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BEST PRACTICES: ORAL AND ORAL

Management Considerations for Pediatric Oral Surgery and Oral Pathology

Latest Revision How to Cite: American Academy of Pediatric . Management 2020 considerations for pediatric oral surgery and oral pathology. The Reference Manual of . Chicago, Ill.: American Academy of Pediatric Dentistry; 2020:433-42.

Purpose Medical evaluation The American Academy of Pediatric Dentistry (AAPD) Important considerations in treating a pediatric include intends this document to define, describe clinical presentation, obtaining a thorough medical history, obtaining appropriate and set forth general criteria and therapeutic goals for common medical and dental consultations, anticipating and preventing pediatric oral surgery procedures and oral pathological emergency situations, and being prepared to treat emergency conditions. situations.5

Methods Dental evaluation Recommendations on management considerations for pediatric It is important to perform a thorough clinical and radiographic oral surgery and oral pathology were developed by the preoperative evaluation of the dentition as well as a clinical Council on Clinical Affairs and adopted in 2005.1 This examination of extraoral and intraoral soft tissues.5-7 Radio- document is a revision of the previous version, last revised in graphs can include intraoral films and extraoral imaging if the 2015.2 It is based on a review of the current dental and med- area of interest extends beyond the dentoalveolar complex. ical literature related to pediatric oral surgery, including a Surgery involving the and of young search of the PubMed /MEDLINE database using the terms: is complicated by the presence of developing follicles. pediatric AND oral ®surgery, oral pathology, extraction, Knowledge of the of a child’s developing maxilla and odontogenic , impacted canines, third molars, mandible and the avoidance of to the dental follicles supernumerary teeth, mesiodens, mucocele, eruption , can prevent complications.8 To minimize the negative effects eruption hematoma, gingival keratin , Epstein pearls, of surgery on the developing dentition, careful planning Bohn’s nodules, congenital of newborn, dental lamina using radiographs, tomography,9 cone beam computed tomo- cysts, natal teeth, , squamous papilloma, verruca graphy,10 and/or three-dimensional imaging techniques11 is vulgaris, irritation , recurrent aphthous , necessary to provide valuable information to assess the presence, localized juvenile spongiotic gingival , and pyogenic absence, location, and/or quality of individual and root ; fields: all; limits: within the last 10 years, humans, development.8,12,13 English, clinical trials. Papers for review were chosen from the list of articles matching these criteria and from references Growth and development with selected articles. When data did not appear sufficient The potential for adverse effects on growth from and/ or were inconclusive, recommendations were based upon or surgery in the oral and maxillofacial region markedly expert and/or consensus opinion by experience researchers increases the potential for risks and complications in the and clinicians. In addition, the manual Parameters of Care: pediatric population. Traumatic injuries involving the maxil- Clinical Practice Guidelines for Oral and Maxillofacial Surgery,3 lofacial region can adversely affect growth, development, and developed by the American Association of Oral and Maxil- function. Therefore, a thorough evaluation of the growing lofacial (AAOMS), was consulted. patient must be done before surgical interventions are per- formed to minimize the risk of damage to the growing facial General considerations complex.14 Surgery performed on pediatric patients involves special considerations unique to this population. Several critical issues deserve to be addressed. ABBREVIATION Preoperative considerations AAOMS: American Association of Oral and Maxillofacial Surgeons. AAPD: American Academy of Pediatric Dentistry. HPV: Human Before any surgical procedure, informed consent must be papilloma virus. VKDB: Vitamin K deficiency . obtained from the parent or legal guardian. For more infor- mation, refer to AAPD's Informed Consent.4

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Behavioral evaluation Ludwig’s angina.17,19 These conditions can be life threatening Behavioral guidance of children in the operative and periopera- and may require immediate hospitalization with intravenous tive periods presents a special challenge. Many children benefit , , and referral/consultation from modalities beyond local and / with an oral and maxillofacial .17,19 oxygen inhalation to minimize their anxiety.4,14 Management of children under sedation or general anesthesia requires Extraction of erupted teeth extensive training and expertise.15,16 Special attention should be Maxillary and mandibular anterior teeth given to the assessment of the social, emotional, and psycho- Most primary and permanent maxillary and mandibular central logical status and cognitive level of the pediatric patient prior incisors, lateral incisors, and canines have conical single roots. to surgery.14 Children have many unvoiced fears concerning In most cases, extraction of anterior teeth is accomplished the surgical experience, and their psychological management with a rotational movement due to their single root requires that the be cognizant of their emotional anatomy.5 However, there have been reported cases of ac- status. Answering questions concerning the surgery is impor- cessory roots observed in primary canines.21,22 Radiographic tant and should be done in the presence of the parent. examination is helpful to identify differences in root anatomy prior to extraction.21 Care should be taken to avoid placing Peri- and post-operative considerations any force on adjacent teeth that could become luxated or Metabolic management of children following surgery fre- dislodged easily due to their root anatomy. quently is more complex than that of adults. Special consider- ation should be given to caloric intake, fluid and electrolyte Maxillary and mandibular molars management, and blood replacement. Comprehensive Primary molars have roots that are smaller in diameter and management of the pediatric patient following extensive oral more divergent than permanent molars. Root fracture in and maxillofacial surgery usually is best accomplished in a primary molars is not uncommon due to these characteristics facility that has expertise and experience in the management as well as the potential weakening of the roots caused by the of young patients (i.e., a children’s ).14 eruption of their permanent successors.5 Prior to extraction, the relationship of the primary roots to the developing suc- Recommendations cedaneous tooth should be assessed. To avoid inadvertent Odontogenic infections extraction or dislocation of or trauma to the permanent In children, odontogenic infections may involve more than successor, pressure should be avoided in the furcation area or one tooth and usually are due to caries , periodontal the tooth may need to be sectioned to protect the developing problems, pathology (e.g., ), or a history of permanent tooth. trauma.17-18 Untreated odontogenic infections can lead to extractions are accomplished by using slow conti- , difficulty or drinking, , , septicemia, nuous palatal/lingual and buccal force allowing for the airway compromise, and life-threatening infections.19 Facial expansion of the alveolar to accommodate the divergent cellulitis results from unresolved abscess that has spread to roots and reduce the risk of root fracture.5 When extracting cutaneous or subcutaneous planes in the head and mandibular molars, care should be taken to support the neck region.19 In these children, dehydration is a significant mandible to protect the temporomandibular joints from consideration; prompt treatment of the source of is injury.5 imperative. With infections of the upper portion of the face, patients Fractured primary tooth roots usually complain of facial pain, , and malaise.20 Care must The presence of a root tip should not be regarded as a positive be taken to rule out sinusitis or non-odontogenic infections, indication for its removal. The dilemma to consider when as symptoms may mimic an odontogenic infection. Occasionally managing a retained primary tooth root is that removing the in upper face infections, it may be difficult to find the true root tip may cause damage to the succedaneous tooth, while cause.14 Infections of the lower face usually involve pain, swelling, leaving the root tip may increase the chance for postopera- and .3,17 They frequently are associated with teeth, skin, tive infection and delay eruption of the permanent successor.5 local lymph nodes, and salivary glands.17 Most odontogenic Radiographs can assist in the decision process. Expert opinion infections occur in the upper face; however, infections in the suggests that if the fractured root tip can be removed easily, mandibular region are more frequent in older children.20 it should be removed.5 If the root tip is very small, located Most odontogenic infections can be managed with deep in the socket, situated in close proximity to the permanent , extraction, or incision and drainage.5 Infections of successor, or unable to be retrieved after several attempts, it is odontogenic origin with systemic manifestations (e.g., elevated best left to be resorbed.5 The parent must be informed and a temperature [102 to 104 degrees Fahrenheit], facial cellulitis, complete record of the discussion must be documented. The difficulty in or , fatigue, nausea) require patient should be monitored at appropriate intervals to eval- therapy.19 Severe but rare complications of odonto- uate for potential adverse effects. genic infections include cavernous sinus and

