Lession In Pediatric ROCHMAN MUJAYANTO, DRG., SP.PM FAKULTAS KEDOKTERAN GIGI UNIVERSITAS ISLAM SULTAN AGUNG Outline
Mouth Sores and Patches
Focal Gum Lesions Tongue Discoloration and Surface Change Swelling Throat Redness Mouth Sores and Patches
Mouth sores and patches are commonly found on
careful oral examination of pediatric patients. Lesions may be asymptomatic or may lead to ulceration, pain, and decreased oral intake. Oral lesions may be categorized as anatomic, traumatic, or infectious. Many of these lesions are isolated to the oral cavity and mucosa, but certain systemic illnesses and conditions can present with oral sores or patches as part of a constellation of symptoms. Diagnosis is primarily clinical. Management is often limited to supportive care, including pain control andensuring adequate hydration. Oral candidiasis is the most common oral fungal infection in infants and children, with Candida albicans being the most frequently identified species. When infections are persistent in children older than 6 months, the clinician should consider an underlying defect in the systemic immune system. Lesions of oral candidiasis include white or whitishyellow plaques and erythema of the tongue, soft palate, or buccal mucosae. When plaques are scraped off, there is often underlying raw, erythematous mucosa, which may bleed. These mucosal changes may help the clinician differentiate the white plaques from milk residue seen on the tongue of infants. Traumatic oral lesions arise from mouthing objects in the period of infancy, and accidental biting or injury from objects placed in the oral cavity in older children. Pain is the predominant symptom, occurring 24 to 48 hours after the initial injury. Drooling and tenderness may be predominant features on physical examination when ulcerative lesions are present. Small gingival vesicles that progress into painful ulcerations following high fever, irritability, and malaise should prompt consideration of primary herpetic gingivostomatitis caused by herpes simplex virus (HSV) type 1 as a diagnosis. Other viruses can cause enanthems, and should be considered in the diagnosis of oral lesions when prodromal symptoms are present. Examples include Koplik spots associated with measles, and ulcerations found in infectious mononucleosis and varicella. Herpangina also produces oral ulcerations and follows a prodrome that includes malaise, sore throat, and low-grade fever. It is caused by coxsackievirus group A, usually in the summer and early fall. The oral ulcerations are isolated in herpangina. When oral ulcerations occur in conjunction with palmar and plantar papulovesicles, hand, foot, andmouth disease should be strongly considered. Location of lesions can help differentiate between HSV gingivostomatitis and herpangina. HSV lesions are located in both the anterior and the posterior oropharynx, and lesions of herpangina are located predominantly in the posterior oropharynx, sparing the lips and gingiva. Both HSV and herpangina present with painful, small, grouped vesicles that eventually ulcerate. Gingival erythema, friability, and edema are commonly seen in HSV gingivostomatitis, but not in herpangina Recurrent aphthous stomatitis (RAS) is the most common inflammatory ulcerative condition of the oral mucosa in patients in North America, with up to 20% of the population affected during childhood or early adulthood. Its cause is unknown. It is categorized into major and minor forms based on size and location of ulcers. RAS may produce ulcers of nonkeratinized mucosa (unattached gingiva) and keratinized surfaces. Lesions of major RAS are larger and can cause scarring. Koplik spots occur early in the course of measles, before other cutaneous signs, and are often missed. Focal Gum Lesions
Natal and neonatal teeth are most commonly
primary, but may be supernumerary. Natal teeth are erupted teeth present at the time of birth.
Bohn nodules are smooth, translucent, pearly
white cysts that range from approximately 1 to 3 mm in size. Bohn nodules may be isolated or clustered. Eruption cysts are usually found in the region of the incisors on the edge of the alveolar ridge where a tooth is erupting. Eruption cysts may feel rubbery, be nontender, and have a bluish hue. Alveolar cysts are visible along the alveolar ridges. A retrocuspid papilla, often bilateral, is a firm, round, pink to red 2- to 3-mm papule attached to the lingual gingiva adjacent to the mandibular canines.
