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Oral Mucosal Persistent and Short Term A Mixed Bag of Oral Lesions in Tots & Teens: Diagnostic Tips Course Objectives & Treatment Options, #1 Improve the practitioners’ ability to: . Diagnose a variety of common oral lesions . Determine the best questions to ask when Catherine M. Flaitz, DDS, MS taking a history Professor, Division of . Discover useful new entities and new Pediatric Dentistry findings about well-known disorders The Ohio State University College of Dentistry . Select the best management approaches for the child-patient. Associate Chief of Dentistry Nationwide Children’s April 2018 Hospital Oral Lesions in Children U.S. Mortality Drops for Infants . Congenital disease; syndromes . Mortality rates declined by 15% (2005 – 2014) . Tooth eruption . 6.86 deaths/100,000 live births in 2005 . Vague history . 5.82 deaths/100,000 live births in 2014 . Family and pets matter . Greatest declines in babies born to Pacific . Traumatic component Islanders and black women . Orthodontic appliances . Deaths declined for congenital defects, SIDS . Growth spurts (29%), prematurity, maternal complications . Infections are common . Rates for fatal accidental injuries rose 11% . Reactive lesions . Reference: CDC NCHS, 3-2017 . Delayed diagnosis of serious disease Increase in Congenital Diseases Zika Virus Infection . Opioid addiction . Zika virus (ZIKV): RNA virus of Flaviviridae family . Old diseases: . Transmit: Aedes species mosquito; in utero, sexual, including oral sex, blood transfusion, transplant . Congenital syphilis . 1 in 5 infected will become symptomatic . Increased by 46% (2012-2015) . Incubation: 3-12 days; duration: 2-7 days . S/S: fever, rash, arthralgia, myalgia conjunctivitis, . 11.6 cases/100,000 headache, oral ulcers, pharyngitis, palatal petechiae live births in 2014 . DX: Travel history; serum, urine ZIKV rRT-PCR and . New diseases: serum IgM ab . Congenital Zika . TX: Supportive, analgesics (acetaminophen) 1 Zika Stats 3/2018 Complications . US cases: 5,673 . Guillain-Barre syndrome: autoimmune disorder with limb . US Territories (PR): 37,177 weakness, paresthesia, facial . Completed pregnancies, US: 2,233 weakness, dysphagia . Live birth defects: 112 . Congenital infection: microcephaly, . Fetal losses with defects: 9 vision, hearing loss, seizures, neurologic abnormalities, feeding . Completed pregnancies, Territories: 4,055 difficulties, dysphasia, . Live birth defects: 157 contractures, muscle hypertonicity, . Fetal losses with defects: 8 hypothyroid, pituitary disorders www.cdc.gov/zika . Fetal Risk: 6%; First trimester: 15% (Similar to French territories) Congenital Zika Syndrome AP: Associated Press, Oct 2016 Prevention: Avoid travel to high risk areas Infected male partner: Use condoms or avoid sex during pregnancy or for 6 months, if not pregnant Oral Lesions in Schoolchildren Symptomatic Oral Lesions • Aphthous ulcers • Fordyce granules . Red mucosal lesions • Erythema migrans • Melanotic macule . Red or Blue Blanching Lesions • Herpes labialis • Mucocele . Red or Blue Non-blanching Lesions • Fissured tongue • Tumors, NOS . Ulcerative lesions • Cheek-biting/linea alba • Hemangioma/vascular malformation • Traumatic ulcer . Ulcers of Sudden Onset & Short Duration • Papilloma, verruca . Ulcers of Variable Onset & Long Duration • Purpura vulgaris • Candidiasis, angular • Overall Prevalence: . White or yellowish mucosal lesions cheilitis 27.5% . White Surface Thickening • Commissural lip pits . White Surface Material • Gingival hyperplasia Fehmida, Flaitz, et al. AAPD abstract, 2014 2 Red Lesions in Children Red-Blue Non-Blanching Lesions . Red or Blue Blanching Lesions . Flat or elevated lesion . Hemangioma or vascular malformation . Pooling of blood or increased vascularity . Red or Blue Non-blanching Lesions . Smooth or granular surface . Bleeding with manipulation . No tissue blanching . May be mildly symptomatic Dx: Ecchymosis Beware: Condylar fracture . History of trauma or irritation Infantile capillary hemangioma . Systemic disease when Photo: Dr. Ian Kott widespread Benign Migratory Glossitis Benign Migratory Glossitis . Geographic tongue, erythema migrans . Cause: Unknown; genetic, allergy . Prevalence: Up to 3%; all ages;  in children . Site: Tongue, esp. dorsum; extraglossal . Duration: Persistent; waxes and wanes . S/S: Multiple, red annular patches with white scalloped border; loss of filiform papillae; +/- Concurrent lesions: burning sensation; +/- fissured tongue Fissured tongue . Concerns: Food restrictions; cosmetic Crenations on lateral borders concern Lingual papillitis Benign Migratory Glossitis Geographic Tongue Early onset may be marker for psoriasis & disease severity BMG tends to be nontender when associated with psoriasis Appliances do not cause the lesion but may exacerbate