PEDIATRIC ORAL MEDICINE, a look through.

Children have oral mucosal conditions and other head and neck medical problems which have both similarities and differences to those found in adults .
A wide variety of oral lesions and soft tissue anomalies are detected in children, but the low frequency at which many of these entities occur makes them challenging to clinically diagnose.

1. PEDIATRIC ORAL MEDICINE MITHILA M(1704001010) CRRI

2. CONTENTS INTRODUCTION DEVELOPMENTAL CONDITION OROFACIAL SOFT TISSUE CONDITION SWELLINGS OF MUCOSA NON DENTAL INFECTIONS SALIVARY GLAND CONDITIONS TEMPOROMANDIBULAR DISORDERS CHILD ABUSE CONCLUSIONS REFERENCES

3. Children have oral mucosal conditions and other head and neck medical problems which have both similarities and differences to those found in adults . A wide variety of oral lesions and soft tissue anomalies are detected in children, but the low frequency at which many of these entities occur makes them challenging to clinically diagnose. In general, benign conditions are more commonly seen in children, and of these, fungal and viral are the most prevalent. Other benign lesions that are frequently seen in children are oral ulcerations, which can result from immune-mediated conditions , trauma, or systemic diseases. These oral ulcerations are often painful and require treatment. INTRODUCTION

4. DEVELOPMENTAL ANOMALIES Partial ankyloglossia(tongue-tie) Present at birth Short, thick lingual frenum or attachment to tip of Tongue; may cause slight cleft at tip Ventral tongue and Floor of mouth. Rarely causes speech, feeding, swallowing or periodontal problems; TREATMENT: Infrequently frenectomy is indicated Natal Teeth Natal teeth are teeth that are present at birth or erupt within 30 days of birth. They often consist of cornified and calcific material, do not have roots, and are mobile. The most common natal teeth are the mandibular central incisors; the mandible is affected 10 times more often than the maxilla. Natal teeth have been reported to cause ulcers of the ventral tongue (Riga- Fede disease) that result from irritation during nursing. TREATMENT extraction may be needed

5. Cleft Lip Cleft lip is the result of a disturbance of lip development in utero. The upper lip is most commonly affected. Cleft lip results when the medial nasal process fails to fuse with the lateral portions of the maxillary process of the first branchial arch. It is of un ilateral and nonmidline or bilateral and incomplete or complete cleft depending upon the involvement of nose. Cleft Palate Disruption in palatal fusion leads to clefting that is either disruption in the fusion of the right and left medial nasal processes or fusion of the palatine processes or shelves of the maxillary process A cleft palate can involve the soft palate only; the hard palate only; the hard and soft palates; or the hard and soft palates, alveolus, and lip.

6. OROFACIAL SOFT TISSUE CONDITIONS Some mucosal diseases are less common in children than in adults, particularly lichen planus and vesiculobullous diseases, whereas the acute herpetic primary infections are seen almost exclusively in children. Other conditions present at any age, including common conditions such as a geographic tongue and recurrent aphthous stomatitis. Oral ulceration -Traumatic ulcer -Recurrent aphthous stomatitis minor aphthous stomatitis major aphthous stomatitis herpetiform ulcers

7. Traumatic Ulcer Traumatic ulceration of the tongue, lips, and cheek may occur in children, especially after local anaesthesia has been administered. It is surrounded by a white keratotic area when the trauma has occurred gradually. rapid onset ulcers are usually bordered by normal or mildly inflamed mucosa and have a red erythematous base of exposed connective tissue. Mainly seen in the child in areas accessible to the teeth and biting, such as the cheek or lower lip in the area of the canine teeth or sharp lower incisor mamelons. Traumatic ulcers will heal or significantly reduce within two weeks if the cause is removed any ulcer not doing so needs closer attention.

8. Recurrent Aphthous Stomatitis Recurrent aphthous oral ulceration is multifactorial and the genetic predisposition is a significant factor in a child developing lesions. Common triggers for aphthous ulcers in children Minor mucosal trauma in a individual Haematinic deficiency – low serum ferritin, folic acid and/or vitamin B12 Sodium lauryl sulphate (SLS)-containing toothpastes Benzoate, cinnamon, chocolate and sorbate preservative containing foods TYPES OF APHTHOUS STOMATITIS Minor aphthous stomatitis Major aphthous stomatitis Herpetiform type

9. MINOR APHTHOUS ULCERS The majority of aphthous ulcers in children are of the minor variety (less than 10 mm in diameter) and usually heal within 10–14 days. Multiple ulcers can be present at the same time and the ulcers are always found on non-keratinized mucosa E xposure to dietary triggers such as chocolate or tomato but in others trauma to the mucosa from toothbrushing or from an orthodontic appliance edge may initiate an ulcer in the damaged tissue. MAJOR APHTHOUS ULCER M uch less common in children than minor aphthae. G enerally bigger than 10 mm in diameter and can last for 8–12 weeks. A ffect any part of the oral mucosa including keratinized tissue . TREATMENT : Major aphthae respond poorly to topical steroids, but high strength and high potency corticosteroid inhalers can be helpful if the ulcer is accessible. A pulse of systemic steroids or intralesional steroids may be needed to settle some persisting ulcers. As with minor aphthae, identification of nutritional deficiency or dietary allergen should be part of the management .

