Pedo# 7

 

Comm mon oral medical con ndition ns in children     We saaid that w we have to o examine the soft ttissues inside the paatient mou uth and  we have to look at what we call "lesio ons", and w we said th hat lesionss are any change  c from the normal ( you shoulld know w what is norrmal then you can d diagnose w what is    not norm mal ).  There are certaiin conditio ons that are commo only seen in children so we caall them   " commo on oral me edical problems  in children "", first of aall we will discuss so ome  terminolo ogy , somee of the  terms thatt you have e to know before yo ou say whaat this    lesion . nge in colo or " non‐palppable" ( e.g.. if you seee a non‐raaised  Macule : a non‐raaised chan change in n color ‐ like nevi that we seee on the skkin ‐  or a ccolored leesion at the same  he oral mu ucosa , so o this lesion is called d Macule ))  .   level of th ‫ﺣﻤﺔ‬ ‫اﻟﻮﺣ‬ ‫اﻟﻠﻲ ﺑﺴﻤﻮهﺎ‬      ‫زي‬    then If you havve a larger area of cchange in color                           n we call th his lesion    " patch "..

ule .   Patch : is a non‐raaised  change in color which iis bigger than macu ‫ ﻲ‬macu ule  ‫ت اﻟﺼﻐﻴﺮة اﻟﻟﻠﻲ ﻣﺎ ﺑﺘﺒﻴﻦ ﺑﻨﺴﻤﻴﻬﺎ‬ ‫اﻟﺸﺎﻣﺎت‬             patch  ‫واﻟﻠﻲ أآﺒﺮ ﺷﻮي ﺑﺑﻨﺴﻤﻴﻬﻢ‬        

 

1/14

Erosion : a denudation epithelium superficial , it means that  there is  a cut, as you can see in this picture (which is a cross‐ section through the skin or mucus membrane ) there is some of  the epithelium removed for some reason , and you end with a  discontinuation of the epithelium in that area  , so this is called    an erosion . The erosion involves only the superficial layer, and it occurs  when you  scrub your skin against something and the area  becomes raw and bleeding then it is covered by a scabs* , If  this lesion is a little bit deeper involving the whole epidermis    then it is called " an ulcer ". *scabs "crusts": result when serum, blood, or purulent exudate dries and it is a hallmark of pyogenic infection. scabs are yellow when they have arisen from dried serum; green or yellow-green when formed from purulent exudate; and brown or dark red when formed from blood.

 

  Ulcer : a loss of epithelium below the basal cell layer   (below  the epidermis) ,ulcers are quite common in the    oral cavity that’s why we are talking about them .  

The Erosion is more superficial  than the ulcer 

 

Wheal: If you have an edematous fluid‐filled plaque ( a plaque is an area which is a little bit  raised) ,fluctuant when I touch it (which means that there is fluid inside it ) this    called a wheal .   The wheal is normally seen when you have an allergy (when you    are allergic to something and you start itching and the area is filled    with fluid and it becomes a little bit raised ).    

  The wheal is commonly seen with the allergic condition

  2/14

  Scar : is a permanent mark of a wound ( we have a wound in the    previous and then it heals and left a permanent mark). As you can    see the scar is usually  below the surface epithelium  and it causes    a change in the morphology of the superficial epithelium. Fissure :  linear crack of epidermis , sometimes if you have    a very dry skin ( e.g. in winter ) and a certain areas like lines    become apparent ,these are called cracks ( sometimes your lips     will crack  if the weather is very dry and cold in winter ) so this    cracked  is called a fissure .also some patients have  what is    called" fissured tongue ".   The fissure is different from the erosion , in the erosion the    epithelium isn’t present ,while here in fissure the epithelium is    present but opened). Sinus : is a tract leading from suppurative cavity or abscess , so there is a cavity  inside the deep layers of skin or mucous membrane and this cavity is filled with pus  " purulent exudates " and then the body ‐in an  attempt to get rid of this pus ‐  will    open a tract leading to outside so this is called a sinus . It is very commonly seen in children when they have an abscessed tooth‐non vital ‐,    so the body will open a tract outside to get rid of this abscess.  Papule : a small elevated solid lesion . any solid lesion which is small (< 1 cm ) and it  is elevated   is called a papule ,and anything which is bigger than papule is called a    plaque . so    Plaque : is a flat raised area which is >1 cm .  

3/14

  Nodule : is a raised  solid mass that has depth and it( the mass )  is < 1 cm.   So the difference between papule and nodule is that the nodule will    have a depth whereas  the papule doesn’t have a depth inside the skin    or oral mucosa ( the surface will only be raised ).  