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Management of unerupted and impacted teeth supports the removal of third molars when pathology (e.g., There is a wide clinical spectrum of disorders of eruption in cysts or tumors, caries, infection, , periodontal both primary and in children. These may , detrimental changes of adjacent teeth or bone) is asso- be syndromic or non-syndromic and include ankyloses,27-28 ciated and/or the tooth is malpositioned or nonfunctional secondary retention,28 , or primary failure of (i.e., an unopposed tooth).37-39 There is no evidence to eruption29. Clinically, it may be difficult to differentiate between support37-40 or refute3 the prophylactic removal of disease-free the various disruptions; however, there have been many re- impacted third molars. Factors that increase the risk for ports30,31 to assist the clinician in making a diagnosis. There is surgical complications (e.g., coexisting systemic conditions, increasing evidence that there is a genetic etiology for some of location of peripheral nerves, history of temporomandibular these eruption disruptions which may help in a definitive joint disease, presence of cysts or tumors)38,39 and position diagnosis.29 Management of unerupted teeth will depend on and inclination of the molar in question41 should be assessed. whether the tooth affected is likely to respond to orthodontic The age of the patient is only a secondary consideration.41 forces. If not, surgical extraction is the preferred treatment Referral to an oral and maxillofacial surgeon for consultation option.29 and subsequent treatment may be indicated. When a decision is made to retain impacted third molars, they should be Impacted canines monitored for change in position and/or development of Tooth impaction may occur due to a mechanical obstruction. pathology, which may necessitate later removal. Permanent maxillary canines are second to third molars in frequency of impaction.32 Early detection of an ectopically Supernumerary teeth erupting canine through visual inspection, palpation, and Supernumerary teeth and are terms to describe radiographic examination is important to maximize success of an excess in tooth number. Supernumerary teeth are thought an intervention.33 Routine evaluation of patients in mid-mixed to be related to disturbances in the initiation and proliferation dentition should involve identifying signs such as lack of ca- stages of dental development.21 Although some supernumerary nine bulges and asymmetry in pattern of exfoliation. Abnormal teeth may be -associated (e.g., cleidocranial dysplasia) angulation or ectopic eruption of developing permanent cus- or of familial inheritance pattern, most supernumerary teeth pids can be assessed radiographically.33 When the cusp tip of occur as isolated events.21 the permanent canine is just mesial to or overlaying the distal Supernumerary teeth can occur in either the primary or half of the long axis of the root of the permanent lateral incisor, permanent dentition.21,42,43 In 33 percent of the cases, a super- canine palatal impaction usually occurs.32 Extraction of the numerary tooth in the primary dentition is followed by the primary canines is the treatment of choice to correct palatally supernumerary tooth complement in the permanent denti- displaced canines or to prevent resorption of adjacent teeth.32 tion.44 Reports in incidence of supernumerary teeth can be One study showed that 78 percent of ectopically erupting as high as three percent, with the permanent dentition being permanent canines normalized within 12 months after removal affected five times more frequently than the primary dentition of the primary canines; 64 percent normalized when the and males being affected twice as frequently as females.21 starting canine position overlapped the lateral incisor by more Supernumerary teeth will occur 10 times more often in than half of the root; and 91 percent normalized when the the maxillary arch versus the mandibular arch.21 Approxi- starting canine position overlapped the lateral incisor by less mately 90 percent of all single tooth supernumerary teeth are than half of the root.32 If no improvement in canine position found in the maxillary arch, with a strong predilection to the occurs in a year, surgical and/or orthodontic treatment were anterior region.21,42 The maxillary anterior midline is the most suggested.32,33 A Cochrane review34 and a systematic review35 common site, in which case the supernumerary tooth is known reported no evidence to support extraction of primary canines as a mesiodens; the second most common site is the maxillary to facilitate eruption of ectopic permanent maxillary canines. molar area, with the tooth known as a paramolar.21,42 A me- A prospective randomized clinical trial demonstrated that siodens can be suspected if there is an asymmetric eruption extraction of primary canines is an effective measure to correct pattern of the maxillary incisors, delayed eruption of the palatally displaced maxillary canines and is more successful in maxillary incisors with or without any over-retained primary children with an early diagnosis.36 Consultation between the incisors, or ectopic eruption of a maxillary incisor.45 The practitioner and an orthodontist may be useful in the final diagnosis of a mesiodens can be confirmed with radiographs, treatment decision. including occlusal, periapical, or panoramic films,46 or com- puted tomography.9,10 Three-dimensional information needed Third molars to determine the location of the mesiodens or impacted tooth Panoramic or periapical radiographic examination is indicated can be obtained by taking two periapical radiographs using in late adolescence to assess the presence, position, and devel- either two projections taken at right angles to one another or opment of third molars.7 The AAOMS recommends that a the tube shift technique (buccal object rule or Clark’s rule)47 decision to remove or retain third molars should be made or by cone beam computed tomography.10,12,13 before the middle of the third decade.3 Evidence-based research

