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Orthodontics and Oral Mucosal Lesions in Children and Teenagers

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Orthodontics and Oral Mucosal Lesions in Children and Teenagers DOI: 10.1051/odfen/2018056 J Dentofacial Anom Orthod 2018;21:207 © The authors Orthodontics and oral mucosal lesions in children and teenagers L. Sicard1, L. Benmoussa2, N. Moreau3, B. Salmon3, A.-L. Ejeil3 1 DESCO 2 AHU 3 MCU-PH Oral Medicine Department of Bretonneau Hospital, Paris Our gratitude to the Orthodontic Department for providing the iconography for this article SUMMARY Children and teenagers with orthodontics may be affected by infectious, hereditary, traumatic, malig- nant, or idiopathic oral mucosa lesions. Orthodontists have to be able to detect, identify, and treat effec- tively or to address the patient to a specialist. Here we discuss this difference to make their diagnosis and management easier for the practitioner. KEY WORDS Oral mucosa, orthodontics, oral appliances, oral lesions INTRODUCTION The estimated prevalence of oral mucosal a greater risk of traumatic or reactive le- ­lesions is 8%–60% in the general popu- sions18. These are either treatment-induced lation1,8,17,2. In children and adolescents, it or of allergic origin. ­increases with age. The causes can be infec- The diagnosis of oral mucosal pathologies tious, ­hereditary, malignant, idiopathic, or iatro- is based on a rigorous approach including a genic in nature. The four main lesions found are thorough anamnesis, clinical examination canker sores, traumatic lesions, herpes, and lin- with the search for elementary lesions, gual lesions5,20,13,9. In addition, certain systemic and additional examinations. Through reg- pathologies (inflammatory diseases of the co- ular check-up appointments during ortho- lon and intestines, IBD, hemopathies, and dia- dontic treatment, the practitioner is able to betes) may also have oral manifestations5. detect the appearance of lesions, to mon- The presence of intraoral material during itor their evolution, and to manage them if orthodontic treatment is associated with necessary. Address for correspondence: Ludovic Sicard - Bretonneau Hospital, Department of Oral Medicine – 23 rue Joseph de Maistre – 75018 Paris Article received: 16-10-2017. E-mail: [email protected] Accepted for publication: 25-12-2017. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Article available at https://www.jdao-journal.org or https://doi.org/10.1051/odfen/2018056 L. SICARD, L. BENMOUSSA, N. MOREAU, B. SALMON, A.-L. EJEIL ELEMENTARY LESIONS AND DIAGNOSTIC APPROACH The elementary lesion (Table I) is appearance of the lesion. The condition used to guide the diagnosis by com- may be accompanied by symptoms or paring it with a nosological group. Its early signs. Its discovery may be fortui- description must include its borders, tous or be mentioned by the patient due texture, color (erythematous, keratotic, to discomfort or pain. The lesion’s and pigmented), suppleness or indura- development can be continuous or via tion, and number of lesions (whether intermittent flare-ups, or even consti- single or multiple). tute a recurrence. Family history, ethnic The diagnostic approach is based origins, lifestyle habits, and medications on the patient’s medical history and (antiseptics in mouthwash, ointments, clinical examination. It leads to one or and antibiotics) can help guide the di- more diagnostic hypotheses or even a agnosis. A particular area, such as cur- positive diagnosis. rent conditions or a systemic disease, Obtaining the diagnosis may require can be the cause of oral lesions (IBD or additional tests, such as biopsy and/or hemopathies in particular). excision, biological assessment, serol- The clinical examination must meet a ogy, and imaging15. strict methodology and must system- atically provide information on various The medical history is of particular 16 interest to children and their parents. points . It examines the history of the condi- The extraoral examination begins tion, its date of onset, and the type and with examining the appearance of Table I: Primary elementary lesions7 Elementary lesion Size Description Macule <5 mm Not indurated, circumscribed, consisting of a color change of the mucosa without relief or hollow (spot). Erythematous (example: acute myeloid leukemia) or pigmented (example: Range >5 mm idiopathic macular melanoma). Papula <5 mm In relief, firm, non-liquid, protruding, circumscribed, palpable. Increased epithelio-conjunctival volume. Red, white, or pigmented. The plaque may result from the confluence of several Plaque >5 mm papules. Firm, non-protruding, round or oval, deep (of the chorion), sometimes painful, linked to Nodule inflammatory or tumoral (benign or malignant) involvement. Generally