 How do we know if the lesion has a depth or not ??  

By palpation (  NOT palpitation   ) , when you palpate the lesion you will know if the  ‫ﺑﺲ ﺗﻌﻠﻴﻘﺎ ﻋﻠﻰ ﺳﺆال اﻟﺪآﺘﻮرة ﺳﻤﺎح اﻟﻠﻲ آﺎن‬   lesion has a depth or doesn’t have a depth    ( when the lesion has a depth , you can feel it's whole    roundness  when you palpate it ).   So this is how to differentiate between  a papule and    a nodule.     The difference between the papule and the plaque is    that the plaque is bigger than the papule  .   if the lesion is a little bit  bigger and involving the    deeper layers then this is starting to become a tumor.

‫ واﻟﻠﻲ آﺎن ﻓﻴﻪ ﻣﻄﺐ‬، ‫ﻓﻲ اﻣﺘﺤﺎن اﻟﺮادﻳﻮ اﻟﻤﻴﺪ‬ ‫ ﻓﻲ ﻃﻼب اﻧﺘﺒﻬﻮا ﻟﻬﺎ اﻟﺴﺆال وﺟﺎوﺑﻮا‬، ‫ﺧﻔﻴﻒ‬ ‫ﺻﺢ و وﻓﻲ ﻃﻼب اﻧﺘﺒﻬﻮا ﺑﺲ ﻓﻜﺮوا اﻧﻪ ﻓﻴﻪ‬ ‫ وﻓﻲ ﻃﻼب ) زي ﺣﺎﻟﻼﺗﻲ ( ﻣﺎ‬، ‫ﺧﻄﺄ ﻣﻄﺒﻌﻲ‬ ‫اﻧﺘﺒﻬﻮﻟﻪ ﺑﺎﻟﻤﺮة وﻗﺮؤوﻩ ﻗﺮاءة ﺳﺮﻳﻌﺔ وﻓﻜﺮوﻩ‬ ‫ اﷲ ﻳﺠﺰﻳﻚ اﻟﺨﻴﺮ‬.. ) ‫ﺳﺆال ﺑﻮﻧﺺ ﻣﻦ ﺳﻬﻮﻟﺘﻪ‬ ‫ اﻟﺪآﺘﻮر ﻋﺒﺪ اﷲ‬،(.. ‫ﻋﻠﻰ هﻴﻚ ﺳﺆال ﻳﺎ دآﺘﻮرة‬ ‫هﺰاع ﻟﻤﺎ رﺣﻨﺎ اﺷﺘﻜﻴﻨﺎ ﻋﻠﻰ هﺎﻟﺴﺆال ﺣﻜﻰ اﻧﻪ‬ ‫ﻻزم ﻧﻜﻮن ﻣﻨﺘﺒﻬﻴﻦ ﻟﻜﻞ ﺣﺮف ﻓﻲ اﻟﺴﺆال وﻣﺎ‬ ‫ زي‬.. ‫ﻧﻔﺘﻲ ﻣﻦ راﺳﻨﺎ اﻧﻪ هﺬا ﺧﻄﺄ ﻣﻄﺒﻌﻲ أو ﻷ‬ ‫و‬.. ‫ﻣﺎ هﻮ ﻣﺤﻄﻮﻃﻠﻚ ﻓﻲ اﻟﺴﺆال ﻻزم ﺗﺠﺎوب‬ . ‫ﺑﺲ‬

All of the followings belong to   the clinical examination of   patient except  : 

  Tumor : it is actually a big nodule ( solid raised mass 

 inspection

  >1cm )  , the difference between tumor and other 

Palpitation 

  Lesions is the involvement of deeper layers ( not just

Percussion 

  the skin ) in case of tumor ( e.g. sometime you have    an insect bite ,it makes a rise in the mucosa or the    skin but it is not have a depth ,if it has a depth then it   is becoming a nodule , if it is a little bit bigger then it    is becoming a tumor .

Auscultation  Non of the above  .( ‫ﺗﻌﻴﺸﻮا وﺗﻮآﻠﻮا ﻏﻴﺮهﺎ ) ﻋﻠﻰ اﻟﻔﺎﻳﻨﻞ ان ﺷﺎء اﷲ‬

☺☺☺

 

4/14

Now we come to the fluid filled lesions, we classify them according to certain    criteria:    First of all , if you have a fluid filled eleva on which is > 1cm  , it is called a" Bulla" . if you have a fluid filled lesion which is smaller than Bulla it is called a " vesicle ",    vesicle is < 1 cm . e.g. it is very common to have a herpes on the lips ( herpes labialis ), if you notice  the herpes at the beginning it is very small fluid filled lesion which is called vesicle(  viral infections usually start as vesicles ), then the surface of this vesicle will break up    and it will become an ulcer      

Most of viral infections  start as vesicle, then this vesicle will break up and becomes an ulcer    which is later on covered with scabs and then it heals .

