Rebecca L. Slayton, DDS, PhD Department of Pediatric Dentistry University of Washington School of Dentistry  I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.  I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation.

 Recognize common pediatric oral pathology lesions  Understand the recommended treatment for lesions of the oral mucosa

– 3 y.o. female with painful, swollen gums for over 1 week duration – Systemic signs include fever, malaise and lymphadenopathy – Gums bleed easily – Gingival papilla appear blunted

Differential diagnosis: A. Primary herpetic gingivostomatitis B. Aphthous stomatitis C. Hand foot and mouth disease

 Causative agent is Herpes Simplex Virus Type I  Findings include vesicles on the mucosa, tongue and gingiva that rupture to form large painful ulcers  Lesions are accompanied by fever, malaise, cervical lymphadenopathy and anorexia  Lesions may be located on keratinized or non- keratinized tissues  20-35% of children are infected by 5 years of age  Transmitted via saliva  Diagnosis of HSV infection is usually made by a combination of clinical findings and by sampling an active lesion and testing it for the presence of the virus by PCR, direct fluorescent antibody methods, or viral culture.

 Difficult to perform thorough examination due to child’s discomfort and behavior  Initially no well-defined lesions  Language barrier/ phone interpreter not ideal  Child had developmental delay and was non- communicative  Symptoms were present for at least a week and not improving

 After 2 days as in-patient, lesions were visualized  Therapy  Symptoms generally last 7-10 days  Treatment should be palliative  Bed rest and antipyretics (acetaminophen or ibuprofen)  Maintain fluids  Young children may require hospitalization and I.V. fluids  Contraindications: antibiotics and steroids  For primary gingivostomatitis, acyclovir may be used.  Treatment should start within 3 days of symptoms  Duration of pain is reduced significantly  Time to loss of crust is reduced by 1 day  Dosage: 15 mg/kg by mouth five times daily for 7 days

P. Chayavichitsilp et al, Pediatr Rev 2009;30;119-130 Alter SJ et al, Curr Probl Pediatr Adolesc Health Care 2015;45:21-53 Red, swollen gums, perioral lesions

Ulcerations on tongue and lips

Symptoms may vary from one child to another PRIMARY HERPES PRIMARY HERPES

May be associated with erupting tooth.  Tissues in the mouth that are keratinized include:  Hard palate, attached gingiva  Lips, dorsal surface of tongue and skin around mouth  Non-keratinized tissues include:  Ventral surface of tongue, buccal and labial mucosa, soft palate – 8 y.o. male with painful vesicles and ulcers on his palate 4 days duration – No systemic manifestations – Otherwise in good health with no allergies and no medical diagnoses – Ulcerated lesions also present on fingers Painful Vesicles on palate  The Differential Diagnosis includes: A. Recurrent herpes C. Aphthous stomatitis D. Hand foot and mouth disease  Painful vesicles and ulcers  Often in clusters  Occurs on keratinized tissues  Recurs in same location – often triggered by cold, sunlight or stress  May have mild flu-like symptoms

Precautions should be taken to prevent spread of infection to susceptible individuals such as infants, and immunocompromised.  1% penciclovir cream 6 times daily at first sign of symptoms and then every 2 hours while awake for the next 4 days  For children over 12 years and adults, alternative therapies are valacyclovir (2000 mg by mouth twice daily) and famciclovir (1500 mg by mouth as a single dose). Short-term (1 to 3 days), high-dose acyclovir or valacyclovir regimens are promising therapies for both genital and orolabial recurrent HSV infections.

 Spruance SL, Jones TM, Blatter MM, et al. Antimicrob Agents Chemother 47:1072, 2003  Alter SJ et al, Curr Probl Pediatr Adolesc Health Care 2015;45:21-53

 10 y.o. female with painful ulceration on inside of cheek for 5 days.  Unable to drink orange juice due to discomfort  Parent reports a family history of “mouth sores”  Is diagnosed with ADHD and takes Ritalin  No known allergies to medications

Ulceration on buccal mucosa What is the most likely diagnosis? A. Erythema multiforma B. Recurrent herpes C. Primary herpes D. Aphthous stomatitis  Idiopathic  Acute onset  No systemic manifestations  Familial tendency  Single or multiple lesions  Painful  Self-limiting  Occurs on non-keratinized tissue

