Protecting All Childrens Teeth

Common Oral Pathology

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Introduction
Mouth pain is a common presenting complaint to the primary care office. It is imperative that pediatric health care professionals feel comfortable in the proper diagnosis, management, and triage of common oral pathology.

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Learner Objectives
Upon completion of this presentation, participants will be able to:

Recall the common causes, bacterial flora, management, and possible sequelae of dental abscesses. Describe the common clinical signs, symptoms, and management options of Temperomandibular joint (TMJ) disorders. Define and discuss the term referred pain as it relates to the mouth. Discuss the clinical presentation, causative agents, diagnosis, and management of primary gingivostomatitis, herpangina, hand-footmouth disease, and thrush. List the 2 common conditions that cause "strawberry tongue.

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Abscess

A dental abscess is a collection of purulent fluid caused by a bacterial infection. The most common cause of a dental abscess is extension of the dental caries process into the pulp of the tooth.

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Abscess, continued
Abscesses can also be caused by trauma to the tooth that allows bacteria to enter the pulp. An abscess limited to the tooth structure (pulpitis) will often present with tooth pain from the increased pressure on the nerve endings within the pulp. This pain is often worsened with heat or cold exposure.

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Abscess Progression

If the infection in the pulp extends beyond the tooth, a periapical abscess will develop. The pressure caused by the expanding area of necrosis and inflammation causes visible swelling and may lead to slight extrusion of the tooth from the socket (as shown in the x-ray to the left).

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Abscess Progression, continued

As the abscess expands, the pus will spread to contiguous surfaces along the path of least resistance to form a fistula to the maxillary, mandular, or palatal mucosa.

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Cellulitis

If the infection remains unchecked, an abscess can progress to facial, submandibular, or sublingual cellulitis. Facial cellulitis presents clinically with swelling, warmth, and tenderness to palpation along the jaw.

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Symptoms of an Abscess
Patients with abscess may present with the following symptoms:

Headache Fever Periorbital edema or pain Cranial nerve abnormalities.

This infection can be life-threatening and must be addressed emergently.

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Abscess Treatment

First-line empiric antibiotic therapy for dental abscesses is penicillin or amoxicillin and clindamycin for penicillin-allergic patients. Suspicion of a dental abscess requires urgent referral to a dentist for definitive care.

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Abscess Treatment, continued

Efforts must be made to locate the site of infection, incise and drain the pus collection, and collect a specimen for culture and sensitivities. An abscessed tooth often must be extracted. Antibiotic therapy is also required, especially in cases of contiguous spread of the infection.

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Temporomandibular Joint Disorders

The temporomandibular joint (TMJ) is the area directly in front of the ear on either side of the head where the upper jaw (maxilla) and lower jaw (mandible) meet.

Temporomandibular joint disorders include a range of problems related

to this joint.

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Signs of TMJ
Signs of TMJ disorders include:

Bruxism
Wear of the occlusal surfaces of the teeth due to tooth grinding Joint sounds (clicking and crepitus) Limited mandibular opening

Pain, including TMJ pain or headache, may occur but is not always present.

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TMJ Treatment
Referral to a dentist or other professional knowledgeable in treating TMJ disorders is appropriate. Treatment is usually initiated when pain is present. Options include:

Non steroidal anti-inflammatory medication A soft diet Warm compresses Occlusal bite guards Counseling Physical therapy
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Referred Pain

Referred pain is felt in an area innervated by a nerve different from that which innervates the primary site of pain. Dental pain can refer to other teeth, the head, ear, eye, periorbital region, or jaw.

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Referred Pain, continued

The following non-oral conditions can cause pain felt in the teeth or mouth:

Acute maxillary bacterial sinusitis or acute otitis media Temporomandibular Joint Atypical facial pain Trigeminal neuralgia Migraine headaches Psychogenic

Neoplasia, such as leukemia

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Primary Herpetic Gingivostomatitis

Primary Herpetic Gingivostomatitis is caused primarily by herpes simplex virus type 1. The primary infection is most severe and usually seen in children younger than 6.

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Primary Herpetic Gingivostomatitis

The clinical syndrome of HSV gingivostomatitis lasts 10-14 days. Diagnosis is usually based on clinical history and exam findings.

Clinical presentation includes:

Fever and malaise (precede the anorexia, oral findings, and cervical lymphadenopathy) Significant lip and gum swelling, erythema, and bleeding

Vesicles on the lips, tongue, and cheeks, which then ulcerate

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Treatment for Primary Herpetic Gingivostomatitis

Treatment is mainly supportive with hydration maintenance and pain control. The acyclovir family of antiviral medications may be used. The infection is life-long, and recurrences occur as cold sores (herpes labialis), usually at times of stress or infection.

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Coxsackie Viral Infections

Coxsackie viral infections include Herpangina and Hand-Foot-Mouth Disease.

Fever, malaise, sore throat, and anorexia precede appearance of the vesicles. Cervical lymphadenopathy is also present.
Symptoms last 7-10 days. Treatment is supportive care.