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Complications of supernumerary teeth can include delayed a soft diet, regular oral , and as needed.69 The and/or lack of eruption of the permanent tooth, crowding, use of electrosurgery or for frenectomies has resorption of adjacent teeth, formation, peri- demonstrated a shorter operative working time, a better ability coronal space ossification, and crown resorption.42,48 Early to control bleeding, reduced intra- and post-operative pain and diagnosis and appropriately timed treatment are important in discomfort, fewer post-operative complications (e.g., swelling, the prevention and avoidance of these complications. Because infection), no need for suture removal, and increased patient only 25 percent of all mesiodens erupt spontaneously, surgical acceptance.62,69,70 These procedures require extensive training as management often is necessary.44,49 A mesiodens that is conical well as skillful technique and patient management.54,60,65,67,71-75 in shape and is not inverted has a better chance for eruption than a mesiodens that is tubular in shape and is inverted.48 The Pediatric oral pathology treatment objective for a non-erupting permanent mesiodens A wide spectrum of oral lesions occurs in children and ad- is to minimize eruption problems for the permanent incisors.48 olescents, including soft and hard tissue lesions of the oral Surgical management will vary depending on the size, shape, maxillofacial region. There is limited information on the and number of supernumeraries and the patient’s dental prevalence of oral lesions in the pediatric population. The development.48 The treatment objective for a non-erupting largest epidemiologic studies in the U.S. place the prevalence primary mesiodens differs in that the removal of these teeth rate in children at four to 10 percent with the exclusion of usually is not recommended, as the surgical intervention may infants.76,77 Although the vast majority of these lesions rep- disrupt or damage the underlying developing permanent resent mucosal conditions, developmental anomalies, and teeth.50 Erupted primary tooth mesiodens typically are left to reactive or inflammatory lesions, it is imperative to be vigilant shed normally upon the eruption of the permanent dentition.50 for neoplastic . Extraction of an unerupted primary or permanent mesio- Regardless of the age of the child, it is important to estab- dens is recommended during the mixed dentition to allow the lish a working diagnosis for every . This is based on normal eruptive force of the permanent incisor to bring itself obtaining a thorough history, assessing the risk factors and into the oral cavity.43 Waiting until the adjacent incisors have documenting the clinical signs and symptoms of the lesion. at least two-thirds root development will present less risk to Based on these facts, a list of lesions with similar characteris- the developing teeth but still allow spontaneous eruption of tics is rank ordered from most likely to least likely diagnosis. the incisors.3 In 75 percent of the cases, extraction of the The entity that is judged to be the most likely disease becomes mesiodens during the mixed dentition results in spontaneous the working diagnosis and determines the initial management eruption and alignment of the adjacent teeth.50,51 If the adja- approach. cent teeth do not erupt within six to 12 months, surgical For most oral lesions, a definitive diagnosis is best made by exposure and orthodontic treatment may be necessary to aid performing a . By definition, a biopsy is the removal their eruption.45,47 of a piece of tissue from a living body for diagnostic study and is considered the gold standard of diagnostic tests.78 The Frenulum attachments two most common are the incisional and excisional Frenulum attachments and their role in oral function increas- types. Excisional biopsies usually are performed on small ingly have become topics of interest among a variety of health lesions, less than one centimeter in size, for the total removal care specialists. (-tie) and hypertrophic/ of the affected tissue. An incisional biopsy is performed when restrictive maxillary frenula have been implicated in difficulties a malignancy is suspected, the lesion is large in size or diffuse breastfeeding53, incorrect speech articulation54,55, caries forma- in nature, or a multifocal distribution is present. Multiple tion56,57, gingival recession58, and aberrant skeletal growth59. incisional biopsies may be indicated for diffuse lesions, in Studies have shown differences in treatment recommendations order to obtain a representative tissue sample. Fine needle among pediatricians, otolaryngologists, lactation consultants, aspiration, the cytobrush technique, and exfoliative cytology speech pathologists, surgeons, and dental specialists.54,60-66 Clear may assist in making a diagnosis, but they are considered indications and timing of surgical treatment remain controver- adjunctive tests because they do not establish a definitive sial due to lack of consensus regarding accepted anatomical and diagnosis.79,80 diagnostic criteria for degree of restriction and relative impact It is considered the standard of care that any tissue on growth, development, feeding, or oral motor function.54,60-66 removed from the oral and maxillofacial region be submitted When indicated, frenuloplasty/frenotomy (various methods for histopathologic examination.81 Exceptions to this rule in- to release the frenulum and correct the anatomic situation) or clude carious teeth that do not have soft tissue attached, extirpated frenectomy (simple cutting of the frenulum) may be a successful pulpal tissue, and clinically normal tissue, such as tissue from approach to alleviate the problem.54,60,65,67 Each of these proce- gingival recontouring.81 Gross description of all tissue that is dures involves , establishing hemostasis, and removed should be entered into the patient record. In general, management.68 Dressing placement or the use of antibi- a soft tissue biopsy should be performed when a lesion persists otics is not necessary.68 Recommendations include maintaining for greater than two weeks despite removal of the suspected

436 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY causative factor or empirical drug treatment. It is also imper- • ; ative to submit hard or soft tissue for evaluation to a pathologist • sialadentis; if the differential diagnosis includes at least one significant • Burkitt’s ; disease or neoplasm. Histopathologic examination not only • melanotic macule; furnishes a definitive diagnosis, but it provides information • ; about the clinical behavior and prognosis and determines the • nevus; and need for additional treatment or follow-up. Another valuable • . outcome is that it allows the clinician to deliver evidence-based medical/dental care, increasing the likelihood for a positive Lesions of the newborn result.78 Furthermore, it presents important documentation Palatal cysts of the newborn include Epstein pearls and Bohn about the lesion for the patient record, including the pro- nodules. These cysts are found in up to 85 percent of new- cedures taken for establishing a diagnosis.78 borns.53,83-90 Epstein pearls occur in the median palatal raphe Many oral biopsies are within the scope of practice for a area53,83-85 as a result of trapped epithelial remnants along the pediatric dentist to perform. However, if the tissue is excised, line of fusion of the palatal halves.49,51 Bohn nodules are the following steps should be taken for optimum results:78-81 remnants of epithelium and usually are found 1. select the most representative lesion site and not the area on the buccal and lingual aspects of the ridge, away from the that is the most accessible. midline.83,85 Gingival cysts of the newborn, or dental lamina 2. remove an adequate amount of tissue. If the biopsy is too cysts, are found on the crests of the dental ridges, and are most small or too superficial, a diagnosis may be compromised. commonly are seen bilaterally in the region of the first pri- 3. avoid crushing or distorting the tissue. Damage is most mary molars.84 They result from remnants of the dental lamina. often observed from the forces of the tissue , Palatal and gingival cysts of the newborn typically present as tearing the tissues or overheating the tissue from the use asymptomatic one to three millimeter nodules or papules. of electrosurgery or laser removal. They are smooth, whitish in appearance, and filled with 4. immediately place the tissue in a fixative, which for most keratin.83,84 No treatment is required, as these cysts usually samples is 10 percent formalin. It is critical not to dilute disappear during the first three months of life.53,83 the fixative with water or other liquids because tissue autolysis will render the sample nondiagnositic. of the newborn 5. proper identification of the specimen is essential. The Congenital epulis of the newborn, also known as granular formalin container should be labelled with the name cell tumor or Neumann’s tumor, is a rare seen of the patient and the location. Multiple tissue samples only in newborns.91 This lesion is typically a protuberant from different locations should not be placed in the mass arising from the gingival mucosa. It is most often same container, unless they are uniquely identified, such found on the anterior maxillary ridge.86,87 Patients typically as tagged with a suture. present with feeding and/or respiratory problems.87 Congenital 6. complete the form including patient epulis has a marked predilection for females at 8:1 to 10:1.86-88 demographics, the submitting dentist’s name and address, Treatment normally consists of surgical excision.86-88 The and a brief but accurate history. It is important to have newborn usually heals well, and no future complications or legible records so that the diagnosis is not delayed. treatment should be expected. Congenital epulis never recurs Clinical photographs and radiographs often are very after excision.88 There have been reports of spontaneous useful for correlating the microscopic findings. regression of untreated congenital epulis.88,91