The presence of fever in association with a focal
gum lesion should raise suspicion for a dental abscess. Dental abscesses may appear as erythema and swelling of the gum, often in the region of dental caries, and may be associated with purulent drainage. Tongue Discoloration and Surface Changes The surface of the tongue may develop changes in color or texture because of intrinsic or extrinsic factors. Discolorations may be related to chewed, ingested, or topical products, or certain infections. Medications, such as antibiotics, antifungal agents, antimalarial drugs (primarily on the hard palate), psychotropic agents (including selective serotonin reuptake inhibitors), phenothiazines, benzodiazepines, and phenytoin, may cause tongue discoloration. Minocycline-associated pigmentary changes may persist for years. White lesions
A white plaque that wipes off easily may be due
to milk or food. If it cannot be scraped off easily, bleeds, or leaves a denuded surface after scraping, the white plaque is usually the result of a fungal infection. The use of antibiotics, immunosuppressive agents, systemic steroids, or inhaled corticosteroids may predispose patients to oral thrush. Immunodeficiency, recent radiation, or cytotoxic therapy predisposes patients to oral thrush and oral hairy leukoplakia. Hairy leukoplakia is caused by EpsteinBarr virus and is seen more commonly in adults affected by human immunodeficiency virus (HIV), but is rare in children affected by HIV. White plaques associated with lichen planus are more common in patients with thyroid disease, particularly hypothyroidism. Lichen planus, an immunological disorder, may cause lacy white plaques on the buccal mucosae and may coexist with oral candidiasis. White sponge nevus is a rare autosomal dominant condition that starts in childhood and is characterized by bilateral white plaques on the buccal mucosae, and sometimes on the lateral border of the tongue and other mucosal surfaces. Linea alba is caused by repeated trauma from biting or chewing and appears as a thin white line on the lateral margins of the tongue (or the buccal mucosae) bilaterally. White tongue plaques associated with nail dystrophy and reticular skin pigmentation are hallmarks of ZinsserColeEngman syndrome, also known as dyskeratosis congenita, a rare, X- linked disorder associated with bone marrow failure. Black grey lesions
Argyria is an irreversible blue gray
mucocutaneous staining caused by exposure to silver and includes ingestion of a silver- containing supplement known as colloidal silver. Ingestion of bismuth-containing products may lead to black tongue staining. Darkly pigmented adults and children are more likely to have pigmented fungiform papillae of the tongue. Dark pigmentation of the fungiform papillae may be seen in iron deficiency. The third involves hyperpigmentation of all the fungiform papillae on the dorsal surface of the tongue. Hairy tongue discoloration may be brown, black, green, or yellow depending on the particles, chromogenic bacteria, or fungi that are entrapped; hence, it is no longer known as black hairy tongue. Redness
Glossitis may be precipitated by the use of
cytotoxic agents. Allergy Fixed drug eruptions occur at the same location on the tongue with each exposure. A red tongue that is smooth indicates glossitis, whereas a red tongue with enlarged papillae is more consistent with strawberry tongue. The raised papillae of strawberry tongue may be visualized better with indirect lighting from the side. Median rhomboid glossitis is a reddened and smooth rhomboid-shaped area of papillary atrophy just anterior to the circumvallate papillae. Overgrowth papillae
Hairy tongue, or elongated filiform papillae in
the midline tongue, is associated with the following: tobacco, tea, coffee, antibiotics, griseofulvin, or certain mouthwashes containing an oxidizing agent, such as sodium perborate, sodium peroxide, or hydrogen peroxide. Hairy tongue has been linked to herbal tea ingestion in an infant. Throat Redness
Throat redness is a familiar complaint to the
general pediatrician or family practitioner. Erythema of the posterior oropharynx suggests an inflammatory or infectious process, but can also be caused by exposure to environmental allergens, airborne irritants, or acid from chronic laryngopharyngeal reflux. Pharyngitis may cause neck pain and stiffness. Throat redness associated with upper respiratory tract symptoms (rhinorrhea, cough, and conjunctivitis) and/or lower gastrointestinal tract manifestations (vomiting with diarrhea) are characteristic of viral infection and rarely represent a bacterial throat infection. Increased throat pain after meals or when supine suggests pain related to gastroesophageal reflux. Chronic mouth breathing associated with obstructive sleep apnea leads to dry, irritated mucosae and a sore throat, which is worse in the morning and improves throughout the day as the patient drinks fluids. Asking about ambient room temperatures, especially in the winter months, can provide useful history to support this diagnosis. Ulcerations are typically seen with viral pharyngitis and stomatitis. Ulcerations on the tonsillar pillars suggest the diagnosis of herpangina caused by coxsackievirus or echovirus. Ulcerations from herpes simplex virus are typically more anterior but may occur posteriorly and in association with gingivitis. Infectious mononucleosis may present with pharyngeal and tonsillar erythema, fever, difficulty swallowing, and posterior cervical lymphadenopathy. Fatigue is a prominent symptom, and may persist in up to 22% of cases beyond 2 to 3 weeks of illness. Drooling results from the inability to swallow ones secretions. Watch for drooling in patients with severe pharyngitis, pharyngeal ulcerations, or a retropharyngeal abscess. Thank You