bag?

Labial mucosa Thumbs . Verruca vulgaris . Squamous papilloma . Condyloma acuminatum . Multifocal epithelial hyperplasia . Giant cell . Localized juvenile spongiotic gingival hyperplasia . Inflammatory papillary hyperplasia Note the mucocele from biting lip and nails . Molluscum contagiosum

Condyloma Acuminatum Condyloma Acuminatum . Cause: HPV 6, 11 (90%), 16, 18 and others . Occurs in 1% of sexually active individuals . Incubation period: 1 to 3 months . Site: Anogenital and . Oral Site: Labial mucosa, palate, ventral tongue . S/S: Pink nodules with short, blunted projections; painless; usually multiple In children may indicate: . TX: Excision, laser, imiquimod cream, other  Vertical transmission  Direct contact . Prognosis: Recurs, malignant potential  Sexual abuse (anogenital)  Sexual activity

Condyloma Acuminatum Multifocal Epithelial Hyperplasia . Cause: HPV 13, 32 . Age: Usually childhood . Risk: Genetic susceptibility (HLA-DR4 in Mexicans), lower SES, malnutrition, vitamin K deficiency, poor hygiene; HIV infection in adults . Site: Buccal, labial mucosa, tongue . S/S: Multiple, soft, , nodules; pink or white in color; clustered or cobblestone pattern . TX: Regression (18 mos), excision, laser, cimetidine, interferon, other . Prognosis: Recurs, no malignant potential

2 Multifocal Epithelial Hyperplasia Multifocal Epithelial Hyperplasia

• Infectious – HPV 13/32 • Site: Anterior oral mucosa Mimics: • Nontender, unless trauma  Hamartomatous syndromes • Mimics: Condyloma  Crohn’s disease

Oral HPV in Children Acquisition of Oral HPV . Detection in newborns: 4-87% when . Transmission: Casual & sexual contact, vertical, mother has HPV cervical infection and autoinoculation . (Syrjanen S et al, 2000) . Breast milk – 4.5% (Giovannelli, 2002) . Overall pediatric prevalence: 2% . Placental HPV = 4.5%; Cord blood HPV = 3.5% . Adolescents: 2.5% for HPV 16/18 . Both ↑ risk for oral HPV at birth:12.2% (Rombaldi, 2008) . (Flake C, et al 2012) . Persistent infection in mother increases risk of HPV infection in infants (OR = 5.7) . Contaminated toys – 4% (Roman & Fife, 1986) . Presence of oral in children are uncommon

HPV Vaccine New Stats Pulled From The Bag . Gardasil© (Merck): Quadrivalent vaccine to prevent cervical and anogenital warts . Protects against HPV types 6,11,16,18; cause 70% of and 90% of genital warts . Gardasil© 9 (Merck): HPV 6,11,16,18,31,33,45,52,58 . Recommended for females and males, ages 11-12 with range of 9-26 yr . Cervarix© (GlaxoSmithKline): Bivalent vaccine; Protects against HPV types 16, 18 . Protective role in oropharyngeal cancer? High-risk Oral HPV: 7 million men and 1.4 million women . ↓ prevalence of oral HPV in vaccinated women Herrero R et al 2013

3 Focal Gingival Focal Gingival Micropapillomatosis Micropapillomatosis • Fibroepithelial hyperplasia • Cause: Chronic irritation, cig smoking, anatomical, lip incompetence • Site: Attached gingiva, esp, anterior maxillary gingiva • S/S: Pink-white to light brown pebbly attached gingiva; nontender • TX: ID cause; mimics warts

Diffuse Micropapillomatosis of the Gingiva Giant Cell Fibroma . Diffuse, widespread . Type: Fibrous reactive hyperplasia gingival pattern . Age: Children and young adults . PTEN hamartoma tumor syndrome . Cause: Unknown - not related to trauma . Cowden syndrome . Site: 50% on gingiva; tongue and palate . Bannayan-Riley- Ruvalcaba syndrome . Oral: Pink nodule with papillary or smooth . ASD with macrocephaly surface; nontender . Drug-induced gingival . TX: Excision overgrowth Celentano A, JADA 145(9), 2014 . Developmental lesion: Retrocuspid papilla . Risk for malignancies in syndrome