Pustule : it is filled with a fluid but this fluid isn’t a clear fluid , it is pus " purulent    exaudate " .   so the bulla and vesicle are usually  filled with clear fluid ( it is  usually serum )while the pustule is filled with purulent.  How we can differentiate between vesicle and pustule ? through the color of the lesion, usually the lesion that has pus inside it will appear    yellowish to a little bit greenish sometimes.   But suppose the lesion is very deep , how we can differentiate between them ? We do what is called " aspiration test " , you stick a needle inside the lesion and  then you aspirate , and you notice the color of the exudate , if it is clear then this is a    vesicle ,if it is purulent then this is a pustule .  The pustule if left untreated it will become a sinus (it will open on the surface in    order to get rid of this pus  ) .

5/14

  Cyst : it differs from other fluid filled lesion because it is lined    with epithelium , as you can see it is encapsulated and lined with    epithelium and this is the only difference between the cyst and    the vesicle . Usually the cyst if it is intraorally you can see it in the radiograph lined with    epithelium. It is very difficult to differentiate clinically ( just by looking ) between bulla and cyst ,  so you need to do aspiration test , and there are certain tests that done to    differentiate between them . Now we come to certain conditions that are quite common in children ,we will talk    about them briefly , you will learn more details about them in oral medicine course:

Cleft lip and palate Some children will have only  cleft lip , some of them will have only cleft palate and    some of them will have both cleft lip and palate .   Some children will have the cleft unilateral , some of them will have it bilateral .   Depending on the condition the severity will be either mild or severe .   This patient ( in the picture ) has only cleft lip , and it is bilateral ( bilateral cleft lip).   There are many theories that explain why the cleft happens  ,   the most accepted is that there are some disturbances that    occurring during the development .   From embryology you know that the face is composed of    some processes that will fuse together , if the fusion failed we will have a cleft . The  etiology might be genetic or certain drugs that the mother might have such as :  antiepileptic , nicotine smokers ( mothers who smoke during pregnancy ),alcohol    consumption during pregnancy ,…. All of these can lead to this problem .    

6/14

Dental lamina cyst It is a common condition that children are born with , some people might come to    you and say :my baby has a small white nodules on    the mucosa .   These white nodules  are remnants of the dental Lamina.   Depending on the location of these nodules you can    call them either:    D  Gingival cyst of newborn ( such as this condition in the picture ) where the  cysts are present on the alveolar ridge and they will resolve when the teeth erupt so    they require NO Treatment ( when the teeth erupt these nodules will disappear ).  D Palatal cyst of newborn :if these nodules appear on the palate ,and they also    called " Epstein's pearls" or " Bohn's nodules"  . So if somebody consult you about this condition you say to him No treatment is    needed  .  

Parulis ( gum boil )   This is vey common , you will see it in the clinic very often.   In this case you have a tooth which has been treated    before  and there is an area of swelling around  it ,    if you hold the tweezers and you raise it ,you will find    that there is a junction between this lesion and the  underlying tissue because of the chronic inflammation ( there is a chronic process  going here, chronic infection that is present and the body will respond to this  infection by gingival growth ), it might be yellow because it filled with  pus or it    might be  red .   If you want to treat this condition you treat the tooth and it will disappear .  

7/14

Thrush It is an acute pseudomembranous candidiasis . It is caused by overgrowth of the candida , as we know candida is present already in  the mouth, it is a commensal that present in the oral cavity, some of conditions will    lead to overgrowth of candida in children . when we have overgrowth of the candida we have to find out why we have this    overgrowth .  The appearance is milky white curds that are easily wiped off leaving red,raw painful    surface underneath . Treatment is by topical antifungal agent ,and not only we provide the patient with  topical antifungal agent but we have to find out why we have this overgrowth of    candida .