10. HERPETIFORM ULCERS When small (5 mm or less) aphthous ulcers are present in great numbers (often up to 100 at a time) and are present throughout the mouth on both keratinized and non-keratinized mucosa, these are termed herpetiform aphthae R esemble the mouth in primary herpetic gingiva-stomatitis. TREATMENT Oral steroid rinsing can be used as a prophylactic therapy but steroid inhalers are of little use due to the widespread ulceration of the oral mucosa.

11. SWELLINGS OF THE MUCOSA The majority of non-dental solid swellings of the oral mucosa in children are fibro-epithelial polyps or pyogenic granulomas and arise as a result of recurrent minor trauma to the mucosa. COMMON ORAL SWELLINGS IN CHILDREN Soft tissue abscess (parulis) Fibroepithelial polyp Congenital epulis Gingival cyst of the new born

12. Soft tissue abscess (parulis) Seen in first and second decades Present as solitary pinkish white or deep red nodule with surrounding erythema with purulent drainage , fluctuates in size and is tender to palpation Commonly seen in gingiva and alveolar mucosa Usually caused by odontogenic infection or entrapped foreign body TREATMENT Manage source of infection local debridement, antibiotics may be indicated recurs if infection is not eliminated Fibroepithelial polyp C ommon symptomless lesion that presents as a firm pink lump. It normally affects the buccal mucosa at the occlusal level. These lesions are caused by trauma such as from malpositioned teeth, sharp tooth edges or from recurrent lip or cheek biting habits. Habit breaking appliances can be used to break the habit and the lesion resolves

13. Congenital Epulis R are lesion that occurs in neonates. It normally presents in the anterior maxilla. C onsists of granular cells covered by epithelium and is thought to be reactive in nature TREATMENT S imple excision is curative . If it is not interfering with feeding then a more conservative approach can be taken. Gingival cysts of the new born The eruption cyst is a soft tissue cyst surrounding the crown of an unerupted tooth. Variant of the dentigerous cyst and affect children younger than 10 years of age It appears as a small, dome-shaped, translucent swelling overlying an erupting primary tooth. The cyst is lined by odontogenic epithelium and is filled with blood or serum and hence casts a red, brown, or blue-gray appearance to the cyst. TREATMENT No treatment is necessary because the erupting tooth eventually breaks the cystic membrane. Incising the lesion and allowing the fluid to drain can relieve symptoms.

14. NON DENTAL INFECTIONS Viruses, bacteria and fungi may cause infections of the oral mucosa, perioral skin and salivary glands. VIRAL INFECTIONS Viral infections are very common in children as the immune system adapts to the large range of pathogens the child encounters in daily life. Many viral encounters result in future immunity against that virus strain, but some, particularly herpes group viruses, can become persistent leading to recurrent emergence of the virus over the years.

15. Primary herpetic gingivostomatitis • Typically occurs in children younger than the age of 5 • HSV-1 responsible for 90% of infections • Virus is acquired through direct contact with oral lesions or saliva of an infected person, or through saliva of an asymptomatic person shedding the virus in the absence of clinical disease • Many infections are asymptomatic and subclinical • After the primary infection, HSV migrates to the trigeminal ganglion, where it remains latent and can be reactivated • Oral lesions start off as 1–3mm vesicles that later ulcerate and coalesce • Typically affects marginal gingiva as edema, inflammation, and bleeding and punched-out ulcers • Other oral sites include tongue, hard and soft palate, floor of mouth, and buccal mucosa • Lips and perioral skin are affected in two-thirds of cases and can show crusting • Associated systemic signs and symptoms include fever, irritability, malaise, sleeplessness, cervical lymphadenopathy, and headaches • Lesion are painful and patients complain of pain on eating, drinking, and swallowing.