Giant Cell Fibroma Giant Cell Fibroma

Facts:  Not HPV-induced  Occurs on keratinized tissues  50% located on gingiva June 2013 October 2013 Dr. Urvi Jadav

4 Localized Juvenile Spongiotic Retrocuspid Papilla Gingival Hyperplasia (LJSGH) . Distinct, new subtype of gingival hyperplasia . Other names: Juvenile spongiotic or juvenile gingival papillomas . Origin: Sulcular/junctional epithelium . Cause: Unknown – not strong biofilm association; cervical enamel irregularities • Developmental anomaly . Factors: (15%), eruption, lip • Site: Lingual gingiva, canine incompetence/mouthbreathing, puberty • Nontender swelling • Usually regresses with age . Age/Gender: Ave = 12 YO (range 5-39)/ F>M

Localized Juvenile Spongiotic Gingival Hyperplasia LJSGH • Site: Anterior facial Post-treatment: gingiva, esp. maxillary Improve (84%); may be multifocal Scale and curettage rinse • S/S: Papillary, red nodule or velvety - granular patch; bleeds easily; nontender • Minimal response to OH

Pre-treatment • TX & Prog: Biopsy; 6-16% recur in 1 yr; may resolve • Chang J et al, OOOOE 2008:106:411-8 Velvety pattern Photo: Dr. Golnar Jahanmir

Localized Juvenile Spongiotic Localized Juvenile Spongiotic Gingival Hyperplasia Gingival Hyperplasia

Velvety pattern was tender when brushing Papillary pattern Excisional biopsy – 1 month post-op

5 Fimbriated Fold of the Tongue Fibrosing Parulis Mimics a . Normal anatomy . Bilateral and parallel on ventral tongue and adjacent to lingual veins . Slender tissue tags may be present; may be tender if irritated . May mimic oral warts NB: Lesions on the gingiva Fimbriated fold – take a radiograph . No treatment

Chronic Hyperplastic Tonsillitis Hyperplastic Foliate Papillae . Enlarged tonsils . Benign lymphoid with multiple hyperplasia tonsillar tags . Posterior lateral tongue; . Mimics often bilateral oropharyngeal . May increase in size and warts be tender . Large size may be . Important site associated with obstructive sleep . Mimics: , soft apnea fibroma, , pyogenic , wart

Oral Lymphoid Hyperplasia Acute Inflammatory Enlargements . Smooth to ulcerated surface . Red, white, blue color . Diffuse to localized swelling . Rapid onset (hours to days) . Tender or painful to palpation . Compressible, fluctuate in size . Fluid, semisolid contents with Oral lymphoid aggregates: periodic drainage • Floor of mouth • Ventral & posterior tongue . Cause is usually apparent • Soft palate . Very common lesions

6 Abscess (Parulis) Atypical Abscess . Localized infectious process . May be more diffuse . Cause: Dental, periodontal, . May be associated foreign body with ulcer . Site: Usually gingiva and . May be located at a alveolar mucosa distant location . S/S: Acute onset; painful, pink or red nodule; purulent . Enlargement of the drainage; fluctuates in size buccal . TX: Manage source of . May not see obvious infection; +/- reason . Complication: . May require a biopsy

Soft Tissue Abscess Gingival Abscess due to LLHA

HX: Recent URI and sinusitis Palatal space abscess Actinomycotic infection Recurrent HSV ulcer Subtle radiographic findings

Chronic Gingivitis & Abscess Cervicofacial

Extraoral drainage from nonvital molar Gingival abscess Difficult to treat: Poor oral hygiene  Debride sinus tract Dental erosion  Long-term antibiotics Slow eruption of teeth  Manage nonvital tooth