large. Keratotic, erythematous, or pigmented. Vegetation Hypertrophic or hyperplastic circumscribed epithelio-conjunctival proliferation consisting of growths (cauliflower appearance). Of variable morphology (filiform or lobulated appearanc- es). Pediculated or sessile. Usually refers to papillomas, warts, and condylomas. Vesicule <5 mm Elevated circumscribed intraepithelial elevation with serous or hemorrhagic fluid content. The thin roof is quickly eliminated in the mouth, giving way to erosion (secondary lesion). Bubble >5 mm Clear, yellowish, or hemorrhagic fluid collection. Fragile roof that breaks easily (formation of a secondary erosive lesion or post-bullous ulcerative lesion). May be intra- or subepithelial. Pustule <5 mm Vesicle that contains pus. A vesicle can turn into a pustule due to bacterial contamination. Erosion Loss of superficial substance (epithelial involvement without involvement of the chorion). Heals without leaving a scar. Most often secondary to a vesicle or an intraepithelial bubble after the rupture of its roof. Surface most often erythematous. Ulceration Loss of epithelial and conjunctive tissue. Leaves a fibrinous layer by exudation after removal of the basal membrane. More painful than erosion. Usually heals in about 10 days, some- times with cicatricial sequelae. Most common causes are canker sores, trauma, subepitheli- al bubbles, and carcinomas. 2 Sicard. L., Benmoussa. L., Moreau N., Salmon. B., Ejeil. A.-L. Orthodontics and oral mucosal lesions in children and teenagers Orthodontics AND ORAL mucosal LESIONS IN CHILDREN AND teenagers Table 2: Types of additional examinations Additional examinations Examples of indication Complete blood count Recurrent ulcerations, testing for anemia, or hemopathy Fasting blood glucose, HbA1c Diabetes control Vitamin assessment (B9, B12 ...) Canker sores with macrocytic anemia Ultrasound Salivary gland tumor Magnetic resonance imaging Assessment of bone/soft tissue tumor Serology HSV1 or HSV2 testing for atypical primary herpes infection Biopsy Histological confirmation of the diagnostic hypothesis Mycological examination Mycosis resistant to first-line treatment integuments (skin and skin- associated any possible induration. For red le- structures, such as nails, hair, and dan- sions, the vitropressure test makes it der) and mucocutaneous diseases that possible to establish if the lesion is of can be associated with oral manifesta- capillary origin or not. If the lesion turns tions. This is followed by palpation for white, it indicates a vascular origin. lymphadenopathy and salivary glands The initial lesion can frequently and and the search for any swelling or facial rapidly undergo changes due to cer- asymmetry. tain elements of the oral environment The extraoral examination is thor- (humidity, variable pH, dental micro- ough. The practitioner spreads the trauma, food, hygiene, and occurrence cheeks, explores the vestibular and lin- of superinfections). gual floor, while holding the tongue in These observations are recorded on place with a compress. They look care- a diagram of the oral mucosa as well as fully at the lesion, describe the clinical images of the lesion. These documents aspect (color, texture, induration, and are attached to the medical file to mon- boundaries) and topography (location itor the evolution of the condition. and size). The lesion may be homoge- Additional tests are ordered when neous (one type of primary lesion) or there is still doubt about the diagno- heterogeneous (multiple primary le- sis. They are guided by the diagnostic sions at the same site). The palpation hypotheses and are not systematic evaluates the consistency and reveals (Table II). MUCOSAL PATHOLOGIES RELATED TO ORTHODONTIC TREATMENTS Mucosal pathologies related to ortho- with the presence of erosion or kera- dontic treatment have three major caus- tosis caused by friction on the corre- es: traumatic, infectious, or reactive. sponding mucous membranes. Arches Traumatic pathologies take different are often associated with wound ulcers forms depending on severity. They by piercing the mucosa facing them18. vary according to the type of orthodon- Mini-screws are frequently associated tic appliance. Brackets are associated with erythema and erosions19. After J Dentofacial Anom Orthod 2018;21:207 3 L. SICARD, L. BENMOUSSA, N. MOREAU, B. SALMON, A.-L. EJEIL removal, they create cicatricial seque- lae in >40% of cases21. The definitive diagnosis of a traumat- ic injury is only made when the lesion disappears after elimination of the sus- pected cause. with regular and light friction. It is clinically translated by a homogeneous white plate. Traumatic ulceration (Fig. 2) is painful; Figure 1 it results from the aggression
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