Worldwide, the most frequently oral biopsied lesions in Melanotic neuroectodermal tumor of infancy children include82: Melanotic neuroectodermal tumor of infancy is a rare occur- • mucocele; rence that develops during the first year of life.88 This lesion • fibrous lesions; may be present at birth. It occurs in the anterior maxilla 70 • ; percent of the time.83 Less frequently, melanotic neuroecto- • dental follicle; dermal tumor of infancy occurs in the , mandible, • human papillomavirus (HPV) lesion; epididymis and testis, and .83,88 The classic presentation • chronic ; is a bluish or black rapidly expanding mass of the anterior • giant cell lesions (soft tissue); maxilla. Radiographic findings include an ill-defined • hyperkeratosis; unilocular radiolucency with the displacement of tooth buds.88 • peripheral ossifying fibroma; There can be a floating tooth appearance.83 Surgical excision is • ; required, and there is a 20 percent recurrence rate. Although • gingival hyperplasia; this is a benign lesion, seven percent of reported cases have • ; behaved malignantly resulting in and death.88 • ;

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Natal and neonatal teeth Mucocele Natal and neonatal teeth can present a challenge when deciding The mucocele is a common lesion in children and adolescents on appropriate treatment. Natal teeth have been defined as resulting from the rupture of a minor salivary gland excretory those teeth present at birth, and neonatal teeth are those that duct, with subsequent leakage of mucin into the adjacent erupt during the first 30 days of life.92,93 The occurrence of connective tissues that later may be surrounded in a fibrous natal and neonatal teeth is rare; the incidence varies from capsule.83,85,99-101 Most mucoceles are well-circumscribed bluish 1:1,000 to 1:30,000.92,93 The teeth most often affected are the translucent fluctuant swellings that are firm to palpation, mandibular primary incisors.94 In most cases, anterior natal although deeper and long-standing lesions may range from and neonatal teeth are part of the normal complement of the normal in color to having a whitish keratinized surface.85,99,100 dentition.92,93 Natal or neonatal molars have been identified in Mucoceles most frequently are observed on the lower , usually the posterior region and may be associated with systemic condi- lateral to the midline.88 Mucoceles also can be found on the tions or (e.g., Pfieffer syndrome, histiocytosis X).94-96 buccal mucosa, ventral surface of the tongue, retromolar region, Although many theories exist as to why the teeth erupt prema- and floor of the ().99-101 Superficial mucoceles and turely, currently no studies confirm a causal relationship with some other mucoceles are short-lived lesions that burst spon- any of the proposed theories. The superficial position of the taneously, leaving shallow ulcers that heal within a few tooth germ associated with a hereditary factor seems to be the days.85,100 Local mechanical trauma to the minor salivary gland most accepted possibility.93 is often the cause of rupture.50,53,86,87 Many lesions, however, If the tooth is not excessively mobile or causing feeding require treatment to minimize the risk of recurrence.85,100 problems, it should be preserved and maintained in a healthy condition if possible.93,95,96 Close is indicated to Squamous papilloma ensure that the tooth remains stable and is not an aspiration Squamous papilloma is a benign human papillomavirus- risk to the infant. induced lesion caused by HPV types 1 and 6.83 Squamous Riga-Fede disease is a condition caused by the natal or papilloma presents as soft painless, pink to white, pedunculated neonatal tooth rubbing the ventral surface of the tongue (stalked) lesions. The surface may display multiple fingerlike during feeding, leading to ulceration.75,92 Failure to diagnose projections and may have a cauliflower like appearance.83,102,103 and properly treat this lesion can result in dehydration and These lesions can occur anywhere in the oral cavity, but the inadequate nutritional intake for the infant.96 Treatment tongue, and soft are the most common sites.103 should be conservative and focus on creating round, smooth Squamous papilloma generally occurs in adulthood, but 20 incisal edges.93-96 If conservative treatment does not correct the percent have been noted prior to age 20.91 Although they are condition, extraction is the treatment of choice.93-96 viral in origin, the infectivity is low.83,102 Squamous papilloma An important consideration when deciding to extract a natal do not have malignant potential.103 Excision is the treatment or neonatal tooth is the potential for hemorrhage. Extraction of choice, and recurrence is uncommon.83,103 is contraindicated in newborns due to risk of hemorrhage.97 Unless the child is at least 10 days old, consultation with the Verruca vulgaris pediatrician regarding adequate hemostasis may be indicated Verruca vulgaris, or the common , is an HPV type 2 prior to extraction of the tooth. In particular, infants may be induced lesion that is generally found on the skin of the at risk for vitamin K deficiency bleeding VKDB( ) if they did hand.102 Finger or thumb sucking can cause autoinoculation not receive a dose of vitamin K shortly after birth (within 6 resulting in the development of intraoral lesions.102 Verruca hours of birth).98 Infants can be at risk for VKDB until the vulgaris is similar in appearance to the squamous papilloma. age of 6 months if they do not receive a vitamin K injection.98 This lesion can be sessile (broad based) or pedunculated and can display a rough bumpy surface.103 Verruca vulgaris can be Lesions occurring in children and adolescents found on the lips, tip of tongue, and labial mucosa.83 There is Eruption cyst (eruption hematoma) no risk of malignant transformation.83 Excision of the entire The eruption cyst is a soft tissue cyst that results from a lesion is recommended and recurrence is uncommon.103 separation of the dental follicle from the crown of an erupting tooth.83,99 Fluid accumulation occurs within this created fol- Irritation fibroma licular space.85,89,100 Eruption cysts most commonly are found in The irritation fibroma is a reactive lesion occurring as a re- the mandibular molar region.89 Color of these lesions can range sponse to chronic trauma of the mucosa. The irritation fibroma from normal to blue-black or brown, depending on the amount presents as a firm nontender pink and is composed of of blood in the cystic fluid.85,89,100 The blood is secondary to fibrous connective tissue.103 The lesion does not exceed two trauma. If trauma is intense, these blood-filled lesions some- millimeters in diameter.104 The irritation fibroma can be found times are referred to as eruption hematomas.85,89,100 Because the on buccal and labial mucosa, the tongue, and attached gingiva. tooth erupts through the lesion, no treatment is necessary.85,89,100 Excisional biopsy is recommended. These can reoccur if the If the cyst does not rupture spontaneously or the lesion becomes source of the irritation is not removed.103,104 infected, the roof of the cyst may be opened surgically.85,89