7 Dens Evaginatus . Cusplike enamel in central groove or lingual ridge of buccal cusp of or molar . Bilateral mandibular ; rare in primary molars . Prevalence: 1-4% . Ethnicity: Asian, Native Amer . Associated: Shovel-shaped  Facial cellulitis,  Crenations on buccal mucosa . Complication: Pulpal necrosis,  Violaceous gingival swelling abscess, esp with enamelopasty  Check contralateral side

Foreign Body Lesion Ring around the collar? . Common for children to put things in their mouth . Material with flat or convex surface; suction effect . Examples: shells, broken toys, parts of bugs, popcorn hulls Popcorn hull mimicking an . Site: Palate, gingiva abscess . May cause a foreign Photo: Dr. Jerry Bouquot body reaction Photos: Dr. Anne O’Connell

Pericoronitis Necrotizing . gingival lesion . Factors: Food, , stress, cement, resin, , viral infections . Site: Mand perm molars . S/S: Pain, foul taste, restricted opening, referred pain, redness, swelling of , cellulitis, , lymphadenopathy . Some cases represent a localized form of NUG

8 HSV Operculitis Pericoronitis . Treatment Options: Identify and eliminate . Acute onset cause, lavage, saline rinses, . Very painful excise tissue, curettage, +/- extract tooth . Clusters of vesicles . No antibiotics unless fever, and punctate ulcers lymphadenopathy, , facial swelling . Significant swelling . Antibiotics: . Amoxicillin: good drug . Irrigate but do not debride the area . Augmentin: beta-lactamase-producing bacteria . : alone or in combination with amoxicillin or Augmentin for broader coverage

What Else Can Be In The Bag? New Infection in US: Chagas . Abscess/Pericoronitis . Parasitic disease: Triatomine insect (kissing bug) – Trypanosoma cruzi infection . . Transmission: bug bites, insect feces, congenital, . Subacute necrotizing organ and blood products; foods/beverages (rare) . Found in Central & South America: 8-12M infected . Tonsilithiasis (est 300,000 in US) . Acute symptoms: weeks - months → Chronic: years . Lymphoepithelial . S/S: Acute: Swelling of eyelids, cutaneous . erythematous nodule, often on face . Eruption sequestrum . S/S: Chronic: 30% develop cardiac arrhythmia, congestive heart disease, dilation of , colon . Neonatal cysts . TX: Benznidazole, just approved for children

Romana’s Sign: Marker for Acute Chagas Cat-Scratch Disease . Infectious disease caused by Mimics Bartonella henselae; 22,000  Odontogenic cellulitis  Acute sinusitis cases/year www.cdc.gov  Insect bite on face . Transmitted by scratch, bite or  Allergic reaction lick; 40% of cats carry bacterium . S/S: Regional lymphadenitis, fever, malaise, anorexia . Lymphadenitis resolves - 2-4 mo . Tx: Symptomatic; +/- antibiotics; azithromycin for 5 days; others

www.WHO.org . Complications may develop

9 Cat-Scratch Disease Cat-Scratch Disease

Eruption Sequestrum Eruption Sequestrum . Dysplastic within . Site: First and second permanent molars . S/S: Bony fragment in the operculum; gingiva may be inflamed and tender; may be multiple . X-ray: Small opacity overlying of molar . TX: Most spontaneously exfoliate; curettage

Odontoma . Common odontogenic lesion . Age: mean age is 14 YO . Site: > . S/S: Delayed eruption; +/- expansion . X-ray: Compound: tooth-like; Complex: calcified mass; S/S radiolucent rim; may be cystic Delayed eruption of premolar  Mild expansion of bone

. Tx & Prog: Excision, do not  Increase in interproximal space recur  May partially erupt  Displace developing teeth

10 Erupted Odontoma • Small, spherical particles of cementum of unknown cause • Types: – Free: lie free in PDL – Attached: superficial attachment to root surface – Embedded: incorporated Mimics: into the cementum layer  Microdontic tooth  Accessory cusp • Mimics: Small odontoma, root  Foreign body fx, stone, ,  Eruption or bone sequestrum foreign body