Natal teeth Some children are born with teeth, these are called natal teeth, it is not a rare    condition . Natal teeth : teeth present at birth or erupt within 30 days of birth , mostly in the  mandible.(1 this is what is written in the slides and the doctor read it , but from oral pathology course : Natal   

teeth are teeth that are already present at the time of birth. They are different from neonatal teeth, which erupt  during the first 30 days a er birth)

  These teeth might me either premature eruption of    deciduous teeth or extra teeth that are present in the    oral cavity (predeciduous consisting of cornfield material ). These teeth are causing irritation , sometimes they cause irritation to the tongue of the    child ( the ventral surface of the tongue ) and this irritation is called riga‐fede. So riga‐fede : is irritation of the ventral tongue by the natal teeth during sucking of the  milk (  during suckling, the tongue is on the lower lip , so if there are any incisors it will  touch the incisors and this will cause rubbing of the teeth against the ventral surface of the    tongue  ). This irritation can cause  severe pain to child and the child might stop feeding ,in this case    you have to extract those teeth .   Sometimes  this may cause harm to the mother during breast feeding .

8/14

Gingival hyperplasia It is overgrowth of the gingiva , the most common condition that might cause  gingival hyperplasia in the children is the taking of some medication ( Drug Induced    Gingival Hyperplasia ). e.g. during taking the medical history for the child who has epilepsy and he is on  antiepileptic drug,then you expect when open his mouth to see gingival hyperplasia.  Antiepileptic ( phenytoin ) and cyclosporine are always related to overgrowth of the    gingiva. Less commonly, sometimes  calcium channel blockers and estrogen can cause this    overgrowth . Sometimes an inflammatory component coexists : the presence of poor oral hygiene    for example can exacerbate the condition .  

Traumatic ulcers Very common in children , they are the most common type of ulcer that you can see    in children . The most common cause of traumatic ulcer is when the child falls on his face so the    lower lip touches the incisors and the teeth cause an ulcer to the soft tissues . This ulcer is associated with edema that is irregular, fluctuant and painful, and    laceration & hemorrhage are seen.   As you can see in the picture (a child's upper lip) that the    mucosa is cut here ,    if it affects the whole thickness of the epidermis then it    is called an ulcer , if it is superficial we call it an erosion ,    sometimes you might see areas of erosion and ulcer at    the same time.          To be continued >>>>            Done by :  

Saleh T. Al-Qadi 9/14

Vesiculobullous diseases we will talk about some common viral infections of the mouth , we defined what do we mean by vesicle and what do we mean by bulla , and we said that the vesicle is a fluid filled cavity and the bulla is a bigger fluid filled cavity , and we said that most of the viral infections will begin as vesicles , that’s why the viral infections are considered one of the vesiculobollous diseases , and the most common vesiculobollous legions in children is caused by viral infections .

{Note that the doctor want from us to know from these diseases the causative virus and the main locations of the ulcers and this is the most important thing}

Primary herpetic gingivo stomatitis : The most common viral infection that affects the oral cavity in children is the primary herpetic gingivo stomatitis and you should be familiar with this condition . sometimes this condition will be in epidemics which means : it occurs in special periods usually during spring and during autumn so you will have outbreaks of this condition during these periods especially in the schools as its highly contagious , and then maybe at a certain time of the year you may have many children who come with this condition. this disease is caused by primary infection with herpes simplex virus type1: now the child will have the virus from someone who has the disease , then there will be an incubation period (where the virus is in the body and there is no symptoms) which is about (3_10) days , and then after ten days of receiving the virus there will be symptoms . note that all the viruses have an incubation period and a prodromal symptoms The symptoms will start again as: prodromal symptoms : which are very mild symptoms that will be the beginning of the ***fulled load ***infection . the prodromal symptoms include too light symptoms for e.g. The child will be a little bit tired , maybe he will have a little fever , sometimes runny nose , so it looks like as if the child is going to have a flu but the age usually occurs in children less than ten or in young adults (between 15_ 25 years) .

10/14

after the prodromal signs the symptoms will appear more severe , the child will have fever and he will have malaise ,they *will be irritable*……… they will be very sick because of the severe condition and the severe phase inside the mouth . you can see here that the……. gingiva is affected by the disease and if you look at the gingiva closely , you will see very small ulcers so you will see vesicles and you will see ulcers on the gingiva , but here in this picture it doesn’t looks like ulcers but it looks like gingivitis but if you look closely you can see very little ulcers especially on the marginal gingiva (which is the gingiva very close to the teeth) . also you might see the ulcers on other parts of the oral cavity such as the lips or the buccal mucosa or you might see them on the tongue , or you might see them on the floor of the mouth , they may extend all the way to the palate , so it depends as you know the viral infections not necessarily affect all people in the same degree , some people will be severely affected and others will not so these ulcers might be only very little ulcers on the gingiva or they might be spread all over the oral cavity . the transmission of the disease is through direct contact means if there is a patient who has the ulcers and he is in direct contact with another one then he will transmit the disease for e.g. If a child uses a patient’s towel or drinks from the same cup that the patient drank from so this is the direct contact . so as we said the marginal gingiva will be red and it will become bullous and it easily bleeds inflamed and the inflammation will spread to the marginal and attached gingiva , you can also see small clusters of vesicles that are rupturing and becoming ulcers on different areas of the mucosa . also the child will have headache , they will have lymphoadenopathy so if you examine the lymph nodes in the cervical region and the submandibular region you will notice that there is lymph nodes (I think the doctor forgot to say enlargement )there is pharyngitis and its very difficult for the child to masticate its very difficult for the child to swallow that’s why the diet will become very bad (means the child cannot eat during the primary herpetic infection ). Then the condition will heal spontaneously (all viral infections heals spontaneously without treatment ) in about (12 – 20) days leaving no scars .

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Q : If it heals spontaneously then what type of treatment should we provide to the

patient ? A: you have to provide what we call supportive treatment .(all viral infections need supportive treatment)

Note : with all types of viral infections we give the patient supportive treatment , for e.g. If someone has a common cold then all the medications that you give him are all supportive (to relief symptoms) they do not actually treat the disease , so its not like a bacterial infection when you have an antibiotic which will kill the bacteria so it will deal with the disease, whereas in viral infection the treatment is always supportive and symptomatic for e.g. The child has fever I give him antipyretic , the child has headache I give him analgesic , the child has poor diet then I maybe give him intravenous drip so all of this is supportive and symptomatic treatment . But in severe cases if we see that the infection is spreading we can give an antivirus and the drug of choice is acyclovir , and note that its not necessary in all patients of the primary infection but only if you notice that the child is having severe symptoms . Its very important to prevent transmission from a child to another which is the impossible thing to do especially in schools . Q: What happens after the initial infection with this virus ? A: after the initial infection it will become silent inside the body latent in the sensory ganglia , now later on any irritant will reactivate the virus and we will have what we call the secondary infection which is:

the recurrent herpes simplex :(the doctor sure that many of us has this condition). As you see here in this picture(in the slide) these small vesicles which will rupture and become ulcers and the ulcers will be covered by a crust and the crust will slough and it will heal . Q: What are the factors that might lead to reactivation ? The reactivation occurs by sunlight exposure , trauma , heat , stress , immunosuppression …..etc.

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Q: What are the prodromal symptoms of recurrent herpes simplex? A: We have tingling sensation on the area then you will have the vesicles then the vesicles will **coallate** they will ulcerate and they will (…….) a cap then cap will heal without scarring.

Note : you have know that recurrent herpes simplex might occur intraoraly on the periosteal bound keratinized mucosa such as the hard palate , it might spread to the periodontal tissue and cause infection of it . The management is by lysine , vitamin C , antivirus (rarely) , so just need to protect the area and that’s all .

Herpangina : Hepangina is a viral infection where you have ulcers which are present in the posterior one third of the palate . And again the prodromal symptoms are the same as any viral infection . And the causative agent is Coxsackievirus A&B .

{Note that the doctor want from us to know from these diseases the causative virus and the main locations of the ulcers and this is the most important thing} Here is the true time when the doctor said this note but I copied it above so that if you are(‫(ﻣﻠﺤﻮق‬and you will be))then you don’t miss time on reading the whole part of this lecture. The ulcers diffuse on the pharynx causing pharyngeal erythema , dysphgia and sore throat and also you well have the same symptoms as any other viral infection (fever , malaise , headache ..etc.). And also the treatment is palliative again its supportive treatment It will heal within (1-2) weeks .

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Chickenpox : The causative agent is the varicella zoster virus and its highly contagious . As you see in the picture in the slides or its also the same thing which is the vesicles (fluid filled small vesicles) . It starts by etching , macules , they will become vesicles , they will rupture, become ulcers , they are covered by (***plaque***) , the (**plaque***) will slough then heal spontaneously without scaring . All the viral infections in the vesiculobullous legions have the same coarse of the disease. Sometimes chickenpox occurs also intraorally , so if I see extra oral legions or vesicles and intraoral legions like this (in the slides) then I do not say that this is herpangina but I say that this is an intraoral chickenpox . In chickenpox intraoral legions are usually few but sometimes they can spread from the oral cavity all the way to the stomach but this is very rare . They heal spontaneously within (7-10) days Vaccination : its available now for this disease and the children take this vaccine in order to prevent the disease . The doctor said that we don’t have lecture next Wednesday but if we want revision then she don’t mind .

The end Done by : muntaser toffaha .

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