Herpangina

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Oral Candidiasis
White plaques or pseudomembranes are noted on the surface of the tongue or the buccal, labial, and gingival mucosa.

Removal of the plaques shows underlying raw, red, bleeding mucosa. Oral surfaces may become painful, which can interfere with feeding.
Oral Candidiasis is common in infants, but triggers for all age groups include systemic antibiotic use, inhaled steroids, diabetes, xerostomia, and poor oral hygiene.
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Oral Candidiasis, continued

Oral Candidiasis can be treated with topical antifungal agents, such as Nystatin or Clotrimazole. If symptoms persist or recur shortly after discontinuation of the antifungal agent, consider re-infection from bottles, pacifiers, or breastfeeding (with maternal breast colonization) or resistance to antifungal medication.

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Strawberry Tongue

Strawberry Tongue refers to an inflamed tongue. It presents as either a diffusely Erythematous tongue with prominent fungiform papillae or a tongue covered by a white membrane except for the fungiform papillae that appear red.

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Strawberry Tongue, continued

Strawberry Tongue is associated with Group A Beta Hemolytic Strep and Kawasaki syndrome.

Group A Beta Hemolytic Strep causes erythematous and enlarged tonsils with white exudates, anterior cervical lymphadenopathy, and fever.
Clinical presentation of Kawasaki syndrome is 5 days of fever associated with other clinical criteria, including oral mucosal findings such as a strawberry tongue.

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Question #1
Which of the following signs is not expected to be seen in a Temporomandibular Joint (TMJ) disorder? A. Swelling and erythema over the joint. B. Clicking of the joint. C. Wearing of the occlusal surfaces of the teeth. D. Limited jaw opening. E. Crepitus over the joint.

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Answer
Which of the following signs is not expected to be seen in a Temporomandibular Joint (TMJ) disorder? A. Swelling and erythema over the joint. B. Clicking of the joint. C. Wearing of the occlusal surfaces of the teeth. D. Limited jaw opening. E. Crepitus over the joint.

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Question #2
What is the most common cause of a dental abscess? A. Trauma to the tooth. B. Ludwig's angina. C. Extension of the dental caries process into the pulp of the tooth. D. Bruxism. E. Facial cellulitis.

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Answer
What is the most common cause of a dental abscess? A. Trauma to the tooth. B. Ludwig's angina. C. Extension of the dental caries process into the pulp of the tooth. D. Bruxism. E. Facial cellulitis.

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Question #3
Which of the following conditions can cause pain in the teeth or mouth? A. Migraine headaches. B. Acute maxillary bacterial sinusitis. C. Leukemia. D. Acute otitis media. E. All of the above.

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Answer
Which of the following conditions can cause pain in the teeth or mouth? A. Migraine headaches. B. Acute maxillary bacterial sinusitis. C. Leukemia. D. Acute otitis media. E. All of the above.

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Question #4
Which of the following statements about Oral Candidiasis is not true? A. It can cause angular cheilitis. B. It should be treated with antiviral medication. C. Re-infection from bottles or pacifiers is possible. D. It can be caused by antibiotic use. E. It is common in infants.

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Answer
Which of the following statements about Oral Candidiasis is not true? A. It can cause angular cheilitis. B. It should be treated with antiviral medication. C. Re-infection from bottles or pacifiers is possible. D. It can be caused by antibiotic use. E. It is common in infants.

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Question #5
Which of the following statements is true when treating an abscess? A. The first step is to locate the site of infection. B. In severe cases, intravenous antibiotics are necessary and hospitalization may be required. C. An abscessed tooth often must be extracted. D. In cases limited to pulpitis, a root canal may be performed to salvage the tooth. E. All of the above.

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Answer
Which of the following statements is true when treating an abscess? A. The first step is to locate the site of infection. B. In severe cases, intravenous antibiotics are necessary and hospitalization may be required. C. An abscessed tooth often must be extracted. D. In cases limited to pulpitis, a root canal may be performed to salvage the tooth. E. All of the above.

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References
1. Avcu N, Gorduysus M, Omer Gorduysus M. Referred dental pain. The Pain Clinic. 2003; 15(2): 173-178. 2. Ferretti GA, Cecil JC. Kids Smile: Oral Health Training Program Lecture Series. Sponsored by the Kentucky Department for Public Health and the University of Kentucky College of Dentistry. 3. Handbook of Pediatric Dentistry. 2nd ed. Cameron AC, Widmer RP (Eds). Mosby; 2003. 4. Krol DM, Keels, MA. Oral Conditions. Pediatr Rev. 2007; 28(1): 15-22. 5. Okeson JP, Falace DA. Nonodontogenic toothache. Dental Clinics of North America. 1997; 41(2): 367-83. 6. Oral Pathology: Clinical Pathologic Correlations. 4th ed. Regezi JA, Sciubba JJ, Jordan RCK (Eds) WB Saunders, St Louis Mo. 2003. 7. Pediatric Dentistry: Infancy through Adolescence. 4th ed. Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ, Nowak AJ (Eds). WB Saunders, St Louis, Mo. 2005.

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