Molar- Malformation Molar-Incisor Malformation . Newly described dental anomaly . Involves molar root malformation and incisors . Cause: Disruption of Hertwig’s epithelial root sheath; epigenetic factors associated with systemic disease at 1-2 yr . Maxillary incisors: cervical hypoplastic notch . First perm molars, second perm molars and primary second molars: normal crowns, . Central incisors: Cervical constricted cervical region, thin narrow and . Molars: Normal crowns, short slender roots, short roots cervical constriction, pulpal obliteration . 1-4 molars affected . Mimics isolated dysplasia, I

Molar-Incisor Malformation Lymphoepithelial Cyst . Type: Developmental lesion . Cause: Entrapped epithelium within lymphoid tissue  cystic degeneration . Site: Floor of mouth, tongue, soft palate, tonsillar region . S/S: Persistent, yellowish- white nodule; discharge of contents occasionally Symmetric multiquadrant isolated (SMIDD), a unique presentation mimicking dentin dysplasia type 1b (Qari H, et . TX: Observe; excisional al. OOOO 2107;123(5):e164-e169) biopsy

11 Lymphoepithelial Cyst Tonsillar Crypt Plugs . Cause: Aggregates of cells, debris, bacteria . Factors: Anatomy of tonsils, dry mouth . Site: Pharyngeal tonsils . S/S: Creamy white aggregates; soft to firm; may be irritating, halitosis . TX: Dislodge by irrigation, coughing or gargling

Tonsillar Crypt Plugs (Tonsilliths) Mucoceles . Type: Reactive lesion of salivary glands . Cause: Trauma to ducts and glands . Age: Children and young adults . Site: Lower lip (81%), buccal mucosa (5%), ventral tongue (6%), floor of the moth (6%) . S/S: Translucent blue, fluid-filled swelling; fluctuates in size; may be tender . TX: Excisional biopsy with adjacent glands; 40% spontaneously resolve; recur – 6% . Variant: – floor of the mouth

Pedunculated Mucocele Sessile Mucocele

12 Mucocele Small Mucocele

 Midline ventral tongue Mucocele is not  Glands of Blandin-Nuhn directly associated with lip piercing, but possible secondary development due to lip swelling or playing with the oral jewelry Photo: Dr. Jerry Bouquot

Ranula Elevated Sublingual Glands

. Anatomical variation  Involves the . Bilateral and symmetrical, bilobed with pink smooth surface  May be translucent pink, blue or red . Painless unless traumatized  Usually not tender, but interferes with eating and speaking . Make sure of patent ductal opening  Do not incise and drain it . Rule out other diseases, especially if unilateral  May progress to plunging ranula . Tx: None required

Angioedema . 2 categories: histaminergic, nonhistaminergic . DX: ID cause, testing . Usually due to mast cell degranulation or IgE- mediated reaction . Mild cases: (Benadryl, hydroxyzine) . Hereditary form: AD; C1-INH deficiency . Severe cases: IM . Triggers: Drugs, foods, plants, inhalants, heat, epinephrine; IV steroids cold, latex, physical stimuli, infection, stress, sun and . Site: Extremities, face, lips, tongue, trunk, . C1-INH deficiency: genitals, , larynx Danazol, stanozolol for . S/S: Rapid onset, nontender swelling, itching, prevention; ecallantide, erythema; single or multiple; lasts - 24-72 hrs icatibant

13 Angioedema & Infection Drugs Causing Angioedema . ACE inhibitors . Buproprion . PCN, Cephalosporins . Selective serotonin reuptake inhibitors . COX-2 inhibitors . NSAIDs & Aspirin . Angiotensin II receptor antagonists Rule out:  Hypothyroidism . Statins 