16. MANAGEMENT Management of PHG is directed at promoting lesion healing providing palliation promoting adequate hydration and nutrition preventing further spread of the infection through avoiding direct contact with other people . Drinks and foods with acid or spice content should be avoided Cold items such as ice cream, popsicles, and ice chips can soothe affected tissues and help with hydration. Analgesics, topical anesthetics, and coating agents help relieve pain and facilitate food intake, with nutritional supplements added as needed. Non-alcoholic antimicrobial rinses may help decrease the risk of secondary infections when there is significant gingival involvement and poor oral hygiene. Systemic acyclovir can be used in a dosage of 15 mg/kg, with a maximum of 80 mg/kg per day to be used every 3 hours when awake or five times a day for 10 days.

17. Hand–foot–mouth disease • Coxsackieviruses A16 and A6 are most commonly involved • Most cases occur in infants and children, particularly those less than 5–7 years old • Typically occurs during the summer and early autumn • Transmission is by person to person, via faecal–oral route • Presents as fever ( < 101 ∘ F), oral or pharyngeal pain (in verbal children), or refusal to eat (in nonverbal children) • Oral lesions are multiple (2–30) 2–7mm vesicles that ulcerate, located on buccal mucosa, labial mucosa, and tongue, but can affect any site. Oral lesions precede the skin lesions • Skin lesions are a macular, maculopapular, or vesicular rash, which is nonpruritic and nonpainful, involving the hands (dorsum of the fingers, interdigital area, palms), feet (dorsum of the toes, lateral border of the feet, soles, heels), buttocks, legs (upper thighs), and arms. Infection usually subsides within 7–14 days.

18. Herpangina • Coxsackieviruses A1–6, 8, 10, and 22 most commonly involved • Occurs most frequently in summer and early autumn • Transmission is through direct contact via faecal–oral route • Some patients may experience malaise, headache, sore throat, dysphagia, and abdominal pain • A small number of lesions (2–6) develop in the soft palate/tonsillar pillar area . Lesions are 2–4mm red macules initially , then form vesicles, which later ulcerate. Treatment • Rest • Analgesics and antipyretics • Fluid intake • Soft diet. Mumps • Highly contagious viral infection caused by paramyxovirus • It is transmitted by respiratory droplets, direct contact, or through Fomites • Prodrome with fever, headache, myalgia, fatigue, and anorexia • This is followed by the development of parotid gland swelling within 48 hours (most often bilateral, but can be unilateral), lasting up to 10 days • Stenson’s duct (parotid duct) is often erythematous and swollen, and there can also be swelling of the sublingual and submandibular glands • Orchitis is the second most common manifestation

19. Measles (rubeola) • Infection caused by paramyxovirus • Transmission is through direct contact • Prodrome consists of fever, malaise, conjunctivitis, and cough • Koplik spots found in the prodrome in over 70% of cases. These are 1–3mm white macules surrounded by erythema, usually located on the buccal mucosa , are thought to represent foci of epithelial necrosis and typically last for 12–72 hours before sloughing off • Skin lesions consists of an erythematous, maculopapular, blanching rash, which classically begins on the face and spreads from head to toe and from the trunk to the extremities • Enamel pitting on permanent teeth has been reported in children who develop measles in early childhood

20. BACTERIAL INFECTIONS Staphylococcal infections Staphylococci and streptococci may cause impetigo. This can affect the angles of the mouth and the lips. It presents as crusting vesiculobullous lesions. The vesicles coalesce to produce ulceration over a wide area. Pigmentation may occur during healing. The condition is self-limiting, although antibiotics may be prescribed in some cases Staphylococcal organisms can also cause osteomyelitis of the jaws in children. Although the introduction of aggressive antibiotic therapy has reduced the serious consequences of osteomyelitis in children, surgical intervention is usually required to remove bony sequestra.

21. FUNGAL INFECTIONS The most common fungal infections seen is pseudomembranous candidiasis and chronic mucocutaneous candidiasis. Pseudomembranous candidiasis Neonatal acute pseudomembranous candidiasis (thrush) is not uncommon. Young children may develop the condition when their resistance is lowered due to another illness, nutritional deficiency or after antibiotic therapy. Use of steroid metered dose inhalers (MDI) in childhood asthma can direct a proportion of the drug to the roof of the mouth and soft palate leading to local immune suppression in the area and allowing pseudomembranous candidiasis to develop.

22. TREATMENT: Topical treatments are usually adequate when the precipitating cause is corrected. Topical antifungal agents include compounded clotrimazole suspension(10 mg/ml) and nystatin oral suspension (100,000 U/ml) to swish for 2 minutes and swallow or expectorate four times daily for 2 weeks, followed by a reevaluation of the oral cavity Systemic antifungal drugs are advantageous when other topically delivered medications are administered concurrently. They include Fluconazole 6 mg/kg orally every 12 or 24 hours for 5 to 7 days. Adolescents can use a 200-mg loading dose and then 100 to 200 mg once a day for about a week . Ketoconazole may also be used inchildren at 5 to 10 mg/kg every 12 or 24 hours, and in adolescents 200 to 400 mg every 24 hours for 5 to 7 days.