 30-40% prevalence  Higher SES more commonly affected  Immune system dysfunction  Dx is based on clinical presentation  If frequent and severe, rule out systemic disease  Sodium lauryl sulphate may induce ulceration in some patients

 Ship, JA Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Feb;81(2):141-7.  Woo, SB and Sonis, ST, J Am Dent Assoc. 1996 Aug;127(8):1202-13 Aphthous Ulcers

Found on: -Buccal mucosa -Labial mucosa -Ventral or lateral tongue Not Found on: -Hard palate -Gingiva -Dorsal tongue -Lips -Perioral region

 Treatment options:  Palliative – avoid additional trauma to area  Kenalog (Triamcinolone acetonide) in Orabase 0.1%  Disp. 15 gm  Apply to affected area q.i.d.  Triamcinolone 0.1% rinse – 5cc q.i.d.  Topical Steroids reduce symptoms but not rate of recurrence

 Celiac disease  Crohn disease  Behcet syndrome  Human immunodeficiency virus  8 y.o. female with cerebral palsy and developmental delay.  Mother is concerned about a red swollen area on the child’s gums that bleeds when brushing her teeth.  Lesion has been present for 1 week  Child is in no apparent distress  Patient is not taking any medications and has no known allergies  Mother reports that the child has a habit of putting her fingers in her mouth which has increased in frequency lately Red, broad based lesion on the marginal gingiva that bleeds easily The most likely diagnosis is: A. Peripheral giant cell granuloma B. Dental abscess with draining fistula C. Hemangioma D. Pyogenic granuloma  Characteristics:  Red or bluish in color, bleeds easily  Pedunculated or broad based  Soft and friable  Non-tender  Located on gingiva, lips, tongue or buccal mucosa

Pyogenic Granuloma

Etiology: Treatment:

-Connective tissue reaction to -Excisional biopsy injury or other stimulus -Identify an eliminate -Hormonal changes/puberty source of trauma

-Composed of hyperplastic -Frequently recurs granulation tissue

-More common in females Pyogenic Granuloma  11-month-old male with Down syndrome presents with ulcerated soft tissue enlargement under his tongue  Lesion has been present and worsening for the past 6 weeks and is interfering with feeding  Child has a repaired atrial septal defect  No known allergies to medications  Patient has been off the bottle for a few months and is using a sippy cup  Parent has consulted the child’s pediatrician over the past few months due to concerns related to his difficulties feeding and slow weight gain Ulcerated sublingual mass The most likely diagnosis is: A. Sublingual ulceration (Riga Fede Disease) B. Ranula C. Irritation fibroma D. Sublingual granuloma  First described by Italian physicians Riga and Fede in the 19th century  May be seen in neonates with natal teeth or in children with repetitive tongue movements  Also referred to as sublingual granuloma or traumatic sublingual ulceration

Riga Fede Disease

Etiology: -Due to irritation from lower Treatment Options: incisors -Smooth edges of teeth with dental handpiece -Occurs in neonates with natal teeth -Bond composite filling material to incisal edges -Occurs in infants from some types of feeding -Modify feeding method behaviors -Extract teeth

-Surgically excise lesion Before 1 Month Follow-up

 This 6 year old female presents for dental care with no complaints.  She is being evaluated for biobehavioral disorder and developmental delay.  History of petite mal seizures  5 y.o. female with lower lip swelling  Lower lip is red and swollen 1 hour after routine dental appointment that included inferior alveolar nerve block, rubber dam isolation and restoration of primary teeth

 Patient is alert and in no distress  Patient currently undergoing inpatient evaluation for biobehavioral disorder (BBD) and developmental delay  Mild asthma not requiring treatment  Current medications  Clonidine 0.1mg HS  Allergic to Ritalin, Alderol and Dilantin  Clinical Findings (1 hour):  Diffuse soft swelling of the bilateral lower lip  Clinical Findings (6 hours)  Diffuse soft swelling of the bilateral lower lip with areas of shallow ulceration  What is the most likely cause of this lesion? A. Latex allergy B. Allergy to lidocaine C. Traumatic lip biting resulting from local anesthetic D. Angioedema