Reactive Hyperplasias Pyogenic Granuloma . Smooth to undulating . Cause: Exuberant response to surface local irritation . Pale to red +/- ulcerated . Age/Gender: Children, F > M . Nodular in shape . Site: Gingiva > lips > tongue > . Moderate growth rate buccal mucosa . Nontender . S/S: Red soft nodule; ulcerated . Soft to firm to palpation surface; bleeds; nontender . Limited growth potential . TX: Biopsy; remove irritation Irritation Fibroma . Recur, if cause not removed . Variants: Pulp polyp, granulomatosum, pregnancy . Very common lesions tumor

Pyogenic Granuloma Gingival Hyperplasia Fibrosed Granulation Irritation Fibroma Tissue

14 Tongue Piercing What Else Is In The Bag? . Pyogenic granuloma . Irritation fibroma . Giant cell fibroma . Peripheral ossifying fibroma . Peripheral giant cell fibroma . Pericoronal odontogenic

©Photo: Dr. C.D. Johnson, University of Texas, Houston, Texas hamartoma . Soft tissue abscess

Peripheral Giant Cell Granuloma Peripheral Giant Cell Granuloma . Reactive hyperplasia – PDL, periosteum . Age/Gender: 2nd decade; F>M . Site: Attached gingiva, alveolar mucosa . S/S: Nontender, firm nodule; red, purple and ulcerated, +/- resorb bone, displace teeth . TX: Excision; 10% recur; rare sign of hypoparathyroidism

Traumatic Neuroma Traumatic Neuroma . Reactive growth of neural tissue following . Cause: Trauma, surgery, extracted tooth, appliance . Site: Mental foremen, tongue, lower lip . Age: Wide age range . S/S: Pink, smooth nodule; dysesthesia; 1/3 are painful Helpful hint: . TX & Prog: Excise; no Tender when palpate the nodule recurrence

15 Benign Cysts & Neoplasms . Dome-shaped enlargement . Vascular . Smooth surface of variable color . Age/Gender: 4-10% of 1 YO; F>M . Solitary lesion with well-defined margins . Site: H & N = 60%; lips, tongue . Nontender and movable to palpation . Growth period: 6-10 months . Slow growth rate . S/S: Red or blue, flat or nodular . Unlimited but localized growth lesion; +/- blanches; 20% are multiple; favor fusion lines Dr. Ron Acquaro . Distort anatomical contours . TX: Involution begins 18 mos; . Uncommon lesions 50% by 5; 90% by 9yr; steroids Hemangeal (propranolol), laser, excision

Hemangioma Hemangioma

Complications: Ulcer, bleeding, infection, scar, NB: Increased vascularity may persist despite change in color displacement of teeth (40%)

Vascular Malformations Cherry Angioma . Superficial vascular lesion . Cause: Trauma in children . Gender/Age: Males > 5y . Site: Vermilion of lip . S/S: Red, blue, purple ; blanches . TX: Laser, sclerosant or NB: Do not involute excise; no involution Photo: Dr. Robert Delarosa . Cosmetic concern

16 Labial Cherry Angioma Caliber-Persistent Labial Artery . If multiple, rule out . Abnormally dilated artery syndrome . Age: Adolescents . Hereditary hemorrhagic . Site: Upper > Lower lip telangiectasia . S/S: Tubular to nodular elevation; pink to blue; pulsatile; disappears when stretched . TX: None required unless symptomatic . Problem: Brisk bleeding

What Else Is In The Bag? Lymphangioma . Soft Neoplasms . Lymphatic malformation . Lipoma . Age: 50% birth; 90% by 2y . Orofaciodigital syndrome . Site: 50-75% in H&N; . Hemangioma tongue . Lymphangioma . S/S: Pebbly, pink, red or purple vesicles; diffuse . Plexiform swelling; “frog eggs” . Neurofibromatosis . Does not blanch or involute . Mucoepidermoid . TX & Prog: Excision; recurs carcinoma

Lymphangioma

Complications: , airway obstruction, , rapid enlargement with URI, disfigurement,

