Protecting All Children's Teeth: Common Oral Pathology

Protecting All Childrens Teeth
Common Oral
Pathology
www.aap.org/oralhealth/pact
Introduction
Mouth pain is a common presenting complaint in 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.
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.
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.
Used with permission from Miller Medical Illustration &

Design
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.
Used with permission from Melinda B. Clark, MD;

Associate Professor of Pediatrics at Albany Medical Center
Abscess Progression
If the infection in the pulp
extends
beyond the tooth, a periapical
abscess will develop.
Used with permission from Noel Childers, DDS, MS, PhD; Department of
Pediatric Dentistry, University of Alabama at Birmingham
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).
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,
mandibular, or palatal mucosa.
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.
A child with facial cellulitis should
be referred for immediate ER
evaluation or admitted to the
hospital for IV antibiotics.
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.
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.
10
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.
11
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.
12
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.
13
TMJ Treatment
Referral to a dentist or other professional knowledgeable in trea

TMJ disorders is appropriate.
Treatment is usually initiated when pain is present. Options include:
Non steroidal anti-inflammatory medication
Soft diet
Warm compresses
Occlusal bite guards
Counseling
Physical therapy
14
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.
15
Referred Pain, continued

The following non-oral conditions can cause pain felt in the
teeth or mouth:
16
Acute maxillary bacterial sinusitis or acute otitis media

Temporomandibular Joint
Atypical facial pain
Trigeminal neuralgia
Migraine headaches
Psychogenic
Neoplasia, such as leukemia
Primary Herpetic Gingivostomatitis
Primary Herpetic Gingivostomatitis is

caused primarily by herpes simplex
virus type 1.
Used with permission from Rama Oskouian
17
The primary infection is most severe

and usually seen in children younger
than 6.
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)
18
Significant lip and gum swelling, erythema, and bleeding
Vesicles on the lips, tongue, and cheeks, which then ulcerate
Treatment for Primary Herpetic

Gingivostomatitis
Treatment is mainly supportive with hydration maintenance
and pain control.
The acyclovir family of antiviral medications may be used for
immunosuppressed patients.
The infection is life-long, and
recurrences occur as cold
sores (herpes labialis), usually
at times of stress or infection.
19
Used with permission from Rama Oskouian
Herpes Labialis
Coxsackie Viral Infections
Herpangina
Used with permission from the AAP Red Book
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.
20
Treatment is supportive care.

Oral Candidiasis
White plaques or pseudomembranes
are noted on the surface of the
tongue
and/or the buccal, labial, and gingival
mucosa.
21
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 gr

include systemic antibiotic use, inhaled steroids, diabetes, xeros
and poor oral hygiene.
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 reinfection from bottles, pacifiers,
or breastfeeding (with maternal
breast
Used with permission from ANZ Photography
22
colonization) or resistance to
antifungal medication.
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.
Used with permission from the AAP Red Book
23
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.
24
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
25
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
26
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
27
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
28
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
29
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
30
Question #4
Which of the following statements about Oral
Candidiasis is
not true?
A. The same fungus causes angular cheilitis

B. It should be treated with antiviral medication
C. Re-infection from bottles or pacifiers is possible
D. It can be triggered by antibiotic use
E. It is common in infants
31
Answer
Which of the following statements about Oral
Candidiasis is
not true?
A. The same fungus causes angular cheilitis

B. It should be treated with antiviral medication
C. Re-infection from bottles or pacifiers is possible
D. It can be triggered by antibiotic use
E. It is common in infants
32
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
33
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
34
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.
35

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What are common causes of dental abscesses?

What are common causes of dental abscesses?

What are the stages of progression of an abscess?

What are the stages of progression of an abscess?

Protecting All Childrens Teeth

Mouth pain is a common presenting complaint in the primary care

Recall the common causes, bacterial flora, management, and

A dental abscess is a collection of

Used with permission from Miller Medical Illustration &

Used with permission from Melinda B. Clark, MD;

The pressure caused by the

Abscess Progression, continued

As the abscess expands, the pus

This infection can be life-threatening and must be addressed

First-line empiric antibiotic therapy for dental abscesses is

Abscess Treatment, continued

Efforts must be made to locate the site of infection, incise

Temporomandibular Joint Disorders

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

Referral to a dentist or other professional knowledgeable in trea

Referred pain is felt in an area innervated by a nerve

Referred Pain, continued

Acute maxillary bacterial sinusitis or acute otitis media

Primary Herpetic Gingivostomatitis

Primary Herpetic Gingivostomatitis is

Used with permission from Rama Oskouian

The primary infection is most severe

Primary Herpetic Gingivostomatitis

Fever and malaise (precede the anorexia, oral findings, and

Significant lip and gum swelling, erythema, and bleeding

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

Treatment for Primary Herpetic

Used with permission from Rama Oskouian

Coxsackie Viral Infections

Used with permission from the AAP Red Book

Coxsackie viral infections include

Treatment is supportive care.

Removal of the plaques shows

Oral Candidiasis is common in infants, but triggers for all age gr

Oral Candidiasis, continued

Strawberry Tongue refers to an

Strawberry Tongue, continued

A. Swelling and erythema over the joint

A. Swelling and erythema over the joint

A. Trauma to the tooth

A. Trauma to the tooth

A. The same fungus causes angular cheilitis

A. The same fungus causes angular cheilitis

A. The first step is to locate the site of infection

A. The first step is to locate the site of infection

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