 A severe swelling that can result from an allergic reaction or from trauma  May be limited to a small area such as the lip or may be more widespread involving the face and neck  Edema that is non-pitting & self-limited  Often occurs with urticaria but can be isolated  Affects deeper dermis and subcutaneous tissues  Causes:  Drugs  Allergens  Trauma  Foods  Infections  Physical factors – cold, heat, vibration  Administer diphenhydramine and monitor for signs of swelling or airway distress  Refer to pediatrician if needed  If severe, Prednisone 15 mg bid for 5 days and expect to see improvement in 24 hours  Angioedema was treated by physician with prednisone 15 mg bid for 5 days.  Swelling diminished considerably within 24 hours  Subsequent dental treatment 2 months later without post-operative complications

Benign Migratory Glossitis (Geographic Tongue)

-Usually asymptomatic

-central portion is red with a white, hyperkeratotic margin

-may disappear and recur

Tx: No treatment necessary. If lesions are painful, test for candida.  Bohn’s nodules  Epstein pearls  Congenital epulis  Natal teeth Bohn’s nodules

-Firm, non-painful nodules -Present on the buccal surface of the alveolar ridge -Present at birth -Remnants of dental lamina -If in the midline of the palate, called Epstein pearl -Will resolve on its own

Epstein’s Pearl Natal and Neonatal Teeth

-Mineralized tooth-like structures present at birth or shortly thereafter

-May interfere with feeding

-Usually are the primary incisors

-Recommend extraction if they interfere with feeding  7 y.o. male, normally developed in no distress  Mother is concerned about swollen, bluish-red area of gum tissue where the permanent incisor should be  There has been no trauma to this area and it is asymptomatic Bluish/red gingival enlargement on the alveolar ridge.  Sometimes associated with tooth eruption

 Requires no treatment – will resolve as the tooth erupts

 Frequently seen in children who are tube fed  Common lesion of the oral mucosa  Most common cause: Local trauma  Non-tender, fluctuant dome shaped mucosal swellings  1 – 2 mm to several cm’s in size  Most common in children and young adults

 Rupture of salivary gland duct with spillage of mucin into surrounding tissues  Some have bluish translucent hue due to mucin being superficial  Those that are deep exhibit normal color  Separation of epithelium from connective tissue

 Duration: days to years  60 – 75% on lower lip  Lateral to the midline  Also found on:  Buccal mucosa  Anterior ventral part of the tongue  Soft palate  Most mucoceles are short-lived, rupture, and heal by themselves  Those that are chronic require local excision  Also, to prevent recurring, remove adjacent salivary glands that feed the lesion  5 year old female was referred to the hospital by her physician for evaluation of an ulcerated lip lesion.  She is normally developed, alert and in no distress, other than lip tenderness.  She is not allergic to any medications and is not currently taking any medications.  The lesion is ulcerated and located on the left side of the lower lip  Parent reports that the child had a dental appointment the day before and is concerned that this might be an infection  18% of children less than 4 years of age experience soft tissue trauma following mandibular block anesthesia (Chi et al, 2008)  Advise parents to monitor children closely to prevent lip biting  If trauma occurs, manage with analgesics, cold compress, salt water rinses  Expect healing in 1-2 weeks  Antibiotics are not indicated Post Local Anesthetic Lip Biting

T. White, DDS – U.Oklahoma Health Science Ctr.  Amir J. Clinical aspects and antiviral therapy in primary herpetic gingivostomatitis, Paediatr Drugs 3(8):593-7, 2001.  Raborn, GW et al. Effective treatment of herpes simplex labialis with penciclovir cream: combined results of two trials. J Am Dent Assoc, 133(3):303-9, 2002.  Whitley RJ. Herpes simplex virus infection, Semin Pediatr Infect Dis, 13(1):6-11, 2002. • P. Chayavichitsilp et al. Herpes Simplex. Pediatr Rev 2009;30:119-130.  Chi D et al. Lip biting in a pediatric dental patient after dental local anesthesia: A case report. J Pediatr Nurs 23(6):490-493.  Alter SJ et al. Common Childhood Viral Infections. Curr Probl Pediatr Adolesc Health Care 2015;45:21-53.