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Recurrent attached gingiva (75 percent) but can be found on tongue, Recurrent aphthous stomatitis is one of the most common oral lower lip, or buccal mucosa.108 Treatment is complete ex- lesions, occurring in 20-30 percent of children.83 Recurrent cision with the removal of the source of irritant.83,108 This aphthous stomatitis is caused by a T-cell mediated immu- lesion can recur in 3-15 percent of cases.83 nologic reaction to a triggering agent.105 Three variants of aphthous ulcers are recognized: References 1. Minor aphthous ulcerations. Minor aphthous ulcerations 1. American Academy of Pediatric Dentistry. Pediatric oral are the most common form, accounting for almost 80 surgery. Pediatr Dent 2005;27(Suppl):158-64. percent of aphthous ulcers.105 They have a yellowish- 2. American Academy of Pediatric Dentistry. Management white membrane and are surrounded by an erythematous considerations for pediatric oral surgery and oral pathol- halo. These ulcers are 3-10 millimeters in diameter. ogy. Pediatr Dent 2015;37(special issue):279-88. Minor aphthous ulcers occur on nonkeratinized 3. American Association of Oral and Maxillofacial Surgeons. mucosa.105 One to five ulcers often present during a Dentoalveolar Surgery. In: Parameters of Care: Clinical single outbreak, and they heal in seven to 14 days practice guidelines for oral and maxillofacial surgery without scarring.106 (AAOMS ParCare 2017 Ver 6). J Oral Maxillofac Surg 2. Major aphthous ulcerations. Major aphthous ulcerations 2017;75(8)Suppl 1:e50-73. are larger and deeper and have a longer duration than 4. American Academy of Pediatric Dentistry. Informed the minor aphthous ulcer. These occur most commonly consent. The Reference Manual of Pediatric Dentistry. on the labial mucosa, soft palate, and the tonsillar Chicago, Ill.: American Academy of Pediatric Dentistry; fauces.105 The major aphthous ulcer can take up to six 2020:470-3. weeks to heal with potential scarring.105 5. Adewumi AO. Oral surgery in children. In: Nowak AJ, 3. Herpetiform aphthous ulcerations. Herpetiform aphthous Christensen JR, Mabry TR, Townsend JA, Wells MH, eds. ulcerations can occur on any intraoral site.106 As many as Pediatric Dentistry Infancy through Adolescence. 6th ed. 100 small ulcerations can be present in a single occur- St Louis, Mo.: Elsevier; 2019:399-409. rence.105 The ulcerations may resemble primary herpetic 6. Kaban L, Troulis M. Preoperative assessment of the stomatitis. These ulcerations may coalesce to form a pediatric patient. In: Pediatric Oral and Maxillofacial larger ulceration.105 Herpetiform aphthous ulcers heal Surgery. Philadelphia, Pa.: Saunders; 2004:3-19. within seven to ten days, but recurrences are frequent.106 7. American Academy of Pediatric Dentistry. Prescribing dental radiographs for infants, children, adolescents, Aphthous ulcers may be treated with topical anesthetics and persons with special needs. The Reference for relief of pain. Topical and systemic steroids, Manual of Pediatric Dentistry. Chicago, Ill.: American rinses, and laser treatments can be used to manage these lesions.83 Academy of Pediatric Dentistry; 2020:248-51. 8. Murray DJ, Chong DK, Sandor GK, Forrest CR. Denti- Localized juvenile spongiotic gingival hyperplasia gerous cyst after of the mandible. Localized juvenile spongiotic gingival hyperplasia was originally J Craniofac Surg 2007;18(16):1349-52. known as puberty gingivitis.107 It is thought to be an isolated 9. Ramesh A. Panoramic imaging. In: Mallya SM, Lam WN, patch of sulcular or junctional epithelium that is subjected to eds. Oral : Principles and Interpretation. 8th local factors such as or orthodontic appli- ed. St. Louis, Mo.: Elsevier; 2019:132-50. ances.83 The lesion presents as an isolated bright red velvety 10. Scarfe WC, Farman AG. Cone-beam computed tom- patch or enlargement of anterior facial gingiva. This lesion ography volume preparation. In: Mallya SM, Lam WN, bleeds easily and does not respond to measures. eds. White and Pharoah’s Oral Radiology: Principles and There is a female predilection.83 Most lesions occur under the nterpretation. 8th ed. St. Louis, Mo.: Elsevier; 2019:165-80. age of 20, with the median age at diagnosis being 12 years.107 11. Mallya SM. Other imaging modalities. In: Mallya SM, Excision is the treatment of choice, and up to 16 percent will Lam WN, eds. White and Pharoah’s Oral Radiology: recur.83 Principles and Interpretation. 8th ed. St. Louis, Mo.: Elsevier; 2019:2218-38. Pyogenic granuloma 12. Katheria BC, Kau CH, Tate R, Chen JW, English J, Bouquot Pyogenic granuloma is a painless smooth or lobulated vascular J. Effectiveness of impacted and supernumerary tooth lesion. The pyogenic granuloma is usually ulcerated and bleeds diagnosis from traditional versus cone beam easily.83,107 This lesion can occur at any age but is most common computed tomography. Pediatr Dent 2010;32(4):304-9. in children and young adults. There is a female predilection,83 13. Serrant PS, McIntyre GT, Thomson DJ. Localization of and the pyogenic granuloma can occur in up to five percent ectopic maxillary canines–Is CBCT more accurate than of .108 The pyogenic granuloma is thought to be an conventional horizontal or vertical parallax? J Orthod exuberant tissue response to a local irritant or trauma.108 Pyogenic 2014;41(1):13-8. granuloma most commonly occurs on maxillary anterior References continued on the next page.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 439 BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