23. SALIVARY GLAND CONDITIONS Most salivary lesions in children are simple mucoceles. Infective salivary gland issues in children are related to either viral infection – predominantly mumps – or to ascending bacterial infection from the mouth when salivary flow has been compromised. Ranula It is a mucocele arising in the floor of the mouth beneath the tongue and can arise from the minor salivary glands or the ducts of the sublingual or submandibular glands . It appears as a bluish swelling of the floor of the mouth and can become quite large. TREATMENT: Surgical excision

24. Recurrent parotitis of childhood A rare condition often starting in the first five years of life. Characterized by swelling and pain of one of the parotid glands and as such may be confused in the early stages with mumps C hild will often be pyrexic, in pain and pus is usually seen exuding from the duct of the affected gland CAUSE: a bacterial infection ascending from the mouth The problem recurs once or twice a year in most cases and seems to remain in the one gland. This low level damage over many years causes increasing cumulative and permanent damage to the acini and duct structures resulting in lower gland flow rates, incomplete emptying of the ductal system and, consequently, increasingly frequent infections. In the third decade the patient usually has to have a surgical procedure to disconnect the gland from the mouth, such as a superficial parotidectomy or ligation of the parotid duct. TREATMENT: Management is through systemic antibiotics such as amoxicillin , targeting bacteria from the oral flora and should be given as early in the infective cycle as possible.

25. TEMPOROMANDIBULAR JOINT DISORDERS Most often non-specific pain in a young child is attributed to teething or ear ache where caries cannot be blamed for the discomfort Chronic relapsing and remitting ‘toothache’ in the absence of a dental or otological cause must raise suspicion and evidence for parafunctional clenching and limitation of mouth opening or meniscal symptoms makes TMD highly probable. TREATMENT Management with reassurance, advice regarding use of a soft diet and avoiding habits such as nail biting together with splint therapy is usually enough. Occasionally, psychological intervention or anxiolytic medication may be used.

26. CHILD ABUSE Child abuse can be defined as “any action (or lack of) which endangers or impairs a child’s physical, psychological or emotional health and development”. Types of child abuse 1. Physical abuse - any act which results in non-accidental trauma or physical injury. 2. Emotional abuse - systematic tearing down of another human being 3. Sexual abuse 4. Munchausen syndrome by proxy- Munchausen syndrome by proxy , a parent or caretaker attempts to bring medical attention to themselves by injuring or inducing illness in their children. 5. Intentional drugging or poisoning 6. Shaken baby syndrome - It is a form of child abuse where the infant’s head is shaken vigorously forward and backward, hitting the chest and shoulders.

27. Guidelines for identification of child abuse 1. Unusual dressing which is not suitable for the season may be intentional to cover the existing physical injuries. 2. A gross physical examination from head to toe without undressing to observe any signs of injuries 3. Any bruise in the shape of an object like belts, hangars, etc. 4. Presence of any bite marks 5. Frenal tears may indicate forced feeding 6. Bruising and petechia of soft palate may indicate sexual abuse 7. A 4-month-old child with a femur fracture 8. A bruise in the shape of a handprint on the cheeks 9. Any bruise in the neck region may be an attempted strangulation On encountering an abused child, the dentists should be careful in confirming the abuse and reporting it. The law does not usually require a precise diagnosis, only suspicion. The professional must document the reasons for the suspicion. Any visible pattern of injury should be photographed if possible. The data collected during the physical examination and medical history must be documented in a complete and objective manner. Any abnormal behavior observed in abused children must be recorded .

28. CONCLUSION Oral medicine conditions in children have a variety of presentations. These may be similar to the equivalent problem in the adult, but the approach to management can be very different. The dentist and oral medicine specialist must be aware of the full range of conditions, presentations and management options to fully serve the needs of the child with these issues . REFERENCES Crighton , A. Oral medicine in children.  Br Dent J   223 , 706–712 (2017). Georgiou, A., Cameron, A., Balasubramanian, R. (2019). Paediatric Oral Medicine. In: Farah, C., Balasubramanian, R., McCullough, M. (eds) Contemporary Oral Medicine. Springer, Cham. Burkets oral medicine 11 th edition Pediatric Dentistry: Infancy through Adolescence Paul S. Casamassimo DDS MS, Henry W. Fields Jr. DDS MS MSD, et al.