17 Eruption Cyst & Hematoma Eruption Cyst . Soft tissue analogue of . Cause: Separation of dental follicle from crown of erupting tooth; surface trauma with bleeding . Age: Most occur in first decade . Site: Any site, especially maxillary incisor region and mandibular molar region . S/S: Amber, red or blue soft tissue swelling; may be tender . TX: Spontaneously resolves; simple excision if delayed eruption Photo: Dr. Greg Whelan

Eruption Cyst & Hematoma Eruption of Primary Teeth . Gingival erythema: 50% of teeth . Gingival swelling: 12% of teeth . Significant signs are uncommon . Oscillating eruption Herniated dental follicle pattern  When red, blue or purple  Unusual site because exclude a vascular lesion tooth is erupting . Time: Mean of 2 months  If treat, take radiograph ectopically for tooth to erupt

Herniated Dental Follicle Herniated Dental Follicle . Eruption of part of the dental follicle . Usually primary teeth . S/S: Nontender, red, white or amber in color . Bleeds with manipulation . TX: None needed; most resolve as tooth erupts . Mimics: Pyogenic granuloma, abscess, tooth

18 Ebinyo: Infant Oral Mutilation Ebinyo . East African therapy practiced by “healers” . Infants: 4-18 months . Infections, , , fever, convulsions . Germectomy of primary canines to remove parasite - “mouth worms” ID: 8 YO Somali boy . Nonsterile, hot Radiographic findings: Missing primary & permanent instruments or fingers maxillary canines

Ebinyo Herniated Buccal Fat Pad . Also known as traumatic pseudolipoma . Cause: Intraoral or facial injury . Age: Usually young children . Site: Buccal mucosa below the papilla, along occlusal plane . S/S: Diffuse to localized swelling; pinkish- yellow or red and ulcerated; pedunculated Complications: extrusion of fat; mild facial swelling  Missing permanent first premolar,  Malformed perm canine, primary 1st molar . TX: Reposition if early and small defect;  Hypoplastic lateral incisors and canine excise if large and necrotic

Herniated Buccal Fat Pad What Else Is In The Bag? . Firm Enlargements . . . Schwannoma & Neurofibroma . & Leiomyoma . Benign fibrous Herniated through mucosa Herniated through muscle .

19 Congenital Epulis Congenital Epulis . Benign congenital tumor . Age/Gender: Newborn; 90% ♀ . Site: Max > Mand alveolar ridge . S/S: Nontender, firm, pink to red polypoid mass, smooth surface; 10% are multiple . TX: Excision; may regress

Minor Tumors Salivary Gland Tumors . Prevalence: 5% of salivary gland tumors occur in children . Higher proportion are malignant: 46% - 55% . Age/Gender: Mean = 15 YO; F > M . Site: Hard palate – most common site . S/S: Slowly growing nodule; nontender . Common benign lesion: Pleomorphic adenoma . Common malignancy: Mucoepidermoid ca . TX: Surgery +/- radiation and chemotherapy . 5-year survival rate: 89% – 95% Pleomorphic Adenoma

Melanocytic . Type: Benign proliferation of nevus cells . Age/Gender: 15% of oral nevi occur in children; may be congenital (10%); F > M . Site: Palate, buccal mucosa, gingiva, lip . S/S: Pink, brown, blue or black macule or nodule; 85% pigmented; 70% elevated . Most common types: Intramucosal, blue . TX & Prog: Excisional biopsy; rare malignant transformation

20 Dysplastic Nevus What Else Is In The Bag? . Melanocytic nevus . Melanotic macule . Amalgam or lead tattoo . Drug-induced pigmentation . Physiologic pigmentation . Inflammatory melanosis . Smoker’s melanosis Melanotic macule . Late petechiae, purpura

Papillary Tip Melanosis Papillary Tip Melanosis • Pigmented fungiform and filiform papillae • Cause: Unknown, normal pigmentation, post-inflammatory melanosis • Starts in childhood; may be congenital • Ethnicity/Race: Hispanic, Black, Asian • Tx: None Ref: Adibi S et al, 2011