14. Ferneini EM, Bennett JD. Oral surgery for the pediatric 30. Rhoads SG, Hendricks HM, Frazier-Bowers SA. Estab- patient. In: Dean JA, ed. McDonald and Avery’s Dentistry lishing the diagnostic criteria for eruption disorders based for the Child and Adolescent, 10th ed. St Louis, Mo.: on genetic and clinical data. Am J Orthod Dentofacial Elsevier; 2016:627-44. Orthop 2013;114(2):194-202. 15. American Academy of Pediatric Dentistry. Use of anes- 31. Sharif MO, Parker K, Lyne A, Chia MSY. The thesia providers in the administration of office-based deep orthodontic-oral surgery interface part two: Diagnosis and sedation/general anesthesia to the pediatric dental patient. management of anomalies in eruption and transpositions. The Reference Manual of Pediatric Dentistry. Chicago, Brit Dent J 2018;225(6);491-6. Ill.: American Academy of Pediatric Dentistry; 2019: 32. Ericson S, Kurol J. Early treatment of palatally erupting 327-30. maxillary canines by extraction of the primary canines. 16. Kaban L, Troulis M. Deep sedation for pediatric patients. Eur J Orthod 1988;10(4):283-95. In: Pediatric Oral and Maxillofacial Surgery. Philadelphia, 33. Richardson G, Russel K. A review of impacted permanent Pa.: Saunders; 2004:86-99. maxillary cuspids – Diagnosis and prevention. J Can Dent 17. Kaban L, Troulis M. Infections of the maxillofacial region. Assoc 2000;66(9):497-501. In: Pediatric Oral and Maxillofacial Surgery. Philadelphia, 34. Parkin N, Benson P, Shah A, et al. Extraction of primary Pa.: Saunders; 2004:171-86. (baby) teeth for unerupted palatally displaced permanent 18. Seow W. Diagnosis and management of unusual dental canine teeth in children. Cochrane Database Syst Rev in children. Aust Dent J 2003;43(3):156-68. 2009;15(2):CD004621. 19. Baker SR, Mat A, Robinson PG. What psychosocial factors 35. Naoumova J, Kurol J, Kjellberg H. A systematic review of influence adolescents’ oral health? J Dent Res 2010;89 the interceptive treatment of palatally displaced maxillary (11):1230-5. canines. Eur J Orthod 2011;33(2):143-9. 20. Thikkurissy S, Rawlins JT, Kumar A, et al. Rapid treat- 36. Bazargani F1, Magnuson A, Lennartsson B. Effect of ment reduces hospitalization for pediatric patients with interceptive extraction of deciduous canine on palatally odontogenic-based cellulitis. Am J Emerg Med 2010;28 displaced maxillary canine: A prospective randomized (6):668-72. controlled study. Angle Orthod 2014;84(1):3-10. 21. Regezi J, Sciubba J, Jordan R. Abnormalities of teeth. In: 37. Song F, O’Meara S, Wilson P, Goldner S, Kleijnen J. The Oral Pathology: Clinical-Pathologic Correlations, 7th ed. effectiveness and cost-effectiveness of prophylactic removal St. Louis, Mo.: Elsevier; 2017:373-88. of wisdom teeth. Health Technol Assess 2000;4(1):1-55. 22. Mochizuki K, Ohtawa Y, Kubo S, Machida Y, Yakushiji M. 38. Haug R, Perrott D, Gonzalez M, Talwar R. The American Bifurcation, bi-rooted primary canines: A case report. Int Association of Oral and Maxillofacial Surgeons age-related J Paediatr Dent 2001;11(5):380-5. third molar study. J Oral Maxillofac Surg 2005;63(8): 23. Andersson L, Blomlöf L, Lindskog S, Feiglin B, 1106-14. Hammarström L. . Clinical, radiographic 39. Pogrel M, Dodson T, Swift J, et al. White paper on third and histological assessments. Int J Oral Surg 1984;13(5): molar data. American Association of Oral and Maxillo- 423-31. facial Surgeons. March 2007. Available at: “https://www. 24. American Academy of Pediatric Dentistry. Management of aaoms.org/docs/govt_affairs/advocacy_white_papers/white developing dentition and in pediatric dentistry. _paper_third_molar_data.pdf”. Accessed July 24, 2020. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: 40. Friedman JW. The prophylactic extraction of third molars: American Academy of Pediatric Dentistry; 2020:393-409. A hazard. Am J Public Health 2007; 25. Tieu LD, SL, Major MP, Flores-Mir C. Management 97(9):1554-9. of ankylosed primary molars with premolar successors: A 41. Almendros-Marques N, Alaejos-Algarra E, Quinteros- systematic review. J Am Dent Assoc 2013;144(6):602-11. Borgarello M, Berini-Aytes L, Gay-Escoda C. Factors 26. O’Connell AC, Torske KR. Primary failure of tooth influencing the prophylactic removal of asymptomatic eruption: A unique case. Oral Surg Oral Med Oral Pathol impacted lower third molars. Int J Oral Maxillofac Surg Oral Radiol Endod 1999;87(6):714-20. 2008;37(1):29-35. 27. Frazier-Bowers SA, Koehler KE, Ackerman JL, Proffit WR. 42. Neville BW, Damm DD, Allen CM, Chi AC. Abnormalities Primary failure of eruption: Further characterization of a of the teeth. In: Oral and Maxillofacial Pathology. 4th rare eruption disorder. Am J Orthod Dentofacial Orthop ed. St. Louis, Mo.: Elsevier; 2016:49-110. 2007;131(5):578, e1-11. 43. Dean JA. Managing the developing occlusion. In: 28. Raghoebar GM, Boering G, Vissink A. Clinical, radio- McDonald and Avery’s Dentistry for the Child and graphic and histological characteristics of secondary Adolescent. 10th ed. St Louis, Mo.: Elsevier; 2016:415-78. retention of permanent molars. J Dent 1991;19(3):164-70. 44. Taylor GS. Characteristics of supernumerary teeth in the 29. Frazier-Bowers SA, Puranik CP, Mahaney MC. The primary and permanent dentition. Trans Br Soc Study etiology of eruption disorders – Further evidence of a Orthod 1970-71;57:123-8. ‘genetic paradigm’. Semin Orthod 2010;16(3):180-5.