the Piccinai B et al: International Journal of Dermatology 2017 symptoms 3 Mimics Median Rhomboid Glossitis Subtle Signs of BMG Key feature: Annular patches move around Lateral tongue may be more tender Extraglossal Erythema Migrans Questions to Ask? . Does it come and go and change patterns? Mimics: allergic reaction . Is it usually on the tongue? . Does the child have allergies, eczema, asthma, or other skin problems? . Does it interfere with eating? Weight loss? Growth rate? . Meds, OTC and oral hygiene products? . Other family members affected? . Is it associated with a fever? Benign Migratory Glossitis What Else Is In The Bag? ID factor; use gentle oral hygiene products . Benign migratory glossitis Topical coating agents, anesthetics: . Contact allergy . Benadryl & Maalox suspension . OTC gels, rinses . Candidiasis Topical steroids +/- antifungals: . Traumatic erosion . Fluocinonide gel .05% . Transient lingual papillitis . Other topical steroids . Lichen planus . Nystatin/triamcinolone ointment . Triamcinolone 0.1% in Nystatin oral rinse . Erythroplakia Pizza burn erosion 4 Median Rhomboid Glossitis Oral Candidiasis . Form of candidiasis . Cause: Candida species, Candida albicans . AKA: Central papillary . Prevalence: 40 – 60% normal oral inhabitant atrophy . Predisposing factors: immune status, medications, poor oral hygiene, appliances, . Site: Midline, posterior pacifiers, poor diet, diabetes, dry mouth dorsal tongue . Site: Usually multifocal oral involvement . S/S: Red rhomboid . Variants: Pseudomembranous, patch, nontender erythematous, hyperplastic types . Kissing lesion on palate . S/S: Red or white patches, erosions, burning sensation, taste perversion, sore throat . Tx: Antifungal agents Erythematous Candidiasis Erythematous Candidiasis Dentinal caries are a reservoir for fungus Cause: Steroid inhaler use Gingivitis, glossitis, palatal erythema, chapped lips Mimics: allergic reaction, viral infection Erythematous Candidiasis Cheilocandidiasis Mimics: Chapped lips 5 Pseudomembranous Candidiasis Pigmented Candidiasis Severe forms many be May trigger an inflammatory melanosis in children with associated with painful increase in skin pigmentation mucosal erosions and dysphagia Oropharyngeal Candidiasis Miconazole (Oravig): Topical Topical Agents: . Form: Adherent, slowly dissolving 50 . Nystatin suspension 100,000 U/mL mg tablet . Clotrimazole troches 10 mg . Usual dosage: . Oravig (miconazole) buccal tabs 50 mg . Adolescents >16 yrs: 1 tablet for 14 . Chlorhexidine gluconate oral rinse 0.12% days. Apply to the upper gum region, Systemic Agents: just above the upper lateral incisor. Diflucan, g (fluconazole) 100 mg tabs, 10 Alternate sides of the mouth. mg/mL, 40 mg/mL susp . Sporanox (itraconazole) 100mg/10mL Pseudomembranous Candidiasis Probiotics and Oral Health . Probiotics: Living microorganisms (primarily bacteria) that are safe for consumption and when ingested in sufficient quantities have beneficial effects on human health beyond basic nutrition Coated tongue alone is not candidiasis Check tonsillar area and posterior ventral tongue, if not responding to topical treatment 6 Probiotics: Mechanism of Action Probiotics . Secrete antimicrobial substances (organic . Purpose: To help prevent diarrhea from acids, hydrogen peroxide, bacteriocins) antibiotics . Compete with pathogenic organisms for . Examples: Culturelle (lactobacillus GG), adhesion sites on mucosa Dan Active (lactobacillus, strep thermophilus), others . Modify environment by modulating pH & O2- reduction potential . Duration: Take probiotics during antibiotic treatment and up to a week afterwards . Stimulates nonspecific humoral immunity . Sig: Take 2 hours after each antibiotic . Modulates humoral & cellular immune dose to improve probiotic survival response . Combination of strains beneficial effects New Evidence in the Bag Breastfeeding Keratosis • Probiotic species: . Frictional keratosis Lactobacillus spp. Bifidobacterium spp. Cause: Forceful sucking Saccharomyces spp. Site: Labial mucosa, • Preventive effect: Candida anterior buccal mucosa colonization . S/S: White adherent • Population: Preterm neonates plaques, nontender; +/- and elderly leukoedema, sucking • Systematic reviews: calluses – Hu H-J, et al: Pediatr Neonatol . Tx: Modify sucking habits 2017 – Ai R, et al: Arch Oral Biol 2017 . Mimics: Candidiasis Kiat-amnuay S, et al, 2013 What Does It Mimic? Oral Erythroplakia • Pseudomembranou . Definition: Red patch that cannot be s candidiasis defined clinically or pathologically as another condition • Mucosal sloughing . Prevalence: Rare in children • Mucosal burn . Risk factor: Same as oral cancer • Plaque/materia . Site: Oral floor, tongue, soft palate alba complex • Koplik spots . S&S: Soft, velvety red patch +/- white foci HX: Infant
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