Congenital Melanotic Congenital Melanotic Macule of the Tongue Macule of the Tongue . Benign pigmented • Focal increase in melanin mucosal lesion • TX: None required . Age: At birth • Mimics: . Ethnicity: White – Papillary tip melanosis, . Site: Dorsum – Congenital melanocytic nevus . S/S: Brown, blue- black macule; single – Smoker’s melanosis or multiple; 1-2 cm – Epidermal choristoma . Behavior: Static, – Atypical melanocytic proliferation grows with child Savoia et al, 2015

21 Atypical Melanocytic Silver Diamine Flouride: Proliferation Soft Tissue Effects occurs in children • Rare allergic reactions Worrisome features: • .1% gingival irritation . Congenital lesion that increases in size • Temporary discoloration on mucosa & skin (2-14d) . Large size • Bad taste . Very dark color . Asymmetric margins • Prevention: . Surface changes – Apply Vaseline around the skin and lips . Overlap features of benign 3 YOM Asian-Indian and malignant Photo: Dr. Priyal Ohri – Good isolation of teeth

Minocycline Pigmentation Pigmentation . Cause: Drug binds to certain types of collagen  pulp, dentin, bone, nails, , sclera . Purpose: Primarily used to treat . Prevalence: 3-6% of chronic users; 15% - acne . Develops: 1 month to several years of use . Site: Ant alveolar mucosa, hard palate, teeth . S/S: Diffuse blue-gray to muddy brown . TX: DC med  soft tissue fades; permanent

Drugs & Doxycycline for Young Children • : Minocycline, . Teeth staining with use of to young children • Pepto-Bismol and others with bismuth (extrinsic staining) . No evidence of teeth staining following multiple short courses • Antimalarial meds: chloroquine, of doxycycline hydrochloroquine, quinidine . When doxycycline is treatment • Estrogen of choice for a serious infectious disease, it should be given • Antipsychotic drug: chlorpromazine regardless of age. • Chemotherapy: doxorubicin, busulfan, . AAP Red Book 2018 cyclophosphamide, 5-fluorouracil

22 Aggressive & Malignant Neoplasms Burkitt’s . Asymmetric enlargement . Type: Rare, B-lymphocyte malignancy . Usually red and ulcerated . Age/Gender: Children; M > F . Firm, indurated and fixed . Poorly defined, infiltrative . Site: Posterior mandible; may be multiple margins . S/S: Lymphadenopathy, facial & gingival . Pain, paresthesia, swelling, tenderness, tooth mobility & loss lymphadenopathy . Moderate to rapid growth . X-ray: Ill-defined radiolucency; floating (weeks to months) tooth appearance . Tissue destruction . TX & Prognosis: Multiagent chemotherapy; . Potential for metastasis 75%-95% 5-yr survival rate

Burkitt’s Lymphoma Burkitt’s Lymphoma Radiographic findings . Post maxilla & mandible . Single or multiple quadrants . Painful swelling . First signs often tooth mobility . Floating tooth appearance . Loss of the lamina dura . “Moth eaten” radiolucency . Periosteal bone formation

What Else Is In The Bag? Langerhans Cell Histiocytosis . Leukemia . Type: Neoplastic disease of myeloid cells - localized and disseminated forms . Lymphoma . Age: Young children; most are <10 yrs-old . Langerhans cell . Site: Multisystem disease in children; any histiocytosis bone; skull, mandible are common; jaws are affected up to 20%; skin, lung, liver, spleen . Metastatic disease . S/S: Ulcers, gingival masses; pink teeth . Systemic disease . X-ray: Periapical radiolucencies; “floating in air” appearance; internal . . TX: Curettage, chemotherapy

23 Langerhans Cell Histiocytosis Pink Tooth & Floating Tooth

Pink teeth:  Internal inflammatory resorption  Trauma, idiopathic  Dental anomalies Hicks J, Flaitz C. OOOOE, 2005  Vitamin D-resistant rickets  Tumor infiltration

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