440 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

45. Primosch R. Anterior supernumerary teeth—Assessment 60. Segal L, Stephenson R, Dawes M, Feldman P. Prevalence, and surgical intervention in children. Pediatr Dent 1981; diagnosis, and treatment of ankyloglossia. Can Fam 3(2):204-15. 2007;53(6):1027-33. 46. Tadinada A, Potluri. Dental anomalies. In: Mallya SM, Lam 61. Boutsi EZ, Tatakis DN. Maxillary labial frenum attach- EW, eds. White and Pharoah’s Oral Radiology: Principles ment in children. Int J Paediatr Dent 2011;21(4):284-8. and Interpretation. 8th ed. St Louis, Mo.: Elsevier; 2019: 62. Kotlow L. Diagnosing and understanding the maxillary 335-63. lip-tie (superior labial, the maxillary labial frenum) as it 47. Mallya SM, White S, Pharoah M. Projection geometry. relates to . J Hum Lact 2013;29(4):458-64. In: Mallya SM, Lam MN, eds. White and Pharoah’s Oral 63. O’Callahan C, Macary S, Clemente S. The effects of office- Radiology: Principles and Interpretation. 8th ed. St. Louis, based frenotomy for anterior and posterior ankyloglossia Mo.: Mosby Elsevier; 2019: 81-8. on breastfeeding. Int J Pediatr Otorhinolaryngol 2013; 48. Christensen JR, Fields HW Jr., Sheats RD. Treatment 77(5):827-32. planning and management of orthodontic problems. In: 64. Finigan V, Long T. The effectiveness of frenulotomy on Nowak AJ, Christensen JR, Mabry TR, Townsend JA, Wells infant-feeding outcomes: A systemic literature review. Evid MH, eds. Pediatric Dentistry: Infancy through Adoles- Based Midwifery 2013;11(2):40-5. cence. 6th ed. Philadelphia, Pa: Elsevier; 2019:512-53. 65. Webb AN, Hao W, Hong P. The effect of tongue-tie 49. Neville BW, Damm DD, White DK. Pathology of the division on breastfeeding and speech articulation: A teeth. In: Color Atlas of Clinical Oral Pathology. 2nd ed. systematic review. Int J Pediatr Otorhinolaryngol 2013; Baltimore, Md.: Williams & Wilkins; 2003:58-60. 77(5):635-46. 50. Russell K, Folwarczna M. Mesiodens: Diagnosis and man- 66. Delli K, Livas C, Sculean A, Katsaros C, Bornstein MM. agement of a common supernumerary tooth. J Can Dent Facts and myths regarding the maxillary midline frenum Assoc 2003;69(6):362-6. and its treatment: A systematic review of the literature. 51. Howard R. The unerupted incisor. A study of the post- Quintessence Int 2013;44(2):177-87. operative eruptive history of incisors delayed in their 67. Devishree G, Gujjari SK, Shubhashini PV. Frenectomy: eruption by supernumerary teeth. Dent Pract Dent Rec A review with the reports of surgical techniques. J Clin 1967;17(9):332-41. Dent Res 2012;6(9):1587-92. 52. Giancotti A, Grazzini F, De Dominicis F, Romanini G, 68. Kaban L, Troulis M. Intraoral soft tissue abnormalities. Arcuri C. Multidisciplinary evaluation and clinical man- In: Pediatric Oral and Maxillofacial Surgery. Philadelphia, agement of mesiodens. J Clin Pediatr Dent 2002;26(3): Pa.: Saunders; 2004:147-53. 233-7. 69. Shetty K, Trajtenberg C, Patel C, Streckfus C. Maxillary 53. Neville BW, Damm DD, Allen CM, Chi AC. Develop- frenectomy using a carbon dioxide laser in a pediatric mental defects of the oral and maxillofacial region. In: patient: A case report. Gen Dent 2008;56(1):60-3. Oral and Maxillofacial Pathology. 4th ed. St. Louis, Mo.: 70. Olivi G, Chaumanet G, Genovese MD, Beneduce C, Elsevier; 2016:1-48. Andreana S. Er,Cr:YSGG laser labial frenectomy: A clinical 54. Suter VG, Bornstein MM. Ankyloglossia: Facts and myths retrospective evaluation of 156 consecutive cases. Gen in diagnosis and treatment. J Periodontol 2009;80(8): Dent 2010;58(3):e126-33. 1204-19. 71. Kupietzky A, Botzer E. Ankyloglossia in the infant and 55. Webb AN, Hao W, Hong P. The effect of tongue-tie division young child: Clinical suggestions for diagnosis and man- on breastfeeding and speech articulation: A systematic agement. Pediatr Dent 2005;27(1):40-6. review. Int J Pediatr Otorhinolaryngol 2013;77(5):635-46. 72. Hogan M, Wescott C, Griffiths M. Randomized, controlled 56. Coryllos E, Genna CW, Salloum A. Congenital tongue-tie trial of division of tongue-tie in infants with feeding and its impact on breastfeeding. Breastfeeding: Best for problems. J Paediatr Child Health 2005;41(5-6):246-50. baby and mother. Am Acad Pedia (newsletter) 2004; 73. Díaz-Pizán M, Lagravère M, Villena R. Midline diastema Summer:1-7. and frenum morphology in the primary dentition. J Dent 57. Kotlow L. The influence of the maxillary frenum on the 2006;26(1):11-14. development and pattern of dental caries on anterior teeth 74. Gontijo I, Navarro R, Haypek P, Ciamponi A, Hadda A. The in breastfeeding infants: Prevention, diagnosis, and treatment. applications of diode and Er:YAG in labial frenec- J Hum Lact 2010;26(3):304-8. tomy in infant patients. J Dent Child 2005;72(1):10-5. 58. John J, Weddell JA, Shin DE, Jones JJ. Gingivitis and 75. Kara C. Evaluation of patient perceptions of frenectomy: . In: JA Dean, ed. McDonald and A comparison of Nd:YAG laser and conventional Avery’s Dentistry for the Child and Adolescent, 10th ed. techniques. Photomed Laser Surg 2008;26(2):147-52. St Louis, Mo.; Elsevier; 2016:243-73. 76. Kleinman DV, Swango PA, Pindborg JJ. of 59. Geddes D, Langton D, Gollow I, Jacobs L, Hartmann P, oral mucosal lesions in United States school children: Simmer K. Frenulotomy for breastfeeding infants with 1986-87. Community Dent Oral Epidemiol 1994;22(4): ankyloglossia: Effect on milk removal and sucking mecha- 243-53. nism as imaged by ultrasound. 2008;122(1): References continued on the next page. e188-e194.

THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 441 BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

77. Shulman JD. Prevalence of oral mucosal lesions in 92. Cunha RF, Boer FA, Torriani DD, Frossard WT. Natal children and youths in USA. Int J Pediatr Dent 2005;15 and neonatal teeth: Review of the literature. Pediatr Dent (2):89-97. 2001;23(2):158-62. 78. Melrose RJ, Handlers JP, Kerpel S, Summerlin DJ, Tomich 93. Leung A, Robson W. Natal teeth: A review. J Natl Med CJ. The use of biopsy in dental practice. The position of Assoc 2006;98(2):226-8. the American Academy of Oral and Maxillofacial Pathol- 94. Galassi MS, Santos-Pinto L, Ramalho T. Natal maxillary ogy. Gen Dent 2007;55(5):457-61. primary molars: Case report. J Clin Pediatr Dent 2004; 79. Rethman M, Carpenter W, Cohen E, et al. Evidence-based 29(1):41-44. clinical recommendations on screening for oral squamous 95. Stein S, Paller A, Haut P, Mancini A. Langerhans cell cell carcinomas. J Am Dent Assoc 2010;141(5):509-20. histiocytosis presenting in the neonatal period: A retro- 80. Kazanowska K, Halon A, Radwan-Oczko M. The role spective case series. Arch Pediatr Adolesc Med 2001;155 and application of exfoliative cytology in the diagnosis of (7):778-83. pathology – Contemporary knowledge with 96. Slayton RL. Treatment alternatives for sublingual trau- review of the literature. Adv Clin Exp Med 2014;23(2): matic ulceration (Riga-Fede disease). Pediatr Dent 2000; 299-305. 22(5):413-4. 81. American Academy of Oral and Maxillofacial Pathology. 97. Rushmah M. Natal and neonatal teeth: A clinical and Submission policy on excised tissue. Available at: “http:// histological study. J Clin Pediatr Dent 1991;15(4):251-3. www.aaomp.org/wp-content/uploads/2016/12/Policy_on_ 98. Centers for Disease Control and Prevention. What is Excised_Tissue-Final-11-9-2013.pdf”. Accessed July 25, vitamin K deficiency bleeding? Available at: “https:// 2020. www.cdc.gov/ncbddd/vitamink/facts.html”. Accessed July 82. Hong C, Dean D, Hull K, et al. World workshop on 25, 2020. oral : VII: Relative frequency of oral mucosal 99. Flaitz CM, Haberland C. Oral pathology and associated lesions in children, a scoping review. Oral Diseases 2019; syndromes. In: Nowak AJ, Casamassimo PS, eds. The 25(Suppl.1)193-203. Handbook: Pediatric Dentistry. 5th ed. Chicago, Ill.: 83. Flaitz CM. Differential diagnosis of oral lesions and American Academy of Pediatric Dentistry; 2018:46-100. developmental anomalies. In: Nowak AJ, Christensen JR, 100. Regezi J, Sciubba J, Jordan R. Salivary gland diseases. In: Mabry TR, Townsend JA, Wells MH eds. Pediatric Den- Oral Pathology: Clinical-Pathologic Correlations. 7th ed. tistry: Infancy through Adolescence. 6th ed. Philadelphia, St. Louis, Mo.: Elsevier; 2017:185-224. Pa.: Elsevier; 2019:8-49. 101. Neville BW, Damm DD, Allen CM, Chi AC. Salivary 84. Hays P. Hamartomas, eruption cysts, natal tooth, and gland pathology. In: Oral and Maxillofacial Pathology. Epstein pearls in a newborn. ASDC J Dent Child 2000; 4th ed. St. Louis, Mo.: Elsevier; 2016:422-72. 67(5):365-8. 102. Regezi J, Sciubba J, Jordan R. Verrucal-papillary lesions. 85. Aldred MJ, Cameron AC, Georgiou A. Pediatric oral medi- In: Oral Pathology: Clinical-Pathologic Correlations. 7th cine and pathology and radiology. In: Cameron AC, ed. St. Louis, Mo.: Elsevier; 2017:148-60. Widmer RP. eds. Handbook of Pediatric Dentistry. 4th 103. Neville BW, Damm DD, Allen CM, Chi AC. Epithelial ed. Philadelphia, Pa.: Mosby Elsevier; 2013:209-68. pathology In: Oral and Maxillofacial Pathology. 4th ed. 86. Lapid O, Shaco-Levey R, Krieger Y, Kachko L, Sagi A. St. Louis, Mo.: Elsevier; 2016:331-421. Congenital epulis. Pediatrics 2001;107(2):E22. 104. Regezi J, Sciubba J, Jordan R. Connective tissue lesions. 87. Marakoglu I, Gursoy U, Marakoglu K. Congenital epulis: In: Oral Pathology: Clinical-Pathologic Correlations. 7th Report of a case. ASDC J Dent Child 2002;69(2):191-2. ed. St. Louis, Mo.: Elsevier; 2017:161-84. 88. Neville BW, Damm DD, Allen CM, Chi AC. Soft tissue 105. Neville BW, Damm DD, Allen CM, Chi AC. tumors. In: Oral and Maxillofacial Pathology. 4th ed. St. and immunologic diseases. In: Oral and Maxillofacial Louis, Mo.: Elsevier; 2016:473-515. Pathology. 4th ed. St. Louis, Mo.: Elsevier; 2016:303-30. 89. Neville BW, Damm DD, Allen CM, Chi AC. Odontogenic 106. Regezi J, Sciubba J, Jordan R. Ulcerative conditions. In: cysts and tumors. In: Oral and Maxillofacial Pathology. Oral Pathology: Clinical-Pathologic Correlations. 7th ed. 4th ed. St. Louis, Mo.: Elsevier; 2016:632-89. St. Louis, Mo.: Elsevier; 2017:23-79. 90. Regezi JA, Sciubba JJ, Jordan RC. and 107. Neville BW, Damm DD, Allen CM, Chi AC. Periodontal neck. In: Oral Pathology: Clinical-Pathologic Correlations. disease. In: Oral and Maxillofacial Pathology. 4th ed. St. 7th ed. St. Louis, Mo.: Elsevier; 2017:245-68. Louis, Mo.: Elsevier; 2016:140-63. 91. McDonald JS. Tumors of the oral soft tissues and cysts 108. Regezi J, Sciubba J, Jordan R. Red-blue lesions. In: Oral and tumors of bone. In: Dean JA ed. McDonald and Pathology: Clinical-Pathologic Correlations. 7th ed. St. Avery’s Dentistry for the Child and Adolescent. 10th ed. Louis, Mo.: Elsevier; 2017:114-33. St. Louis, Mo.: Elsivier; 2016:603-26.

442 THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY